Health inspection·July 10, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few get him to go bac to his room. Other residents were yelling about him being naked. When I asked him to go, he started staring at my breast and said he was going to do nasty things to them. He has groped me before and I did not want to him touching me again and I shoved his arm away from me. I did not hurt him or intent to harm him in any way. Record review of the Sheriff's Office report Case #10610 with date of event 5-30-2023 and date of report 6-4-2023 revealed the following narrative: Per statement taken from the administrator by the officer is that NA A struck the resident with her hand and the administrator reported that the resident has no visible signs of injury. Record review of Resident #1's clinical record revealed he had been discharged to a mental health facility on 7-3-2023 due to increasing sexual behaviors and wandering. Record review of the facility provided trainings revealed that NA A was trained on 4-14-2023 on the policy titled Abuse, Neglect, Exploitation General Policy. During an interview on 7-10-2923 at 10:51 AM the Administrator verified that NA A was videoed striking Resident #1 on the arm (on 5-29-2023 at 09:33 PM) and the Administrator reported the following: That another resident reported the following morning (on 5-30-2023) that he witnessed NA A hit Resident #1 late the evening before, the Administrator immediately reviewed the video footage, verified the incident did happen, immediately suspended NA A (who reported that she reacted to the residents repeatedly appearing naked at the nurses station and repeatedly staring at her breasts), and had Resident #1 assessed (who did not remember the event and did not have any injuries or ill effects from the event). The Administrator provided the video for this surveyor who verified that NA A did strike Resident #1 on the left upper right arm with her open palm and then according to the Administrator appeared to threaten to hit Resident #1 again but did not act on that threat. Resident #1 did not seem to be affected by the confrontation and did not appear to be injured. The two-nursing staff behind the nurse's station denied witnessing the event. The police were notified, have investigated, and are charging NA A. The Administrator reported that if an employee acts in a manner of threatening a resident that employee will be terminated, and that behavior could affect a resident and could result in negative affects to their care and condition. Review of the video footage on 7-10-2923 at 10:51 AM revealed NA A did strike Resident #1 on the left upper right upper arm with her open palm. During an interview on 7-10-2023 at 11:13 AM the DON verified that she had reviewed the video of the incident and that staff member NA A did strike Resident #1 on the left upper arm with the palm of her right hand, that NA A did not deny the event, and NA A reported that she was frustrated with Resident #1 continually trying to touch her breast and vagina, and the DON reported that NA A was immediately terminated for her actions. The DON reported that if a staff member is reported as acting in a manner towards a resident that is abusive or neglectful, they are immediate suspended, investigated, and if the allegation is found to be true then they are terminated. The DON reported that if a resident is treated in such a manner by a staff member it could affect the resident negatively emotionally. Record review of the facility provided policy titled Abuse, Neglect, Exploitation General Policy undated, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 2 of 3 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 07/10/2023 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Standard: This facility has developed and implemented this policy and procedure to prohibit mistreatment, neglect, and abuse of all elder and misappropriation of elder property. Abuse means any act or failure to act performed intentionally or recklessly that caused or is likely to cause harm to an elder .Facility staff will not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Residents Affected - Few Record review of the facility provided policy titled, Resident Rights undated, revealed the following: Right of the Elderly. b. An elderly individual has the right to be treated with dignity and respect . 2. has the right to be free from abuse, neglect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 3 of 3