Health inspection·November 13, 2023

F 0578 number lines for the second physician. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 10:17 AM LVN C stated a DNR not dated by the physician is not a DNR. When asked if she would refrain from providing CPR to a resident with a DNR that was not dated by the physician, she replied, I mean, you can't it is not a DNR. Residents Affected - Few During an interview on [DATE] at 10:23 AM BOM stated a DNR that was not dated by the physician was not valid. She said a possible negative outcome of having a DNR with no date by the physician was, It would be invalid, and we would have to do CPR on him. During an observation and interview on [DATE] at 10:37 AM Resident #1 was lying in his bed with his walker next to the head of the bed. He had his eyes closed but opened them at the sound of his name. He stated he was not feeling very good due to having COVID (a severe acute respiratory syndrome). When asked if he still wanted to be DNR he looked away and closed his eyes and would not open his eyes or answer any other questions. During an interview on [DATE] at 12:35 PM BOM said of Resident #1's DNR not being dated by the physician, That could have been real bad! She held up a new copy of the DNR that was dated by the physician and said, Now I just have to go get it notarized. During an interview on [DATE] at 01:08 PM Resident #1's emergency contact was asked if she knew if Resident #1 still wanted to be DNR. She replied, Yes. I do know for sure. Record review of the INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER dated [DATE] revealed in part: The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. Record review of facility policy titled, Advance Directives and dated 2001 revealed in part: Advance directives will be respected in accordance with state law and facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 2 of 5 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 11/13/2023 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and hazards. Resident #1 was left alone in the shower, fell, and was injured on 10/13/23. Resident #1 was coded as needing assistance by one staff person for bathing in his MDS completed 08/08/23. This failure could place residents requiring assistance with ADLs in danger of injury. Findings included: Record review of Resident #1's face sheet dated 11-13-23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes (insufficient production of insulin, causing high blood sugar), chronic congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), personal history of cerebral infarction (stroke), major depressive disorder, muscle wasting and atrophy, vascular dementia with behavioral disturbance (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), anemia (lower than normal amount of healthy red blood cells), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and restlessness and agitation. Record review of Resident #1's Quarterly MDS, completed 08/08/23 revealed a BIMS of 9 which indicated moderately impaired cognition. Section G of the MDS revealed Resident #1 required physical help in part of bathing activity with one-person physical assist. Section G noted Resident #1 utilized a walker. Section GG of the MDS noted Resident #1 required partial to moderate assistance when showering; meaning the staff member lifts or holds trunk or limbs, but provides less than half the effort. Record review of Resident #1's care plan revised on 08/09/23 revealed the following focus areas: I have limited physical mobility r/t Disease Process Muscle Wasting and Atrophy initiated on 10/15/20. I have impaired cognitive function and impaired thought processes with fluctuating cognition r/t Dementia and impaired decision making initiated on 11/19/19. I have the potential for communication problems r/t Difficulty understanding others initiated on 10/16/20. I am at risk for falls because I have a fall risk score of 5 and risk factors such as Gait/balance problems initiated on 10/16/20. Record review of Resident #1's progress notes revealed a note on 10/13/23 at 10:00 PM by LVN A stating CNA B came to tell her Resident #1 was on the floor in the shower room. Resident #1 stated to LVN A, She [CNA B] came and told me to wait and she would help but I thought I could do it myself so I stood up and then I accidentally fell. The note stated the doctor had Resident #1 sent to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 3 of 5 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 11/13/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few hospital for evaluation due to hitting his head and taking a blood thinner. Another note dated 10/14/23 at 02:50 AM revealed an ER nurse contacted LVN A and informed her Resident #1 was ready for discharge and had a closed fracture to his left pinkie finger. Record review of Resident #1's Order Summary Report revealed an order of keep left Pinky finger and third finger wrapped together, if wrap comes off or needs changed d/t being soiled rewrap until follow-up appt on 11/30/23 dated 11/02/23. Record review of Resident #1's Fall Risk assessment dated [DATE] revealed a score of 11 which placed Resident #1 in the high risk for falls category. Resident #1 was noted to have had 1-2 falls in past three months and a balance problem while standing/walking. During an interview on 11/13/23 at 05:22 AM LVN A stated she remembered Resident #1 falling in the shower, but she would need to read her notes to remember specifics. She then looked on her computer at her notes and stated she remembered CNA B had Resident #1 seated in the shower and told him to stay seated while she left to retrieve a washcloth or a towel. LVN A said Resident #1 was a standby assist with showering. She said, He does everything himself, but we only have 3 or 4 residents who are allowed to be in the shower alone. LVN A said after CNA B left Resident #1 sitting in the shower, he tried to stand by himself and fell and hit his head on the wall and the floor of the shower. She stated she and another nurse on duty heard a thump and the two of them reached the shower at the same time CNA B returned to the shower and they saw Resident #1 lying on the floor. LVN A said Resident #1 was able to verbalize to her after the fall that CNA B told him to stay seated, but he thought he could do it himself, so he attempted to stand and he fell. LVN A said after she notified Resident #1's physician about the fall the physician had her send Resident #1 by ambulance to the hospital because he was on blood thinners, and he hit his head. During an interview on 11/13/23 at 05:52 AM CNA B stated she remembered Resident #1 falling in the shower. She said, I told him to wait, I had to get some washrags, but he didn't wait. She said when she left Resident #1 in the shower he was seated but he tried to stand up on his own instead of waiting for her to return. When asked if it was normal for her to leave a resident who required assistance with bathing alone in the shower, she replied, Normally I don't leave them. I told him to sit right there, but he didn't. During an interview on 11/13/23 at 10:23 AM BOM stated it was not at all okay to leave a resident alone in the shower if they required supervision to shower. During an observation and interview on 11/13/23 at 10:37 AM Resident #1 was lying in his bed with his eyes closed. He opened his eyes when his name was called. When asked if he remembered falling in the shower and hurting his finger he nodded, which indicated yes. During an interview on 11/13/23 at 11:48 AM CNA D stated she would never leave a resident who required assistance with showering alone in the shower. She said a possible negative outcome of doing so would be, He would fall. During an interview on 11/13/23 at 11:50 AM CNA E stated he would never leave a resident who required assistance with showering alone in the shower. He said a possible negative outcome of doing so would be, They try to get up and fall. During an interview on 11/13/23 at 12:02 PM CNA F was asked if she would ever leave a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 4 of 5 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 11/13/2023 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 0689 alone in the shower if the resident required assistance to shower. She said, Oh no ma'am. We're not supposed to do that. They have a chance of falling. Level of Harm - Actual harm Record review of facility policy titled, Falls-Evaluation and Prevention and dated 01/2014 revealed in part: Residents Affected - Few .Intrinsic risk factors for falls include .Gait and balance disorders .Muscular weakness .Confusion .Stroke .Depression .Previous falls .Extrinsic risk factors for falls are part of the resident's environment .The following are typical examples of extrinsic risk factors: . Wet floors . Record review of facility policy titled, Quality of Life - Resident Self Determination and Participation and dated 2016 revealed in part: . 1. Each resident is allowed to choose health care .consistent with his or her interests, values, and assessments .including: . b. Personal care needs, such as bathing methods . 2. In order to facilitate resident choices, the administration and staff: . d. Document and communicate any medical conditions or limitations that may inhibit or interfere with participation in preferred activities. 4. Residents are provided assistance as needed to engage in their preferred activities on a routine basis. Record review of facility policy titled, Accidents and Incidents - Investigating and Reporting and dated 2017 revealed no information relevant to this investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 5 of 5