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Complaint Investigation

Harmony Care At Brookshire

February 14, 2025 · Brookshire, TX · 710 Hwy 359 S
Citations 2
CMS Rating 2/5
Beds 130
Provider ID 675700
Healthcare Facility
Harmony Care At Brookshire
Brookshire, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Harmony Care at Brookshire in Brookshire, TX — inspection on February 14, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0755
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the

consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in

jeopardy to resident health or communicate, address and resolve concerns and issues related to the provision of pharmaceutical safety services.

This includes, but not limited to:5 d) Assisting in the identification and evaluation of medication-related issues, including the prevention and reporting of medication errors and the

regiment of each resident at least monthly or [NAME] frequently under certain conditions, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review, and documenting the review findings in the resident's medical record or in a steadily retrievable format if utilizing electronic documentation, 6g) reviewing medication administration records (MARs), treatment administration records (TARs) and physician orders to ensure proper documentation of medications orders and administration of medications to residents.

Record review of the facility's Medication Regimen Review Verification (MRR) dated January 2025 revealed on 1/9/2025 the pharmacist consultant reviewed Resident # 1 MRR and documented Medication Regimen Review has been performed and any inappropriate findings were communicated to the Physician and Director of Nursing through the utilization of the Pharmaceutical Consultant Report.

The current prescription therapy is considered appropriate at this time and any indicators concerning the Interpretive Guidelines will be addressed when clinical conditions warrant such attention.

Record review of the facility's Nursing Policies and Procedures dated (revised 6/2019) revealed read in part The facility's nursing and pharmacy services will assess, monitor and evaluate the effectiveness of the therapeutic medication regimen including all drugs ( prescription and non-prescription) in order to enhance the resident's quality of life; 3) the authorized licensed or certified/permitted medication aide or by state regulatory or guidelines staff members follow the MAR prepared for the patient/resident/by identifying: a)right resident, b)right drug, c)right dose, d)right time, e) right route, f)right charting, g)right results and h) right reason, 4) The authorized licensed or certified /permitted medication aide or by state regulatory guidelines staff member identifies, that the following information, but not limited to, id documented on the MAR: a)correct physician's order, b)medication and label are correct, and c) label and physician's order are correct; 5) The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member reads the label on the medication three (3) times: a)before removing the medication from the drawer, b) before pouring the medication and c)after pouring the medication;6) The authorized licensed or certified/permitted [NAME][TRUNCATED]

Resident was administered 100mg of Midodrine instead of the verbally ordered amount of 10mg.

Resident assessed by LVN and sent to ER for evaluation. (returned 2/11/2025)

Family called

MD/NP notified.

Audit all Midodrine orders by DON 2/10/2025

Resident #1 medication clarified/fixed 2/10/2025 (ultimately discontinued upon hospital return)

Notify Medical Director 2/10/2025 11:03am brief QAPI discussion to establish plan (this)

New orders will be reviewed by DON/designee daily to ensure accurately transcribed and that the computerized order matches the medication card.

Results of these audits will be discussed in morning meeting and any discrepancies will be rectified immediately.

LVN disciplinary action and 1:1 education 2/10/2025 related to transcription and medication administration to ensure the computerized order matches the medication card.

MA disciplinary action and 1:1 education 2/10/2025 related to medication administration to ensure the computerized order matches the medication card.

MA removed from MA role as of 2/10/2025 until further education and training occurs and she successfully completes 3 competency checks by DON.

Facility MAs and nurses re-educated on medication administration started 2/10/2025 by the DON.

Education was completed on 2/11/2025 and staff not allowed to work without training completion.

The education consisted of right person, right time, right dosage, right route, right drug.

Also included matching computerized order to medication card.

Nurses and MAs were provided education and post-test for Midodrine administration specifically by the DON on 2/10/2025 and no one can return to work unless education has been completed.

675700

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 675700 B.

Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Brookshire, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Harmony Care at Brookshire or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.