Health inspection·July 12, 2022

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in 2 of 2 medication carts (hall 1 medication cart and hall 2 medications cart) reviewed for expired medications. The hall 2 medication cart contained 2 loose medication tablets and one multidose vial of insulin that was open and without an indicated open or expiration date. The hall 1 medication cart contained two multidose vials of insulin that were open and without an indicated open or expiration date. This failure could place residents at risk of drug diversion or exposure to medications and/or biologicals that are expired and/or contaminated. Findings included: During an observation and interview on 07/10/2022 at 10:22 AM, there were two loose medication tablets in the bottom of the second drawer of the hall 2 medication cart. In the third drawer of the medication cart, there was one multidose vial of Lantus (insulin glargine) that was open, had about one-fourth of its contents remaining in the vial, was labeled with a pharmacy fill date of 05/23/2022, and was labeled as belonging to Resident #21. The insulin vial was not labeled with a use by, expiration, or open date. LVN B reported that she was responsible for the hall 2 medication cart currently and that there should not be any loose medication tablets in the medication cart because those tablets would be contaminated. LVN B reported that every nurse should check their medication cart for loose medications when they come on shift and clean them up when they're dropped. LVN B reported that there were loose medication tablets in the medication cart because somebody may have dropped the pills and didn't get them out. LVN B reported that the vial of Lantus for Resident #21 was still in use but that it should not be because it's outdated. LVN B reported that she did not know when the vial had been opened and that insulin vials should be labeled with an open date because they are only good for 30 days after being opened. LVN B reported that she did not know why the vial of Lantus was not labeled with an open date and that the consequences of it missing labeling included that they (residents) could get outdated insulin which could cause them to become sick. During an observation and interview on 07/10/2022 at 10:34 AM, there were two multidose vials of insulin that were not labeled with a use by, expiration, or open date in the third drawer of the hall Page 1 of 7 676411 676411 07/12/2022 Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1 medication cart. One of the vials was Levemir (insulin detemir), which was open, had about one-fourth of its contents remaining in the vial, was labeled with a pharmacy fill date of 12/27/2021, and was labeled as belonging to Resident #55. The other was a vial of Lantus (insulin glargine) that was open, had about three-fourths of its contents remaining in the vial, was labeled with a pharmacy fill date of 05/23/2022, and was labeled as belonging to Resident #48. LVN C reported that she was currently responsible for the hall 1 medication cart. LVN C reported that she did not know when the two vials of insulin had been opened and that they should both contain open dates on them because the amount of time they are good for once they're opened. LVN C reported that she was not sure exactly how long insulin vials are good for once they're opened. LVN C reported that she did not know if the two vials were currently in use. LVN C was asked about the potential consequences of insulin vials not containing an open or expiration date and she replied, I'm not sure of the answer. They (residents) could get sick for having outdated insulin. LVN C reported that she did not know why the vials had not been labeled with an open or expiration date. During an interview on 07/11/2022 at 2:04 PM, the ADON reported the DON was out of town and not currently at the facility. The ADON reported there should not be loose medication tablets in medication carts. The ADON reported the floor nurses are responsible for conducting weekly audits of medication carts on the night shift. The ADON reported that the potential consequences of loose medications being in medication carts included that somebody could get the wrong medication or that it may indicate that someone did not receive a medication that they should have. The ADON reported that there may have been loose tablets in the medication cart because they (staff) did not audit very well. The ADON reported all insulin vials should be dated with an open date when they are opened so everyone knows when they will expire, which is 28 days after being opened. The ADON reported that the potential consequences of not having such labeling included we could be giving insulin that is out of date. The ADON reported that she did not know why there were insulin vials in the medication carts that were not labeled with an open date. Record review of facility provided policy titled Medication Storage, dated January 2014, revealed in part: Policy It is the policy of the home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse. Procedure 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed Record review of facility provided policy titled Medication-Labels, dated December 2013, revealed in part: Policy It is the policy of this home to assure medications are properly labeled. Record review of facility provided policy titled Medications-Vials and Ampules of Injectables, dated March 2012, revealed in part: 676411 Page 2 of 7 676411 07/12/2022 Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226

F 0761 Policy Level of Harm - Minimal harm or potential for actual harm It is the policy of this home that vials and ampules will be handled, stored, and discarded properly. Procedure Residents Affected - Some 2. The date opened and the initials of the first person to use the vial are recorded on the multi-dose vials. Record Review of facility provided policy titled Administering Medications, dated December 2012, revealed in part: 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-done container, the date opened shall be recorded on the container. 676411 Page 3 of 7 676411 07/12/2022 Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests. Residents Affected - Some Flies, spiders, cockroaches. and a scorpion were observed in multiple areas of the facility These failures could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: During an observation on 07/10/22 at 9:15 AM, a dead scorpion was observed on the floor of the staff bathroom nearest the conference room. During an observation on 07/10/22 at 9:19 AM, 4 flies were observed in the kitchen area and 1 dead bug in the hallway outside the kitchen office. During an observation on 07/10/22 at 09:27 AM, 5 flies were observed in room [ROOM NUMBER]. No resident was present. During an observation on 07/10/22 at 09:30 AM, 8 flies were observed in room [ROOM NUMBER] on bed A and B. There was no resident present. During an observation on 07/10/22 at 09:32 AM, Resident #20 (room [ROOM NUMBER]) was laying in his bed under a blanket. There were 12 flies observed in his room. During an observation on 07/10/22 at 09:33 AM, Resident #34 was laying in bed with 5 flies on him. Upon awaking he attempted to shoo the flies. The resident stated that he did not like the flies and that they bothered him. During an observation on 07/10/22 at 09:37 AM, a fly was observed in the bathroom of room [ROOM NUMBER]. There was no resident present. During an observation on 07/10/22 at 09:38 AM, Resident #47 (room [ROOM NUMBER]) was laying on his bed under a blanket. 5 flies were observed in the room. During an observation on 07/10/22 at 09:40 AM, 8 flies were observed in the room [ROOM NUMBER]. There was no resident present. During an observation on 07/10/22 at 09:41 AM, 29 dead bugs (3 beetles, one spider, and 25 flies) were observed in the hallway between room [ROOM NUMBER] and the end of the hall exit near room [ROOM NUMBER]. During an observation on 07/10/22 at 09:54 AM, 8 flies were observed on bed A in room [ROOM NUMBER]. There was no resident present. During an observation on 07/10/22 at 10:01 AM, 10 flies were observed in room [ROOM NUMBER] on Bed 676411 Page 4 of 7 676411 07/12/2022 Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226

F 0925 A and 5 flies were observed on Bed B. There was no resident present. Level of Harm - Minimal harm or potential for actual harm During an observation on 07/10/22 at 10:05 AM, 4 flies were observed in room [ROOM NUMBER] on Bed B with the Resident #47 present. Residents Affected - Some During an observation on 07/10/22 at 10:14 AM, 7 flies were observed in room [ROOM NUMBER] on bed A. During an observation on 07/10/22 at 10:14 AM 4 flies were observed room [ROOM NUMBER] on Bed A and 6 flies were noted on bed B. There was no resident present. During an observation on 07/10/22 at 10:15 AM, Resident #23 was observed rolling down the hall in his wheelchair in an agitated state cursing. He continued to curse in his room. He was heard screaming, Goddamn flies! M-fing flies! During an observation on 07/10/22 at 10:49 AM, a resident in the dining room was observed eating a snack with a drink present. 3 flies were noted on the table. The resident was noted repeatedly attempting to keep the flies off his snack. During an observation on 07/10/22 at 12:05 PM, Resident #36 was observed sitting at his table at lunch. His cup had a fly on it. During an observation on 07/10/22 at 12:07 PM, a resident was sitting at his dining room table eating his meal and shooing flies. Upon approaching the table this surveyor observed a total of 5 flies on the table. A second resident present stated, How about getting rid of all these flies. When asked if the flies were a problem the second resident stated, Ya there are about 15 flies on each table. During an observation of the dining room on 07/10/22 at 12:16 PM, this surveyor observed flies on 9 of the 11 dining room tables with residents present and eating meals. During an observation on 07/10/22 at 12:23 PM, flies were observed in the bowls and on the plates of two residents. One resident at the table had 8 flies on his person and 7 on his table. During an observation on 07/10/22 at 01:42 PM, 5 flies were observed on the lobby coffee table. During an observation on 07/10/22 at 01:47 PM, a spider was observed crawling on the floor of a resident's area in room [ROOM NUMBER]. During an observation on 07/10/22 at 01:49 PM, Resident #47 was in his bed with 6 flies on him. He said the flies keep him awake when asked if they bother him. During an observation on 07/10/22 at 01:52 PM, a dead cockroach was observed in the hallway outside the ADMIN office. During an observation on 07/11/22 at 08:43 AM, 8 flies were observed on the wall in room [ROOM NUMBER] during the AM medication pass. During an observation on 07/11/22 at 03:06 PM, a dead cockroach was observed in hallway outside the ADMIN office. 676411 Page 5 of 7 676411 07/12/2022 Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226

F 0925 During an observation on 07/12/22 at 08:54 AM, 5 flies were observed in the conference room. Level of Harm - Minimal harm or potential for actual harm During an observation on 07/12/22 at 08:56 AM, a surveyor was stopped in hall by Resident #1 in his wheelchair. The resident asked, You with the state? When the surveyor told him yes, he said, Y'all need to do something, there are way too many cockroaches and flies in this place, we eat that stuff with our food every day. They spray a little can of that stuff but that doesn't work, they just come back out at night and crawl all over us. Residents Affected - Some During an observation on 07/12/22 at 09:17 AM, Resident #38 stopped a surveyor in the hall and asked that surveyor to take a picture of the flies under his bed. The resident said he kills the flies and puts them under his bed to see how long it will take housekeeping to sweep them up. The resident said he counted more than 100. The resident also showed surveyor several flies on his bathroom floor. The resident had a folded-up Coca-Cola box from a 12 pack that he was using as a flyswatter. The resident said housekeeping came down his hall yesterday, but they stopped cleaning at room [ROOM NUMBER] and didn't start again until room [ROOM NUMBER] so his room was skipped. During an interview on 07/11/22 at 09:33 AM, HM A stated Yes, they are horrible. HM A said the bugs and flies were a problem for the residents. HM A stated, We have the fly spray on each door but that is not working. HM A said problems which can occur from not controlling flies and bugs include, You can have flies on everything. If they have an open wound or something like that, they can be on it. During resident council meeting interview on 7/11/22 at 10:30am, five residents attending stated that they knew how to file grievances but had not done so. The five residents in attendance stated that they kill the flies with fly swatters. The five residents did not indicate that they were bothered by the flies. During an interview on 07/12/22 at 08:33 AM, the MS replied that they have fly sprayers at each doorway and several in each hall. They have a contract with {pest control company} that spays the building monthly and prn if needed. The MS stated, We try to keep our patio door in the dining room that lead to the smoking area closed and I try to educate the staff to keep them closed but the residents go in and out frequently to smoke. We have a wind machine on the patio door, but I noticed that it is making a strange noise the last couple of days, so I am going to get it fixed. We usually have 1-2 scorpions per year because they are common for this area and its summertime, but the flies are the real problem. We also have a landfill that's about a 1/4 mile from this facility that causes a problem. When asked what problems these issues could cause for the residents, the MS reported that if left unattended they can lay eggs and be severely annoying. The MS did verify that to his knowledge they have never had any fly larva in the building. During an interview on 07/12/22 at 08:39 AM, the ADON said that the issues with flies, scorpions, spiders and cockroachescomes and goes. The ADON reported she was aware that the blower above the patio doors to the smoking area had been broken. The ADON reported the patio doors are the main issue for the infestation due to the residents leaving them open, that they often urinate on the patio, and feed stray animal on the patio that led to difficulty keeping insects out of the facility. The ADON reported they have fly swatters they will give to resident who can use them properly. The ADON reported that flies and bugs can carry/cause bacteria, land on food, land on wounds, or anything like that. The ADON reported that they plan to educate/provide written training for staff on observation and prevention of insect infestation. 676411 Page 6 of 7 676411 07/12/2022 Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 07/12/22 at 08:43 AM, the ADM said the issue with flies, scorpions,s piders and cockroaches It's not an everyday thing. It's this time of year. We do have fly spray and I noticed some of them are out, so we have reordered replacements. We do have a contract with Orkin to treat every month. Our main issue is the patio doors that the residents go in and out to smoke. Staff need to pay more attention and make sure they are closed. The ADM said problems the issues with flies and bugs could cause for the resident were spider and scorpions can sting residents and scare staff and flies can cause infection problems. The administrator reported they were going to in-service staff on paying attention to the patio door for insect prevention. During an interview on 07/12/22 at 09:10 AM, the MS reported that for the facility policy for pest control they usually provide the {pest control company} contract/monthly treatments. The facility does not have a pest control policy, but they will get one written. The MS also stated that they have fly lights at each door that attracts and kills flies. The MS provided the last 3 months of Orkin treatments. Record review of facility provided pest control log revealed, in part, dates and treatments as follows: Treatment dates: 6-24-2022 5-16-2022 4-15-2022 Species listed in treatment: Cockroaches, flies, scorpions, spider . Record review of the facility provided pest control logs for the dates listed above did not reveal documentation that the pest control applicator had noted any issues with flies, cockroaches, bugs or spiders. Record review of facility incident reports revealed no documentation of pest-related injuries or bites to residents. 676411 Page 7 of 7