Health inspection·August 31, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility for more than 30 days and the baseline care plan was missing from their assessments. DON indicated a negative outcome would be a change in the resident's baseline and staff would have not noticed. In an interview on 8/31/2023 at 9:56 AM, MDS Nurse indicated an MDS assessment was opened and completed within 13 days of a resident being admitted . MDS nurse stated DON signed it and MDS nurse places their information in Section X. MDS Coordinator indicated a baseline care plan should be completed immediately once someone returns from being discharged . MDS nurse stated if the resident was out after 30 days, it would be a new baseline care plan. MDS Nurse confirmed there was not a baseline care plan located in Resident #14's chart. MDS Nurse stated that a negative outcome would be the resident does not get the proper care. Record review of facility's policy titled Care Plans, Comprehensive Person-Centered, revised in December 2016, reveals that policy does not cover timeframe dedicated to baseline care plan timeline. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 2 of 13 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 08/31/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 2 of 15 residents (Residents #7 and #16) whose care plans were reviewed. The facility failed to develop a comprehensive person-centered care plan indicating services as follows: 1. Failure to develop person-centered goals reflecting medical needs outside the facility of dialysis for Resident #16 2. Failure to develop person-centered goals reflecting psychosocial needs for activities for Resident #7. These failures could place all residents at risk of receiving care that is substandard, not individualized to the resident, or not meeting the highest practical medical and psychosocial needs. Findings included: Resident #7 Record review of Resident #7's face sheet, dated 8/30/23, indicated a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #7's diagnoses included, but not limited to, schizoaffective disorder, anxiety disorder, chronic pain, major depressive disorder, and multiple sclerosis. Record review of Resident #7's BIMS, dated 7/7/23, revealed a score of 15 indicating that the resident was cognitively intact. Record review of Resident #7's care plan, revised on 8/9/23, did not address the resident's activity needs and did not include individualized goals for the residents' psychosocial needs. Resident #16 Record review of Resident #16's face sheet, dated 8/30/2023, indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident's diagnoses included but not limited to acute and chronic respiratory failure with hypoxia, type 2 diabetes, end stage renal disease, and heart failure. Record review of Resident #16's MDS, dated [DATE], indicated a BIMS score of 15 indicating that resident was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 3 of 13 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 08/31/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Record review of resident progress notes indicated that resident attended dialysis on the following days: 8/28/23, 8/23/23, 8/18/23, 8/14/23, 8/11/23, 8/9/23, 8/7/23, and 8/4/23. Record review of Resident #16's care plan, dated 7/19/23, revealed there is no goal related to resident's dialysis treatments. Residents Affected - Few In an interview on 8/31/23 at 9:46 AM, the DON stated she oversaw care plans with the MDS coordinator. Care plans are done every Wednesday based on the MDS nurse assessment. In an interview on 8/31/2023 at 10:10 AM, the DON indicated a negative outcome of not having all needs care planned would be the care team does know what was going on with the residents. Record review of facility policy title Care plans, Comprehensive Person-Centered, revised December 2016, Section 8, Line B states to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Line G states to incorporate identified problem areas. Line L states to identify the professional services that are responsible for each element of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 4 of 13 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 08/31/2023 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay for 1 (Resident #60) of 2 residents reviewed for discharge summaries. A. The facility failed to ensure a Discharge Summary for Resident # 60 was completed which included a complete recapitulation of the resident's stay for a resident discharged to another facility. This failure could place residents discharged from the facility at risk for incorrect, incomplete, or misleading information recorded regarding discharged residents, and failure in the continuity of care for residents. The Findings included: Record review of Resident #60's electronic face sheet dated 8/31/23 indicated a [AGE] year-old male admitted on [DATE] with the following diagnoses: Alzheimer's disease, unspecified convulsions, personal history of brain injury, intermittent explosive disorder, diabetes, unspecified mood disorder, dementia, chronic kidney disease, retention of urine and psychotic disorder with delusions. A discharge MDS dated [DATE] documented a BIMS score of 5 out of 15 indicating cognition was severely impaired. A care plan dated 7/11/23 documented Resident #60 was independent in ADLs, required medications to be crushed, had a history of UTI's, had the potential for verbal aggression, physical aggression, and sexually inappropriate behaviors. Record review of Resident #60's physician progress note revealed the last note was dated 6/27/23. Nurses progress note dated 6/28/23 indicated Resident #60's family requested resident to be referred to a facility closer to family. A Nurses progress note dated 7/10/23 documented Resident #60 was accepted to another facility. A Nurses progress note on7/11/23 documented Resident #60 was discharged to another facility. Record review of Resident #60's record indicated there was no Physicians discharge summary in the record. During an interview on 8/31//2023 at 11:27 am the DON stated there was no discharge summary. The DON stated she did not know what happened to it and could not find it. The DON said resident's clinical records, including an accurate discharge summary, were supposed to be forwarded or faxed to the receiving facility in addition to verbal communication. The DON stated the facility did not send any resident paperwork with the resident. The DON stated the consequences of not having a physician discharge summary was if something happened to the resident the facility during the transfer, the facility would be responsible and the receiving facility would not have any history of his care. A policy was requested but never provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 5 of 13 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 08/31/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Residents Affected - Few The facility did not have an RN in the facility on 06/3/2023, 06/04/2023, and 06/18/2023, accounting for 3 days in the last 90 days. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care. Findings include: Record review of the facility's last 90 days of time sheets for RN coverage revealed that the facility did not have an RN in the facility on 06/03/2023, 06/04/2023, and 06/18/2023. During an interview on 08/31/2023 at 11:27 AM with the DON stated she had the job posted and did not have an RN hired at that time which was why the facility was without RN coverage for 06/03/2023, 06/04/2023 . The DON stated on 06/18/2023 she did have a RN scheduled but was not sure why she did not show up. During an interview on 08/31/23 at 02:38 PM with the DON, stated a negative outcome would be for insufficient RN hours was lack of patient care. Record review of facility presented policy titled Departmental Supervision revision dated August 2006, did not address the need for RN coverage for at least 8 consecutive hours a day, 7 days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 6 of 13 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 (X3) DATE SURVEY COMPLETED A. Building 08/31/2023 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 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 drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication rooms. Multiple vials of insulin left out on the counter. -The medication refrigerator was not kept at a temperature between 36 to 46 degrees. The facility's failure to ensure drugs and biologicals were stored in accordance with the currently accepted professional principles, this could place all residents receiving medication that have lost integrity to not receive their therapeutic dose. Findings included: 08/29/23 11:59 AM- Per observation of the Medication Storage Room completed with MA A. Noted the temperature monitoring of the refrigerator to be 28-30 degrees on average for the month of August. Noted multiple medications in the refrigerator with instruction no to store below freezing. Noted no expired medications. 1.08/29/23 10:46 AM- Observed LVN B prepare insulin for a resident, after LVN B left 20 bottles of resident insulin on the counter next to the sink at the nurses station out in the open. 2.08/29/23 10:51 AM - Per observation and interview with LVN B who verified that temperature log on the medication room refrigerator from 8-1-2023 from 8-29-2023 has read from 28-30 degrees. LVN B verified that she read the refrigerator temperature this am as 30 degrees. She stated freezing temperature was 32 degrees. In the refrigerator the following medications were observed: *a bottle of Lantus Insulin with instructions to store at 36-46 degrees, *a bottle of Levemir with instruction to store between 36 to 46 degrees, *an opened bottle of TB solution with instruction to store at 35 to 46 degrees, *two open bottles of Influenza Vaccine and 6 unopened bottles of Influenza Vaccine with instruction of store at 36 to 46 degrees, *Engerix-B injection with instructions to store at 36-46 degrees, *Acidophilous with instruction to store unopened container at room temperate and refrigerate after opening, *2 packages of acetaminophen suppository with instructions to store at 68-77 degrees, *4 packages of Zyprexa with instructions to store at room temperature not to exceed 86 degrees, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 7 of 13 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 08/31/2023 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 0761 *3 packages of Respiridol with instructions to store at 36 to 46 degrees. Level of Harm - Minimal harm or potential for actual harm LVN B stated that the refrigerator was to cold and that maybe the thermometers were not correct and needed to be replaced. LVN B stated if medications are not stored properly then they would not be effective in resident treatment and could affect their condition. Residents Affected - Some Observation on 08/29/23 at 11:47 AM, 20 Resident Insulin bottles, 5 insulin pens still on the counter at the nurse's station next to the sink used by staff for handwashing. Observation on 08/29/23 at 12:08 PM, 20 Resident Insulin bottles, 5 insulin pens and insulin testing supplies at the nurse's station next to the sink. Observed 5 staff to include 2 CNA, 1 MA, and 1 Hall Monitor wash their hands at the sink in the nurse's station. Observation on 08/29/23 at 02:04 PM of the nurse's station wash area, observed 20 Resident insulin bottles and 5 insulin pens were not present Interview on 08/29/23 at 03:14 PM , DON and ADON stated they were aware of the thermometer monitoring in the refrigerator and felt that staff were reading the thermometer wrong. Staff stated the current thermometer temperature was 40 degrees but they were aware the temp was below 32 degrees since the first of the month and they could not verify that the medications were not store properly. 08/30/23 09:02 AM- Per interview with the DON and the ADON . The DON stated if medications are not stored at the recommended temperatures, then they will not be therapeutic. The DON stated if the medications in the facility refrigerator did freeze it would destroy the medication and it would not be effective; that would affect the residents care, it could affect the residents blood sugars, and their behavioral issues. ADON agreed with the statement DON had provided above. 08/30/23 09:04 AM- Per interview with the DON and the ADON, the DON reported all medications should be stored safely in a medication care safely. If the medication required refrigeration, then it should be in the refrigerator in the medication room that was locked. The DON stated the insulins that were left on the counter in the nurse's station should not have happened because a resident could access the medication which would result in issues that could affect a residents condition and the medication should have been in the medication carts or in the medication room and locked to prevent access. The ADON agreed with the statement that DON had provided. 08/30/23 10:20 AM- Per interview with LVN B stated all medication should be kept locked up to maintain resident and staff safety. LVN B stated if medications are not kept in a locked secured location, then they can be accessed by resident or staff that are not supposed to have them, that someone would steal the medication. LVN B stated it would not be safe for a resident if they were to access the mediation that was not meant for them and took that medication, that it could affect them and their condition. Record Review of a policy provided by facility, titled Nursing Policy and Procedure, dated March 2012 indicated the following: 2. Only licensed nurse the consultant pharmacist, and those lawfully authorized to administer medication (i.e., medication aides, etc.) are allowed access to medications. 11. Medications requiring refrigeration or temperatures between 2 degrees C (36 degrees F) and 8 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 8 of 13 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 08/31/2023 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 0761 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 9 of 13 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 08/31/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the freezer was free from dirt, debris and rust. Freezer items were not properly stored, labeled, and dated. 2. The facility failed to ensure refrigerator and pantry foods were properly stored, labeled, and dated. 3. The facility failed to ensure general cleanliness was maintained in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 8/29/23 @ 9:10 AM revealed the following: 1. (1) plastic bag of egg omelets, open to air, not in original box, with no label. 2. (1) plastic bag of frozen meat patties, open to air, not in original box with no label. Observation of the kitchen food prep area and the pantry area on 8/29/23 at 9:15 AM revealed the following: 1. A metal rolling rack holding canned foods had food splatters and dirt on the rails holding the canned goods. 2. Crumbs were observed on the front and sides of the industrial toaster and on the stainless-steel table holding the toaster. There were crumbs of food under and behind the toaster. 3. Crumbs were observed on the metal shelf above the kitchen prep table holding the spices. 4. The front and sides of the fryer had food splatters and food debris on the sides of the fryer. 5. There were food crumbs on the lower ledge of the shelves holding clean pans and dishes. 6. A half used jar of grape jelly was on the pantry shelf. The label stated to Refrigerate after opening. 7. A white plastic tub labeled powdered milk had food splatters and dirt on the lid. 8. There were individual sugar packets, cracker packages and food crumbs on the floor under the wire shelving units holding food items in the pantry area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 10 of 13 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 08/31/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm 9. The white Insignia freezer had no handle on the outside of the freezer. The front of the freezer was sticky to the touch. Observations of the kitchen prep area, the pantry area, and the kitchen appliances on 8/30/23 at 8:30 AM revealed there were no changes in the cleanliness in the kitchen. Residents Affected - Many Observations of the kitchen prep area, the pantry, and the kitchen appliances on 8/31/23 at 9:00 AM revealed there were no changes in the cleanliness in the kitchen. In an observation and interview with the DS on 8/31/23 at 8:42 AM, the DS stated she missed the grime and crumbs in the freezer and the pantry. The DM stated she was sorry she missed it and she will get it cleaned. The DS stated she expects all staff to be cleaning daily. The DS stated she does spot checks on a weekly basis. Cleaning practices are standard and should be adhered to. The DS stated she trained the staff on how to clean. The DS stated the consequences of not cleaning the kitchen thoroughly would be food borne illnesses and unsanitary surfaces which could make residents sick. The DS stated the jar of used jelly should have been refrigerated. The DS stated she would throw the opened jelly out and keep it refrigerated from now on. The DS stated the consequences of not refrigerating the jelly according to the instructions would possibly make the residents sick if consumed. She further stated residents could get sick from the food not being covered or refrigerated after being opened. Record Review of the facility policy dated October 2008, titled Sanitation documented: All kitchen areas shall be kept free of litter and rubbish All counters, shelves and equipment shall be kept clean, maintained in good repair and free from breaks corrosion open seams cracks and chipped areas that may affect their use or proper cleaning. All equipment, food contact surfaces and utensils shall be washed to remove soils Kitchen surfaces not in contact with food shall be cleaned on a regular basis. Record Review of the facility policy dated October 2017, titled Food Receiving and Storage documented: All foods in the refrigerator and freezer will be covered, labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 11 of 13 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 08/31/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 biohazard/sharps containers located at facilities only nurse's station. Residents Affected - Few The facility failed to ensure that residents were safe from exposed biohazard materials. This failure could place the residents at an increased risk for potentially exposing them to, injury, viral infections, secondary infections, and communicable diseases. The findings include: On 08/29/23 at 12:08 PM - an observation of biohazard/sharps container in the diabetic testing supplies was overfilled and the handle of the plunger end of a used syringe sticking out of the top of the sharps container. 08/29/23 02:04 PM- at the nurses station, observation of one biohazard/sharps container was full with the handle of the plunger end of the insulin pen sticking out of the top of the sharps container. 08/30/23 07:42 AM- Per observation of the nurse's station wash area, observed two biohazard/sharps containers with the one that was full with the handle of the plunger end of the insulin pen sticking out of the top of the sharps container. 08/30/23 09:06 AM- Per interview with the DON and the ADON stated all biohazard/sharps containers should be securely attached to the medication carts, locked, and should be disposed of when they are full. The [NAME] stated when the used syringes and biohazard/sharps reach the fill line marked on the sharps container, then the sharps container needs to empty and the container should be able to close freely. The DON reported that if a biohazard/sharps container is overfilled then staff and/or residents are placed at risk of blood borne pathogens from needle/sharps sticks. The ADON agreed with the statement DON provided above. 08/30/23 10:18 AM- interview with LVN B stated the biohazard/sharps container left on the counter in the nurses station with the hub end of a used syringe sticking out of the top was a problem due to the container being too full. LVN B stated the biohazard/sharps container being too full was not safe and a resident or staff member could get hurt from a needle stick. Record review of facility provided policy titled Medical Waste Container, Revised May 2012, indicated the following: 3. Medical waste containers used by this facility will be: a. Closable; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 12 of 13 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 08/31/2023 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to develop, implement, and permanently maintain and effective training program for all staff, which includes trainings on abuse, neglect, exploitation, misappropriation of resident property, and dementia management, that is appropriate and effective, as determined by staff for 12 of 15 (ADM, DON, ADON, Dietary Supervisor, Activities Director, MA B, Monitor Tech D, MA E, CNA C, Monitor Tech F, [NAME] G, and [NAME] H) employees reviewed for Abuse, Neglect, and Misappropriation training and Dementia training. The facility failed to ensure all staff were trained at time of hire and annually on Abuse, neglect, exploitation, restraints, and falls. This failure could place all residents at risk for abuse, neglect, exploitation, bodily injury, and decline in overall health. Finding include: Record review of employee record for Dietary Supervisor revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 02/28/2023 Record review of employee record for Monitor Tech D revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 08/08/2023 Record review of employee record for Monitor Tech D revealed that there were no trainings listed on an annual basis for this employee. DOH was 08/08/2023 Record review of employee record for CNA C revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 07/18/2023 Record review of employee record for [NAME] G revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 03/01/2023 Record review of employee record for [NAME] H revealed there were no trainings listed at time of hire or on an annual basis for this employee. DOH was 02/28/2023 Interview on 08/31/23 at 02:54 PM with BOM who verified that she is responsible for employee orientation, and trainings. Record review of Employee New Hire Packet does reveal a document for the employee to fill out upon completion of training at time of hire. No documentation provided for annual trainings. No policy provided by facility on initial or annual training for employees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 13 of 13