Harmony Care At Beaumont

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview on 09/23/25 at 8:40 a.m. in the bathroom for room [ROOM NUMBER] with the Administrator and

the Maintenance Director, they acknowledged the caulk and floor around the toilet were stained brown and black. There were numerous missing, cracked and falling tiles from the bathroom walls. The vanity counter was not properly centered and did not cover the particle board vanity. There were dead roaches under the vanity sink. The Maintenance Director said whoever set the vanity top did not set it up correctly and it would have to be taken off and replaced in the correct position. He said the tiles required replacement and/or repair. He said he was not made aware of the required repairs. The Administrator said she was not aware of

the condition of the bathroom. During an observation and interview on 09/23/25 at 8:45 a.m. in the bathroom for room [ROOM NUMBER], with the Administrator and the Maintenance Director, they both acknowledged the bathroom vanity was missing two of two doors. There were dead cockroaches on the floor next to the toilet and under the vanity sink. He said he was not aware of the missing vanity doors. He said staff should place maintenance requests on a log at the nurse station. The Maintenance Director said

he would look at each room at least once every other week for repairs needed. He said he was not aware of

the observed needed repairs. He said there were no requests filed out for repairs. He stated it could affect

the residents' quality of life, and it could irritate them if repairs were not completed. He stated he tried to get

on maintenance issues as quickly as he could. The Administrator said it was her expectation the facility would be clean and in good repair. During an interview on 09/23/25 at 10:00 a.m. CNA W said housekeeping cleaned resident rooms and bathrooms daily. She said she was not aware of dead bugs or dead cock roaches. She said all needed repairs would be written on a log at the nurse station. During an

interview on 09/25/25 at 11:00 a.m., CNA V said housekeeping cleaned resident rooms and bathrooms daily. She said she was not aware of the dead bugs or dead cock roaches. She said all needed repairs would be written on a log at the nurse station.During an interview on 09/25 25 at 3:29 p.m., the Housekeeping Supervisor said the bathrooms, or the vanities were as thoroughly cleaned as they should have been. She said she trained the housekeepers, and they were aware they were supposed to clean the bathroom thoroughly. She said she had been off and had not followed the housekeeping staff to ensure

they had completed the cleaning as required. She said she did not have a cleaning list or check off list for

the staff to follow to ensure cleaning was completed. She said all required repairs should be reported to the Maintenance Director and documented on the maintenance request log located at the nursing station.Record review of the facility's policy Homelike Environment dated 2001 indicated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; .Record review of the facility's Maintenance Service policy dated 2001 Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards. The maintenance director is responsible for maintaining the following records/ reports. a.

Inspection of building; b. Work order requests; .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmony Care at Beaumont

2660 Brickyard Rd Beaumont, TX 77703

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

diagnoses which included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), aphasia (disorder that affects language after a stroke), dysphagia (difficulty swallowing after a stroke), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).

Record review of Resident #1's quarterly MDS Assessment, dated 8/08/2025, indicated she was sometimes able to make herself understood and usually understood others. She had severe cognitive impairment, identified with a BIMS score of 3. She had an active diagnosis of psychotic disorder and depression in the last 7 days. She had no behaviors identified within the 7 days look back period.

Record review of Resident #1's care plan revision dated 11/11/2024 indicated Resident #1 had physical aggression. Interventions included to Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychogeriatric as indicated.

Record review of Resident #1's care plan dated 7/12/2025 indicated Resident #1 had impulse control.

Interventions included assessing coping skills and support system, analyzing key times, places, circumstances, triggers, and what de-escalates, and assessing and anticipating resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.

Record review of Resident #1's care plan revision dated 8/13/2025 indicated Resident #1 had physical aggression. Interventions included to place on 1:1 monitoring for 2 hours and separate from another resident, intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychog

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmony Care at Beaumont

2660 Brickyard Rd Beaumont, TX 77703

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Reimbursement regarding reporting alleged abuse allegations to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then staff would report to her), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator to do so. She said if abuse was reported to her in the absence of the abuse coordinator that

she would report the alleged allegation to HHSC within 2 hours of the alleged incident. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an Interview on 09/25/2025 at 5:10 p.m., the Administrator said he was in-serviced one-on-one with the corporate nurse, VP of operations, and VP of Clinical Reimbursement regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to begin investigating alleged allegations immediately and if he was not available, she was to delegate investigation responsibilities to the DON and/or management staff.

She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. The Administrator said 95% of the active employees had been in-serviced and

the remaining employees would be in-serviced before the start of their next shift. The Administrator said all new hires would receive training on abuse, neglect, and timely reporting prior to providing any resident care. The Administrator was informed that the Immediate Jeopardy was removed on 09/25/2025 at 5:33 p.m. The facility remained out of compliance at a severity level of potential for more than minimal harm, that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmony Care at Beaumont

2660 Brickyard Rd Beaumont, TX 77703

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

initiated and completed by the next business day following identification of behaviors. … Social services and Nursing Department are responsible for updating acute or new care plans identified between quarterly Care Plan Review …”

An Immediate Jeopardy (IJ) was identified on 09/24/2025 at 9:45 a.m. The IJ template was provided to the facility on [DATE REDACTED] at 11:00 a.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.

The following Plan of Removal (POR) submitted by the facility was accepted on 9/25/25 at 10:45 a.m.: Resident-Specific Interventions - 09/24/2025 - Completed by VP of Clinical Reimbursement Resident #1's care plan was updated 09/24/25 psych NP discontinued Buspirone 5 mg with new order for Buspirone 20 mg every evening.

Resident #2, #3 and #5 care plans updated 09/24/2025 regarding receiving abuse

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harmony Care at Beaumont

2660 Brickyard Rd Beaumont, TX 77703

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

reflected CNA CCD's signature was on the in-service, but CNA CCC's was not. The summary stated in part . It is imperative that you wash your hands in between dirty and clean hands. Review of the facility policy dated September 2022 and titled Standard Precautions reflected, . 1. Hand hygiene is performed with ABHR or soap and water.before and after contact with the resident.before moving from work on a soiled body site to a clean body site on the same resident.after removing gloves.2. Gloves.After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments.

Event ID:

Facility ID:

If continuation sheet