Harmony Care at Brookshire

In the surveyor’s words

From the most serious findings on record at Harmony Care at Brookshire, in the surveyor’s own words.

• Immediate jeopardy, isolatedF755Feb 14, 2025

  Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 1 of 7 residents (Resident # 1) reviewed for pharmacy services. The facility failed to ensure that Resident # 1 received her prescribed medication, Midodrine, according to physician's orders on 2/9/2025. Resident #1 was administered 10 tablets of Midodrine (medicationused to treat low blood pressure) instead of the ordered one tablet. Resident # 1's blood pressure was 189/96 before being transported to the hospital for an overdose of Midodrine An Immediate Jeopardy (IJ) was identified on 2/13/2025. […]

• Actual harm, isolatedF697Dec 6, 2024

  Based on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 (Resident #29) residents reviewed for pain management. C.NA A failed to stop performing incontinent care while Resident #29 was in pain. C.NA A failed to notify the LVN B of Resident #29's pain in a timely manner after incontinent care in AM. This failure could place resident at risk for increased pain causing undo suffering. […]

• No harm, potential for more than minimal, widespreadF812Feb 12, 2026

  Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food to be used later with a temperature in the danger zone was discarded which pan of mechanical soft sausage in the steamtable 131.1 degrees Fahrenheit2. The facility failed to ensure that food past the used by date were discarded which included a pan of cooked rice in the refrigerator use by date 2/7/26, a pan of mashed potato use by date 2-3-26, a pan of Salisbury steak use by date 1-7-26, a package of shredded cheddar cheese use by date 1-12-26, a package of deli meat turkey use by date 1-29-26,a package of… […]

• No harm, potential for more than minimal, widespreadF835Sep 13, 2025

  Based on interviews and record review, the facility failed to ensure effective administration to maintain the highest practicable well-being of each resident. The facility operated without an administrator from 08/20/25 to 09/13/25, in the 1 of 1 facility reviewed for administration.Record review of personnel records revealed the Former Administrator was terminated on 08/19/2025, there was no record of a licensed interim or permanent replacement appointed from the period of 08/20/2025 - 09/13/2025. During an interview on 09/13/2025 @ 10:30am with the nurse supervisor, she stated that the facility had not had a facility administrator, since 08/2025. She stated that DON, who was not a state-licensed nursing home administrator, was informally made responsible for the Administrator's tasks. […]

• No harm, potential for more than minimal, widespreadF584Dec 6, 2024

  Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 3 of 5 halls (100-hall, 400-hall and 500-hall). - The facility failed to address discoloration on ceiling tiles throughout the facility. - The facility failed to address missing floor and wall tiles. - The facility failed to address exposed sheetrock in the halls and resident rooms. - The facility failed to address chipped wall paint in the halls and resident rooms. - The facility failed to address damaged exit door handles. […]