Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harmony Care At Brookshire during CMS and state inspections, most recent first.
Two residents with cognitive impairment and dysphagia were assisted with meals by an LVN and a CNA who stood over them while feeding, contrary to facility policy requiring staff to sit at eye level to preserve dignity and assess swallowing. One resident, fully dependent for eating and on a mechanical soft diet, was fed by an LVN standing at her side. Another resident on a pureed diet, care planned as independent with eating but needing setup help, was intermittently fed by a CNA who stood beside him, even though the resident demonstrated ability to self-feed part of his meal. Multiple staff, including the ADON and DON, acknowledged that staff are expected to sit when feeding residents, and a resident reported feeling bad when staff stood while feeding him.
The facility operated without a licensed administrator for an extended period, with administrative duties informally reassigned to the DON and department heads, none of whom were licensed administrators. Staff and residents were unaware of a designated acting administrator, and required documentation was not provided, resulting in a failure to meet regulatory requirements for facility administration.
The facility did not provide required training to staff on abuse, neglect, and exploitation reporting procedures, nor did it update or communicate the identity of the current Abuse Coordinator after the previous coordinator was terminated. Six direct care staff members could not identify the Abuse Coordinator or describe the reporting process, and the facility could not produce documentation of recent training.
A resident with severe cognitive and physical impairments was not relocated during active sheetrock repairs in her room, resulting in her exposure to construction debris and dust. Only her roommate was moved, and staff cited limited space and challenges with memory care residents as reasons for not relocating both individuals. The room remained unclean during the repairs, contrary to facility policy requiring a clean and homelike environment.
The facility did not maintain an effective pest control program, as evidenced by the presence of live gnats in two hallways and the conference room. Observations confirmed multiple instances of gnats in these areas, and the pest control log for the past 90 days was not provided. Staff interviews revealed uncertainty about the pest control schedule and lack of communication regarding the pest issue. Documentation of pest control services was unclear about dates and locations treated.
A resident with multiple health conditions was administered 100 mg of Midodrine instead of the prescribed 10 mg due to a transcription error in the medication order. The error was not caught by the staff, leading to a significant increase in the resident's blood pressure and hospitalization for a drug overdose. The facility's failure to verify medication orders against the MAR and blister pack contributed to the incident.
A resident with severe cognitive impairment and osteoarthritis experienced unmanaged pain during incontinent care. Despite showing signs of pain, the CNA did not stop care or notify the LVN promptly. The resident's care plan required total assistance, and although there were physician orders for pain management, no pain assessments or medication administration were documented. The facility's pain assessment policy was not adhered to, resulting in unmanaged pain for the resident.
The facility failed to maintain a safe and homelike environment, with observations of disrepair such as discolored ceiling tiles, missing tiles, exposed sheetrock, and damaged handrails across multiple halls. Staff interviews revealed a lack of awareness and communication regarding these issues, with the Facility Maintenance Director and other staff unaware of the extent of the problems. Residents reported that some issues had been ongoing for a significant time, and the lack of maintenance logs contributed to the facility's failure.
The facility's kitchen failed to meet food safety standards, with uncovered and undated food items, unsanitary conditions, and lack of regular cleaning. Observations revealed discolored ceiling vents, stained ice machines, and a deep fryer with food particles. The Dietary Manager confirmed the absence of a deep cleaning since May 2024, and no cleaning schedule was provided.
The facility failed to submit complete and accurate direct care staffing information to CMS for the 4th quarter of FY 2024, lacking 24-hour licensed nursing/staff coverage. The Administrator and BOM were unsure of the submission process, and the corporate office failed to submit the PBJ for two quarters, leading to the termination of the responsible company. The facility also lacked a policy for PBJ submissions.
The facility failed to manage medications properly, with expired and discharged residents' medications found in multiple medication carts. Staff interviews confirmed that these medications should have been removed to prevent errors and potential theft.
The facility failed to properly label and store medications in two medication carts, with issues such as opened and undated medications, handwritten labels, and insulin pens not in original packaging. Additionally, a medication cart was left unlocked and unattended, compromising security. Interviews with staff confirmed these practices were against facility policy.
The facility failed to maintain privacy and confidentiality for two residents. An LVN left a computer screen unlocked, displaying a resident's medication information, while administering care. Additionally, a CNA did not provide privacy during incontinent care for another resident, leaving the door open and privacy curtain unpulled. Both incidents were acknowledged by staff and recognized as violations of resident rights.
A resident's MDS and care plan inaccurately indicated she was on anticoagulant and antiplatelet therapy, despite no physician orders for such medications. The resident, with severe cognitive impairment, was not receiving these medications at the time of assessment. Interviews with staff revealed the medication had been discontinued prior to the MDS assessment, highlighting a documentation error.
The facility failed to develop comprehensive care plans for two residents, one receiving hospice care and another residing in a memory care unit. The care plans lacked necessary components, such as hospice services and memory care unit residence, potentially affecting the residents' care. Interviews with staff revealed gaps in the interdisciplinary team's care plan development process.
Two residents in an LTC facility did not receive necessary personal grooming services, specifically shaving, due to staff's inconsistent understanding and execution of the facility's policy. One resident with severe cognitive impairment and another with moderate impairment and blindness were observed with facial hair, despite expressing a desire to be shaved. The lack of proper documentation and communication among staff contributed to this deficiency.
A resident with severe cognitive impairment and frequent incontinence did not receive proper incontinent care from a CNA, who failed to clean the resident's groin, buttocks, or open labia. The CNA placed a new brief without changing gloves, leaving residual stool, which could increase infection risk. The CNA cited the resident's pain as a factor, and the facility's policy lacked specific guidance on cleaning the labia and groin area.
A resident with a gastrostomy tube was at risk due to RN C's attempt to administer crushed potassium chloride ER, despite knowing it should not be crushed. The resident, with a history of heart failure and hypokalemia, was prescribed the medication to be given via PEG-Tube. The DON confirmed that crushing the medication could lead to inadequate dosage. The facility's policy prohibits crushing extended-release tablets, yet RN C did not adhere to this guideline.
A CNA failed to follow proper hand hygiene protocols during incontinent care for a resident with severe cognitive impairment and multiple medical conditions. The CNA did not wash hands before donning gloves, used the same gloves throughout the procedure, and did not adequately clean the resident, contrary to the facility's infection control policy.
A facility failed to regularly inspect and maintain bed frames and mattresses, resulting in a resident experiencing a fall due to significant gaps between the mattress and bed frame. The resident, with multiple health conditions and requiring assistance for bed mobility, reported a fall that led to a skin tear and a swollen finger. Observations confirmed the mattress did not fit well, posing a risk of injury.
The facility failed to maintain a safe and sanitary environment, with issues such as dirty floors, unsanitary bathrooms, and broken fixtures observed on multiple halls. Staff interviews revealed that short staffing contributed to delays in addressing these problems, and the new housekeeping supervisor was working to organize cleaning efforts. The facility's policy emphasizes a homelike environment, but these standards were not met, particularly in the secured unit.
A resident with mobility issues was transported to dialysis in a personal vehicle due to a facility van issue, requiring her to use a walker instead of her wheelchair. After dialysis, she was left to wheel herself back to her room without assistance, contrary to her care plan. Facility staff were unaware of the transportation arrangements, and the driver did not ensure the resident's safety at the dialysis center.
Two residents in an LTC facility did not receive scheduled showers due to staffing shortages and inadequate documentation. A resident with Parkinson's and dementia had not been showered since early May, while another with severe cognitive impairment missed a scheduled shower. Staff interviews revealed issues with communication and documentation, contributing to the deficiency.
A resident requiring feeding assistance was consistently served cold meals due to staff delays, despite her preference for hot food. Interviews revealed that there was often only one aide available to feed multiple residents, leading to food cooling before it could be served. The ADON acknowledged the issue, agreeing that meals should be warmed if necessary, aligning with the facility's policy on treating residents with dignity.
Failure to Maintain Dignity and Proper Positioning During Assisted Feeding
Penalty
Summary
The deficiency involves staff failing to treat residents with respect and dignity and to provide meal assistance in a manner that promotes quality of life, as required by facility policy and resident rights. Surveyors observed that a licensed vocational nurse (LVN B) stood while feeding lunch to Resident #1 in the dining room, rather than sitting at eye level. Resident #1, an elderly female with dementia, dysphagia following cerebrovascular disease, epilepsy, Parkinson’s disease, and depression, had a severely impaired BIMS score of 5 and was dependent on staff for eating. Her care plan identified risk for malnutrition related to a mechanically altered diet and need for assistance with eating, with interventions to monitor for signs and symptoms of dysphagia. Despite this, LVN B stood at the resident’s left side while feeding a mechanical soft diet. Surveyors also observed that CNA A stood while assisting Resident #2 with his lunch. Resident #2, an elderly male with cerebral infarction, GERD without esophagitis, epigastric pain, lack of coordination, and dysphagia, had a BIMS score of 8 indicating moderately impaired cognition. His MDS showed he required setup or clean-up assistance with eating, and his care plan noted an ADL self-care performance deficit related to fatigue and impaired balance, with an intervention stating he was independent with eating. His physician orders included a regular diet with pureed texture and thin liquids. During the meal observation, CNA A initially set up the food and then began feeding Resident #2 while standing at his right side, left the resident briefly during which the resident fed himself ice cream, and then resumed feeding while still standing until instructed by another CNA (CNA C) to sit. Interviews confirmed that the observed feeding practices were inconsistent with facility expectations and policies. CNA C stated she was taught in CNA school to never stand while feeding a resident but to sit at eye level to avoid making the resident feel threatened and to respect the resident. LVN B acknowledged that staff should not stand while feeding residents and admitted he knew he should sit, later recognizing that being fed by someone standing would feel disrespectful. CNA A reported he had been instructed to sit and make eye contact when feeding residents but chose to stand because he saw LVN B standing and did not want LVN B to “look bad.” The ADON and DON both stated staff were supposed to sit at eye level when assisting with feeding to assess swallowing and preserve dignity and respect. Resident #2 reported he did not like when staff stood while feeding him, stating it made him feel bad. Facility policies on Assistance with Meals and Resident Rights specified that residents should be assisted with meals in a manner that meets individual needs, with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals, and that employees must treat all residents with kindness, respect, and dignity.
Failure to Maintain Licensed Administrator and Effective Facility Administration
Penalty
Summary
The facility failed to ensure effective administration to maintain the highest practicable well-being of each resident by operating without a licensed administrator from 08/20/2025 to 09/13/2025. The former administrator was terminated on 08/19/2025, and there was no record of a licensed interim or permanent replacement during the subsequent period. Interviews with the nurse supervisor, DON, and VP of Operations confirmed that no state-licensed nursing home administrator was present on staff, and administrative duties were informally reassigned among department heads, none of whom were licensed administrators. The VP of Operations, who holds a state administrator license, was not physically present at the facility and communicated with department heads remotely. Staff interviews indicated a lack of awareness of a designated acting administrator, and administrative responsibilities were primarily handled by the DON. Residents interviewed during the survey reported not knowing who the administrator was since the previous administrator's departure, though they expressed no immediate safety concerns and stated they would report issues to the DON. The facility was unable to provide documentation of a designated acting administrator or a signed administrator job description when requested. The facility's policy requires a licensed administrator to be responsible for day-to-day operations, including ensuring adequate staffing and compliance with laws and regulations, but this requirement was not met during the period in question.
Failure to Train Staff on Abuse Reporting Procedures and Update Abuse Coordinator Information
Penalty
Summary
The facility failed to ensure that all staff were trained in the procedures for reporting abuse, neglect, exploitation, or misappropriation of resident property. Six out of six employees reviewed had not received training on the identity of the Abuse Coordinator or the procedures for reporting abuse. Observations during the onsite visit revealed that the facility had not updated the signage and posting of the facility's Abuse Coordinator, which still reflected the contact information of a former employee who was terminated nearly a month prior. Interviews with the Director of Nursing and the VP of Operations confirmed that the facility had not provided updated training or information to staff regarding the new Abuse Coordinator or the reporting process. During staff interviews, all six direct care staff members were unable to identify the current Abuse Coordinator and reported not having received recent or updated in-service training on abuse reporting protocols. The facility was unable to provide documentation or sign-in sheets showing that such training had been conducted within the last 30 days, despite multiple requests. This lack of training and updated information on abuse reporting procedures was directly observed and confirmed through interviews and record review.
Failure to Maintain Safe and Homelike Environment During Room Repairs
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for a resident with severe cognitive impairment and significant physical limitations. Maintenance staff conducted sheetrock repairs, including sanding drywall, in the resident's room while she remained present in close proximity to the work area. Observations revealed large pieces of debris and dust on the floor and windowsill near the resident, and the room was not cleaned during or after the repairs. The resident, who required supervision or assistance for transfers and did not use mobility devices, was exposed to the ongoing construction environment. Interviews with facility staff indicated that only the roommate closest to the repairs was relocated, while the resident remained in the room due to limited space and challenges associated with memory care residents wandering. The ADON and Maintenance Director both acknowledged that efforts were made to keep residents out of their rooms during repairs, but these were not always successful. The facility's policy required a clean, sanitary, and orderly environment, but this was not maintained during the repair work in the resident's room.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live gnats in two of five hallways (Hall 100 and Hall 400) and the conference room. Observations on multiple occasions revealed approximately 10 gnats in the conference room, 12 gnats near the dining area in Hall 100, and 5 gnats in Hall 400. The pest control log for the last 90 days was requested but not provided. The pest control service documentation was unclear regarding the date of service and the specific locations treated. Interviews with facility staff revealed a lack of awareness and communication regarding the gnat issue. The ADON acknowledged a recent problem with gnats and stated that staff had been educated to pick up food trays promptly, but was unsure of the pest control schedule. The Maintenance Director reported that pest control visits occurred monthly or as needed but was not aware of any gnat issues due to lack of notification. The Administrator confirmed the last pest control visit but was not aware of any current complaints or additional follow-up. The facility's pest control policy states an ongoing program is maintained to keep the building free of insects and rodents.
Medication Administration Error Leads to Resident Overdose
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications, leading to a significant medication error involving a resident. The resident, who had a history of dementia, diabetes, hypotension, psychosis, lack of coordination, and hypertensive heart disease with heart failure, was prescribed Midodrine to manage hypotension. However, on a specific date, the resident was administered 100 mg of Midodrine instead of the prescribed 10 mg, resulting in a severe increase in blood pressure and necessitating hospitalization for a drug overdose. The error occurred due to a transcription mistake where the order was incorrectly entered as 10 tablets instead of 10 mg. This mistake was not caught by the staff responsible for administering the medication, leading to the resident receiving an overdose. Interviews with various staff members, including the Medical Director, nurses, and medication aides, revealed that the error was identified after the medication was administered, and the resident's blood pressure had significantly increased. The staff failed to verify the medication order against the medication administration record (MAR) and the blister pack, which contributed to the error. The facility's pharmacy consultant and nursing staff did not adequately review and verify the medication orders, which allowed the error to go unnoticed until after the medication was administered. The facility's policies and procedures for medication administration and verification were not effectively followed, leading to the resident's adverse reaction and subsequent hospitalization. The incident highlights a breakdown in communication and verification processes within the facility's pharmaceutical services.
Failure to Provide Adequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #29, who required such services. During an observation, CNA A was seen performing incontinent care on Resident #29, who was grimacing, moaning, and verbally expressing pain. Despite these clear signs of discomfort, CNA A did not stop the care process to address the resident's pain. Furthermore, CNA A did not notify LVN B about the resident's pain in a timely manner after the morning care, which could have led to further assessment and intervention. Resident #29, a female with severe cognitive impairment and a history of osteoarthritis, was admitted to the facility with a need for assistance with personal care and pain management. The resident's care plan indicated a requirement for total assistance with activities of daily living, including incontinent care. Despite having physician orders for pain management medications, there was no documentation of pain assessment or administration of pain relief in the resident's records for November and December 2024. Additionally, a nurse's note indicated the resident had a deep venous thrombosis, which could contribute to her pain, yet the facility's pain assessment policy was not followed, leading to unmanaged pain for the resident.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by numerous observations of disrepair and uncleanliness across multiple halls. Observations revealed discoloration on ceiling tiles, missing floor and wall tiles, exposed sheetrock, chipped wall paint, damaged exit door handles, and damaged handrails. These issues were noted in various rooms and common areas, including the 100-hall, 400-hall, and 500-hall, as well as the main dining room and corridors. Interviews with staff and residents highlighted a lack of awareness and communication regarding the maintenance issues. The Facility Maintenance Director (FMD), who began employment in November 2024, stated that he was not informed about the missing tiles, loose faucets, peeling paint, and other issues. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) also expressed unawareness of these problems. The Housekeeping Supervisor (HS) mentioned that her team was responsible for identifying and reporting damages, but she was not aware of any specific issues in the resident rooms or facility areas. Residents and staff reported that the disrepair had been ongoing for some time, with one resident stating that the brown watermark discoloration on ceiling tiles had been present since their arrival. The FMD attributed the discoloration to a past water leak, but he was unsure of when it occurred. The lack of maintenance logs and a clear communication process for reporting and addressing maintenance issues contributed to the facility's failure to provide a safe and homelike environment for its residents.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, leading to potential risks of foodborne illness for residents. Observations revealed that food items, such as gelatin with fruit and pureed carrots, were stored in the refrigerator uncovered and undated, contrary to the facility's policy of discarding food after 72 hours. The Dietary Manager acknowledged that these items were not properly labeled or covered, which could lead to bacterial contamination. The kitchen environment was found to be unsanitary, with discolored and debris-covered ceiling vents, discolored shelves in refrigerators, and missing tiles on walls. The ice machine had stains and rust, with a consistent water puddle observed in front of it. The deep fryer was caked with stains and contained food particles in the grease. The Dietary Manager confirmed that the kitchen had not undergone a deep cleaning since her employment began in May 2024, and there was no cleaning schedule provided. Interviews with the Dietary Manager and observations highlighted the lack of regular maintenance and cleaning in the kitchen. The Dietary Manager admitted that the kitchen had not been deep cleaned and that the ice machine and deep fryer were not maintained according to the facility's cleaning policy. The Administrator and DON were shown pictures of the unsanitary conditions, and the Administrator acknowledged the need for addressing these concerns. However, no cleaning schedule was provided, and the facility's policy on food storage and equipment sanitization was not followed.
Failure to Submit Accurate Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the 4th quarter of the fiscal year 2024. This deficiency was identified through interviews and record reviews, revealing that the facility did not have licensed nursing/staff coverage 24 hours a day as required. The Administrator was unaware of who was responsible for the submission, and the Business Office Manager (BOM) was uncertain about the actions taken by the corporate office with the staffing data she provided. The BOM also lacked documentation for the Payroll-Based Journal (PBJ), which is necessary for compliance. Further investigation revealed that the corporate office had not submitted the PBJ for approximately two quarters, and the company responsible for this task was subsequently terminated. The Administrator expressed his expectation that the corporate office should have fulfilled their responsibilities. Additionally, the facility did not have a policy in place for PBJ submissions, as confirmed by the Administrator when requested for documentation.
Medication Management Deficiencies in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were accurately acquired, received, dispensed, and administered according to professional standards. This deficiency was observed in three medication carts across different halls. Specifically, the 100 and 200 hall MA medication cart C contained medications belonging to discharged residents, which should have been removed to prevent medication errors. During interviews, staff acknowledged that these medications should have been pulled from the cart and given to the DON for proper disposition. The 500 hall nurse medication cart A was found to contain expired medications, as well as medications belonging to discharged and discontinued residents. An observation revealed that Breo Ellipta had expired, and control medications such as Acetaminophen-Codeine and Tramadol were still in the cart despite being discontinued or belonging to discharged residents. Staff interviews confirmed that these medications should have been removed to prevent errors and potential theft. Similarly, the 400 hall nurse medication cart B contained expired medications, including Albuterol Sulfate and Lantus insulin pen, which were past their effective dates. Discontinued and discharged residents' medications, such as fluticasone propionate and salmeterol inhalation powder, were also found in the cart. Staff interviews highlighted the importance of removing these medications to prevent ineffective treatment and potential adverse reactions.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed in two of the six medication carts. Specifically, the 500-hall nurse medication cart contained opened and undated medications, such as Levetiracetam and insulin pens not stored in their original packaging. The 400-hall nurse medication cart also had similar issues, with opened and undated medications, handwritten resident names on medication containers, and insulin pens not stored in their original packets. Interviews with the Assistant Director of Nursing (ADON) and Registered Nurse (RN) confirmed that medications should be stored in their original packaging to ensure proper administration instructions and expiration dates are followed. Additionally, the facility failed to secure all drugs and biologicals in locked compartments, as evidenced by an incident involving the 400-hall nurse medication cart. A Licensed Vocational Nurse (LVN) left the medication cart unlocked and unattended while attending to a resident and clarifying a medication order. This lapse in security was acknowledged by the LVN, who admitted forgetting to lock the cart, and by the Director of Nursing (DON), who stated that leaving the cart unlocked was not part of the facility's practice. The facility's policies on medication management and pharmacy services were reviewed, revealing that the facility had established systems to meet regulatory requirements. However, the observed deficiencies indicate a failure to adhere to these policies, as medications were not properly labeled, stored, or secured, potentially compromising resident safety and medication efficacy.
Privacy and Confidentiality Breaches in Resident Care
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information, as evidenced by two separate incidents involving two residents. In the first incident, a Licensed Vocational Nurse (LVN) left a computer screen unlocked and visible while administering care to a resident, displaying the resident's name and medication information. This oversight was acknowledged by the LVN, who admitted forgetting to lock the computer screen, and was confirmed by the facility's Administrator and Director of Nursing (DON), who recognized it as a violation of HIPAA regulations. In the second incident, a Certified Nursing Assistant (CNA) failed to provide privacy for a resident during incontinent care by not closing the entrance door or pulling the privacy curtain. The resident's roommate, who was disoriented but awake, was present in the room during the care. The CNA admitted to forgetting to provide privacy due to nervousness. The DON emphasized the importance of treating all residents with dignity and respect, as outlined in the facility's nursing policy on resident rights.
Inaccurate Medication Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess the status of a resident, identified as Resident #7, regarding her medication regimen. The resident's Minimum Data Set (MDS) and care plan inaccurately indicated that she was on anticoagulant and antiplatelet therapy, despite there being no physician orders for such medications. This discrepancy was discovered during a review of the resident's records, which included her admission record, MDS assessment, and care plan. The resident, a female with severe cognitive impairment and requiring substantial assistance with activities of daily living, was not receiving anticoagulant or antiplatelet medications at the time of the assessment. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the medication had been discontinued prior to the MDS assessment. The DON acknowledged the error and noted that the care plan and MDS would need to be corrected. The inaccurate documentation could lead to staff being unaware of the resident's actual care needs, potentially impacting the quality of care provided.
Deficiency in Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #22, a male with chronic obstructive pulmonary disease and receiving hospice care, did not have hospice services addressed in his care plan. Despite having a hospice care consult order, the care plan only included directives related to his Do Not Resuscitate status, lacking any mention of hospice care. Resident #65, a male with severe cognitive impairment and residing in the memory care unit, also lacked a comprehensive care plan addressing his living situation. His care plan included interventions for depression and elopement risk but did not mention his residence in the memory care unit. The absence of this information could lead to staff being unaware of the risks associated with his care and behaviors, such as wandering and elopement. Interviews with facility staff, including the Director of Nursing and the Social Worker, revealed that the interdisciplinary team was responsible for developing these care plans. However, the necessary components were not included, potentially affecting the residents' care. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timeframes, which were not adequately addressed in these cases.
Failure to Provide Necessary Personal Grooming Services
Penalty
Summary
The facility failed to provide necessary personal grooming services, specifically shaving, to two residents who were unable to perform activities of daily living (ADLs) independently. Resident #55, a female with severe cognitive impairment due to dementia and other health issues, was observed with facial hair and reported that she had not been shaved since her admission to the facility. Despite her request to be shaved, the staff did not fulfill this need, and there was a lack of clarity among the staff regarding who was responsible for shaving female residents. Interviews with various staff members, including LVNs, RNs, and CNAs, revealed inconsistencies in understanding and executing the shaving protocol, with some staff unaware of the resident's needs or the facility's policy. Resident #28, who has moderately impaired cognition and is blind in one eye, also experienced a lack of personal grooming. She was observed with facial hair and expressed feeling unkempt because she could not shave herself. The staff failed to offer shaving services consistently, and there was no documentation of her refusal to be shaved. Interviews with CNAs and LVNs indicated a lack of communication and documentation regarding the resident's preferences and needs, leading to her not receiving the necessary grooming services. The facility's failure to ensure these residents received appropriate personal grooming services could lead to discomfort and dignity issues. The staff's inconsistent understanding and execution of the facility's shaving policy contributed to this deficiency, as did the lack of proper documentation and communication regarding the residents' grooming needs and preferences.
Inadequate Incontinent Care Provided to Resident
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident who was incontinent of bladder and bowel. During an observation, CNA A did not clean the resident's groin, buttocks, or open labia while providing care. The CNA used a cleaning cloth wipe after the resident had a bowel movement and placed a new brief under the resident's buttock without changing gloves, despite the presence of residual stool. This improper care practice could place residents at risk for infection. The resident involved was a female with severe cognitive impairment, requiring substantial assistance with personal hygiene and frequent incontinent care. The CNA, who had recently started working at the facility, acknowledged the failure to clean the resident properly, citing the resident's pain as a factor. The facility's policy on perineal care did not specifically address cleaning the labia and groin area, and the CNA's personnel file indicated a skill check for incontinent care had been completed shortly after hire.
Failure to Administer Medication Correctly
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the actions of RN C, who attempted to administer crushed potassium chloride extended-release (ER) to a resident with a gastrostomy tube. The resident, a male with a history of heart failure, hypokalemia, dementia, and a gastrostomy, was prescribed potassium chloride ER 20 MEQ tablet to be given via PEG-Tube once daily for low potassium. Despite knowing that potassium ER should not be crushed, RN C proceeded to crush the medication, believing it was the only way to administer it through the G tube. During an interview, the Director of Nursing (DON) confirmed that crushing potassium ER tablets would break down the extended-release mechanism, potentially leading to inadequate dosage and symptoms of hypokalemia. The facility's policy on medication administration explicitly states that extended-release tablets should not be crushed, and staff are instructed to seek assistance from a nursing supervisor or consulting pharmacist if there are any questions about medication administration. Despite these guidelines, RN C continued to crush the medication, indicating a lapse in adherence to the facility's medication administration policy.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during incontinent care for Resident #29. CNA A did not perform proper hand hygiene before donning gloves and throughout the procedure. The CNA used the same gloves for the entire process, which included handling soiled materials and touching clean items, without changing gloves or washing hands. This practice was observed during the care of Resident #29, who had a bowel movement and required assistance due to severe cognitive impairment and physical limitations. Resident #29, a female resident with a history of multiple medical conditions including severe cognitive impairment, was dependent on staff for personal hygiene and incontinent care. During the observed incident, CNA A did not adequately clean the resident's buttock area and failed to open the labia for proper cleaning. The CNA placed soiled items on the floor and reused them without changing gloves, which is against the facility's hand hygiene policy. The resident was in pain during the procedure, which may have contributed to the CNA's oversight. Interviews with the facility's staff, including the ADON and DON, revealed that there was an expectation for staff to perform hand hygiene before and after resident contact. However, CNA A, who was newly hired, did not adhere to these protocols. The facility's policy on hand hygiene emphasizes the importance of washing hands before and after direct contact with residents and after removing gloves, which was not followed in this instance.
Failure to Inspect and Maintain Bed Equipment Leads to Safety Hazard
Penalty
Summary
The facility failed to conduct regular inspections and maintenance of bed frames, mattresses, and bed rails, leading to potential entrapment hazards for a resident. Observations revealed significant gaps between the mattress and bed frame, specifically a 4-inch gap at the head and a 2-inch gap at the foot of the bed. This deficiency was identified during a review of the resident's safety, where it was noted that the mattress did not fit well on the bed frame, posing a risk of injury from equipment malfunction, entrapment, or falls. The resident involved was a male with multiple diagnoses, including bipolar disorder, type 2 diabetes, epilepsy, and a history of falls. The resident required substantial assistance for bed mobility and had a BIMS score indicating slight cognitive impairment. The resident reported falling out of bed three days prior to the observation, which resulted in a skin tear and a painful, swollen finger. Interviews with the DON and the Administrator revealed that the mattress shifted when the head of the bed was elevated, and there was an expectation for staff to report mismatched mattresses and bed frames to maintenance.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as observed on three of the five halls. Specifically, Hall 100 exhibited numerous issues, including dirty and stained floors, unkempt and unsanitary bathrooms with strong urine odors, and broken or missing fixtures such as window blinds, baseboards, and sheet racks. Additionally, there was an accumulation of spider webs and green residue on the windows, and the toilet bowls had brown and black stains. These conditions were confirmed through observations and interviews with staff, who acknowledged the need for cleaning and maintenance. On Hall 400, similar deficiencies were noted, including missing slats in vertical window blinds, broken sheet racks, and peeling paint. Interviews with housekeeping and maintenance staff revealed that the facility was short-staffed, which contributed to the delay in addressing these issues. The housekeeping supervisor, who was new to the facility, was in the process of organizing the cleaning schedule and addressing the backlog of maintenance tasks. The facility's policy on providing a homelike environment emphasizes cleanliness, pleasant scents, and the minimization of institutional characteristics. However, the observations and interviews indicate that these standards were not being met, particularly in the secured unit and other affected areas. The administrator acknowledged the environmental issues and attributed some delays in addressing them to a recent storm, which required immediate attention to storm-related problems.
Failure to Accommodate Resident's Transportation Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, specifically in relation to transportation to dialysis appointments. The resident, a seventy-year-old woman with end-stage renal disease and mobility issues, was taken to a dialysis appointment in a personal vehicle because the facility van was out of service. Her wheelchair could not be accommodated in the personal vehicle, and she was required to use a walker, which caused her anxiety due to her unsteadiness and fear of falling. Upon returning from dialysis, the resident, who was often tired after the procedure, was left to wheel herself back to her room without assistance. This was contrary to her care plan, which indicated she required supervision or assistance for mobility. The resident expressed concerns about the lack of assistance and the anxiety it caused her, as well as the fact that the driver did not ensure she was safely inside the dialysis center before leaving. Interviews with facility staff revealed a lack of communication and awareness regarding the transportation arrangements. The Director of Nursing was unaware of the use of a personal vehicle, and the Administrator did not see potential harm in the situation. The driver admitted to using her personal vehicle due to the van's condition and did not consistently assist the resident as required by her care plan. This lack of proper accommodation and assistance could negatively impact the resident's quality of life and safety.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary grooming and personal care services for two residents, leading to deficiencies in their care. Resident #1, a sixty-eight-year-old woman with multiple health conditions including Parkinson's disease and dementia, had not received a shower since May 11, 2024, despite being scheduled for showers three times a week. Her care plan indicated a need for substantial assistance with bathing due to her cognitive and mobility impairments. The lack of documentation and failure to adhere to the shower schedule were confirmed through interviews and record reviews, highlighting a gap in the facility's care practices. Resident #2, a sixty-four-year-old man with severe cognitive impairment and other health issues, did not receive his scheduled shower on May 28, 2024. His care plan also required partial assistance with bathing three times a week. Interviews with staff revealed that due to staffing shortages, Resident #2 missed his shower, and there was no documentation to indicate that the shower was rescheduled or completed. The staff's inability to provide the necessary care due to understaffing was a significant factor in this deficiency. The facility's documentation practices were inadequate, as evidenced by the lack of shower sheets and updates in the resident information database. Interviews with staff, including CNAs and the DON, revealed inconsistencies in communication and documentation, contributing to the failure to provide scheduled showers. The facility's policy on activities of daily living emphasized the importance of maintaining residents' hygiene, but the observed practices did not align with these standards, resulting in potential risks for the residents involved.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that Resident #4, who required total assistance during feedings, received food that accommodated her preferences. Resident #4, an eighty-one-year-old woman with diagnoses including hemiplegia, hemiparesis, dysphagia, and dementia, was served cold food during mealtimes. Her care plan indicated she required substantial assistance to eat and g-tube feeding. Interviews with residents revealed that there was often only one aide available to feed multiple residents, resulting in delays that caused the food to become cold. Resident #4 confirmed that while her food was delivered hot, it was often cold by the time she was fed, and she would only have it warmed up upon request. The issue was corroborated by another resident who observed that Resident #4's food had sat for up to 30 minutes before being served. The Assistant Director of Nursing (ADON) acknowledged that residents requiring feeding assistance were receiving cold food and agreed that staff should warm up meals if necessary. The facility's policy on Resident Rights emphasized treating residents with kindness, respect, and dignity, but no specific dietary policy was reviewed. This deficiency highlights a failure to meet resident preferences and ensure meals are served at an appetizing temperature.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 184 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brookshire
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paradigm At Katy | 7.2 mi | ★★★★★ | 4 | 0 |
| Heritage Park Of Katy Nursing And Rehabilitation | 7.5 mi | ★★★★★ | 0 | 0 |
| Sterling Oaks Rehabilitation | 9.2 mi | ★★★★★ | 13 | 0 |
| Ignite Medical Resort Katy, Llc | 9.5 mi | ★★★★★ | 4 | 0 |
| Falcon Point Post Acute | 10.1 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Harmony Care At Brookshire.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.