Health inspection·June 28, 2023

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 in that: Residents Affected - Some Flies were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: Observation on 06/27/23 at 10:10 AM revealed Resident #2 was in the dining room eating a snack with a drink present. Three flies were noted on the table. The resident was noted repeatedly attempting to keep the flies off his snack. Observation and interview on 06/27/23 at 10:28 AM in resident room [ROOM NUMBER] revealed two flies on Resident #1's bed and one fly flying around his head. Interview with Resident #1 revealed the flies kept him up at night getting in his nose and ears. He stated he tried to keep it clean in his room, but it didn't make any difference. He stated he would swat at them all the time. Resident #1 stated the flies were constantly in his room on a daily basis and they were worse the hotter it got. Observation on 06/27/23 at 10:35 AM revealed Resident #4 (room [ROOM NUMBER]) was laying in his bed under a sheet. There were six flies observed in his room. One fly landed on his pillow and one fly landed on his ankle. Observation and interview on 06/27/23 at 10:50 AM in resident room [ROOM NUMBER] revealed four flies on Resident #3's bed. Interview with Resident #3 revealed the flies bother him all day and aggravate him. Resident #3 stated the flies were constantly in his room on a daily basis and they get in his food. He stated he has a fly swatter, but it doesn't help. Observation on 06/27/23 at 11:05 AM revealed two flies were observed in resident room [ROOM NUMBER]. There was no resident present. Observation and interview on 06/27/23 at 12:28 PM revealed about seven flies in the dining room while residents ate lunch. Flies were observed on the plates and cups of five residents. Residents were observed to be swatting at flies and four flies landed on residents. Interview with Resident #3 revealed the flies were bad especially during meals. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 676411 Printed: 05/15/2026 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 676411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226 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)