Harmony Care at Floresville

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biological were stored in a manner that permitted only authorized personnel to have access to the keys for 1 of 2 Medication Rooms (Medication room [ROOM NUMBER]) and, 1 of 4 carts (medications cart #1) reviewed for pharmacy services. 1. The facility failed to ensure Medications cart #1 remained locked while not being used.2. The facility failed to ensure Medications room [ROOM NUMBER]'s doors remained locked. This failure could place residents receiving medication at risk of potential harm, medication diversion and access of medications by unauthorized personnel, visitors and residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an encoded, accurate and complete discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 4 residents (Resident #2) reviewed for discharge MDS assessments. The facility failed to ensure a discharge MDS was completed and transmitted for Resident #2's within 14 days of his discharge to the hospital. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. Dietary Aide E had a moustache, was not wearing a moustache guard, and was preparing food. 2. The wall air conditioning unit above the dry goods storage was emitting small pieces of gray pellets onto the stored dry goods items. 3. A 22-gallon container of loose sugar also contained a cup for scooping the sugar. 4. A 16-ounce container of beef base paste labeled refrigerate after opening had been opened and was not stored in a refrigerator. 5. A 5-pound container of cottage cheese was labeled use by March 2026.6. A box of lettuce dated 04/07/2026 was withered and brown with parts covered by a wet and slimy substance. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 residents (Residents #3 and #11) observed for nursing care: 1. The Facility failed to ensure resident's privacy was provided during care when LVN C did not close Resident #3's room door while providing colostomy care.2 The Facility failed to ensure resident's privacy was provided during care when CNA D did not completely close Resident #11's privacy curtain while providing catheter care for the resident. This failure could place residents at risk for loss of dignityThe

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 residents (Resident # 38) reviewed for oxygen : The facility failed to ensure Resident #38's nebulizer tubing was bagged. This failure could place at risk for an increase in respiratory complications.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 reviewed residents' refrigerators. The facility failed to date open food items in the resident's #39 personal room refrigerator. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #3) reviewed for infection control: The facility failed to ensure LVN C sanitized her hands between change of gloves while providing colostomy care for Resident #3. This failure could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on record review and interviews, the facility failed to maintain spaces of at least 80 square feet per resident for 14 of 15 Resident rooms (Resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, 408, and 409) inspected for resident room sufficient space for privacy and comfort, in that: The facility failed to ensure resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, 408, and 409 were maintained with at least 80 square feet of space per resident. This failure could place residents at risk of restricting their resident rights for comfort and privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 of 1 kitchen reviewed for staffing. The facility failed to employ sufficient staff to prepare resident meals resulting in meals not served according to the posted start times for dinner on 9/10/25 and lunch on 9/11/25. This failure could put residents at risk for altered nutritional status and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 7 of 21 residents (Residents #12, #35, #70, #39, #80, #190 and, #198) reviewed for infection control: 1. The facility failed to ensure CNA-D sanitized her hands in between feeding and assisting Residents #35, # 39 and #70 with their meal on 03/18/2025. 2. The facility failed to ensure RN-E followed EBP when administering G-tube medication to Resident #190 on 03/19/2025. 3. The facility failed to ensure MA-F sanitized the blood pressure cuff in between use with Residents #80 and #12 on 03/20/2025. 4. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 2 of 20 residents (Resident #20 and #62) reviewed for advanced directives, in that: 1. Resident #20's DNR was not signed twice by the physician. 2. Resident #62's DNR was not signed twice by the physician. These deficient practices could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 residents (Resident #42) whose assessments were reviewed, in that: Resident #42's quarterly MDS assessment incorrectly documented the resident as not receiving an antipsychotic medication. This failure could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Residents #188 and #195) of 8 residents reviewed for baseline care plans. 1. The facility failed to include Resident #188's risk for falls and epilepsy in his baseline care plan. 2. The facility failed to include Resident #195's oxygen therapy and wound care in his baseline care plan This failure could result in residents not receiving needed care and treatment. Findings Included: 1. Record review of Resident #188's face sheet dated 03/21/2025 revealed he was a [AGE] year-old man who was admitted to facility on 03/06/2025 with diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to a meet resident's medical, nursing, mental, and psychosocial needs for 1 of 6 residents (Resident #36) reviewed for care plans, in that: The facility failed to develop a comprehensive person-centered care plan to address Resident #36's indwelling catheter care requirements. This deficient practices could affect residents who require an indwelling catheter by not having their needs met and putting them at risk of being inappropriately cared for.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #195) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #195's used oxygen tubing and nasal cannula were disposed of and not left in the resident's room. This failure could place residents on respiratory therapy at risk for respiratory compromise and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #195) of 8 residents reviewed for Medication storage. 1. The facility failed to ensure Resident #195 did not have a jar of mentholated ointment (a topical analgesic and decongestant) at the bedside. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. Access to the handwashing sink was blocked by two rolling carts. 2. There was a sand-like substance on top of the dish sanitizing machine. These deficient practices could result in residents consuming meals and/or snacks prepared in an unsanitary manner.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 beauty shop reviewed, in that: The beauty shop was unlocked and contained potentially dangerous materials. This deficient practice could result in residents, staff, and visitors living, working, and visiting in a potentially dangerous environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents hazards and supervision, in that: On 01/10/2025 Resident #1 was transferred by CNA A using standing pivot transfer x 1 staff instead of a mechanical lift. During transfer Resident #1 was injured resulting in left tibia /fibula fracture. The non-compliance was identified as past non-compliance. The IJ began on 1/10/25 and ended on 1/13/25. The facility had corrected the non-compliance before the survey began. This failure could lead to injury or death to residents.

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for nursing services. The facility did not have RN coverage for 24 days on 10/5/24, 10/12/24, 10/13/24, 10/20/24, 10/26/24, 10/27/24, 11/16/24, 11/17/24, 11/23/24, 11/24/24, 11/30/24, 12/1/24, 12/7/24, 12/8/24, 12/14/24, 12/15/24, 12/21/24, 12/22/24, 12/28/24, 12/29/24, 1/4/25, 1/5/25, 1/18/25, and 1/19/25. This failure could place the residents at risk of not receiving needed care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had the right to receive reasonable accommodation of resident needs and preferences that would not endanger the health or safety of the residents for 1 of 6 residents (Resident #5) reviewed for reasonable accommodations of needs and preferences, in that: The facility failed to ensure Resident #5's call light was within reach. This failure could place the residents at risk of failing to achieve or failing to maintain independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident # 2) reviewed for privacy. The facility failed to ensure Medication aide B locked the computer, which exposed Resident #2's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #5) reviewed for comprehensive care plans, in that: Resident #5's call light was not within reach according to one of the resident's care plan interventions for falls. This failure could place the resident at risk of inadequate care that may cause severe injury for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #3) reviewed for gastrostomy tube management., in that: 1. LVN A failed to check the placement of Resident #3's PEG tube prior to administering flushes and medications. 2. LVN A failed to check Resident #3's gastric residual volume prior to administering flushes and medications via Resident #3's PEG tube. 3. LVN A failed to follow Resident #3's order for flushes when administering flushes and medication via Resident #3's PEG tube. 4. LVN A failed to administer medications and flushes via Resident #3's PEG tube using gravity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal and medical records for 1 of 1 facility reviewed for privacy and confidentiality, in that: The confidential information of various residents was left in 3 clear plastic trash bags outside of the Medical Records office, and was left on top of a printer in area accessible to all staff, residents, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals, in accordance with State and Federal laws, were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 residents (Resident #5) reviewed for storage of drugs, in that: The facility failed to ensure Resident #5's medications were secured when LVN C left Resident #5's room prior to administering medications. This failure could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent elopements for 2 of 5 residents (Residents #1 and #2) reviewed for accidents and supervision, in that: 1. The facility failed to provide adequate supervision to Resident #1. As a result, Resident #1, who had dementia, eloped from the facility on 5/7/2024 and was unaccounted for after approximately 5:45 pm. Resident #1 was discovered to be walking approximately 4 blocks from the facility near a busy street at approximately 6:10 PM. The weather for that day at around that time was in the upper 80s F and Resident #1 was purported to say she was thirsty and lost and was seen to be visibly perspiring. 2. The facility failed to provide adequate supervision to Resident #2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #s 1 and 2) of 5 residents reviewed for abuse, neglect, and misappropriation of property, in that; 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' records were complete and accurate for 3 of 32 residents (Resident #5, #73, and #82) reviewed for clinical records, in that: 1. Resident #5's clinical record included a progress note which was inaccurate and appeared to have been written about a different resident. 2. Resident #73's diagnosis of Bipolar Disorder was not included on her face sheet. 3. Resident #82's colostomy care was completed by the resident not nursing staff, but nurses were signing off on the TAR as if they were completing care. These deficient practices could result in inadequate care due to incomplete and inaccurate medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure the recommendations from the PASARR level II determination and the PASARR evaluation report were included into a resident's assessment, care planning, and transitions of care for 1 (Resident #5) of 3 residents reviewed for PASARR services, in that: Resident #5 did not receive specialized PASRR services as agreed upon during his Interdisciplinary Team meeting. This failure could place residents with a positive PASRR evaluation at risk for the loss of opportunity to reach their highest level of functioning and could contribute to a decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident with a mental disorder was screened prior to admission for 1 of 3 of (#2) residents reviewed for PASRR: The facility did not correctly identify Resident #2 on the PASRR Level 1 Screening Form as having Mental Illness and did not submit a request to correct their PASRR negative screening. This failure could affect residents with mental illness that was not considered to be a Positive PASRR and could result in a decrease in services.

Inspectors wroteBased on interviews and record reviews, the facility failed to complete the baseline care plan for 1 of 32 residents (Resident #153) reviewed for baseline care plans in that: The facility failed to complete (Resident # 153's) baseline care plan within the required time frame. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Residents #82 and #92) reviewed for care plans, in that: 1. The facility failed to care plan Resident #82's self-care for colostomy. 2. The facility failed to ensure Resident #92's indwelling catheter was free of kinks; a dignity bag and anchor were used. These failures could have placed residents at risk of not having their needs met.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director, reviewed in that: The facility failed to ensure the AD was qualified to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 of 12 residents (Residents #82 and #7) reviewed for indwelling catheters and perineal/incontinent care, in that: 1. The facility failed to ensure Resident #82 indwelling catheter was attached to prevent pulling or tugging to the urethra. 2. The facility failed to ensure Resident #7's indwelling catheter was attached to prevent pulling or tugging to the urethra and failed to provide a dignity bag. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #6) reviewed for unnecessary medications, in that: 1. Resident #6 received Lorazepam 0.5 mg three times a day for general anxiety disorder. 2. Resident #6 received Buspirone 7.5 mg three times a day for general anxiety disorder This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labled and stored in loccked compartments in 1 medication cart of 6 medication carts (Nurse's Cart 400-hallway) and one crash cart of 2, reviewed for medication storage, in that: 1. The facility failed to ensure the Nurse's Cart 400 hallway was left unlocked and unattended in the hallway. 2. The facility failed to ensure the irrigation solution in the crash cart for the south building was not expired. These deficient practices could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. Dietary Aide A was not properly wearing a hair restraint. 2. A food item in the dry storage area was not properly dated and labeled. 3. A kitchen drawer had a drawer cover and a drawer surface area that were not cleaned. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, and improper sanitation in the kitchen area.

Inspectors wroteBased on record review and interviews, the facility failed to maintain spaces of at least 80 square feet per resident for 14 of 15 Resident rooms (Resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, 408, and 409) inspected for resident room sufficient space for privacy and comfort, in that: The facility failed to ensure resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, 408, and 409 were maintained with at least 80 square feet of space per resident. This failure could place residents at risk of restricting their resident rights for comfort and privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, for 1 of 6 halls (400 hall) reviewed for physical environment, in that: The facility failed to secure loose flooring on the 400 hall. This failure could place residents who reside in the facility at-risk of falls and further injuries due to an unsafe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, in that: The janitorial closet on 600 hall was unlocked and accessible to residents. This deficient practice could place residents at risk of coming into contact with harmful substances. Observation on 12/07/2023 at 5:45 a.m. revealed the janitorial closet on 600 hall was unlocked and accessible to residents; stored within were a gallon container of bleach and four varied containers of cleaning fluids, each labeled with caution, keep out of reach of children and harmful if swallowed. During an interview with ADON A on 12/07/2023 at 5:45 a.m., ADON A verbally confirmed the janitorial closet on 600 hall was unlocked, accessible to residents, and stored within were hazardous materials. [...]