Health inspection·October 30, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #43's care plan initiated 08/19/24 revealed the following focus area initiated on 08/19/24, I am on [name of hospice] hospice, under the care of [name of physician]. Another focus area initiated on 08/29/24 stated, I use antipsychotic medications and listed the name of the medication as well as his diagnosis of intermittent explosive disorder as the reason for the medication. Residents Affected - Few Record review of Resident #43's active orders dated 10/29/24 revealed the following: An order with start date of 08/19/24 to monitor Resident #43 for antipsychotic medication side effects. An order with start date of 08/16/24 to admit Resident #43 to hospice. An order with start date of 08/17/24 for Ariprazole oral tablet 15 MG (Ariprazole) Give 1 tablet by mouth one time a day related to INTERMITTENT EXPLOSIVE DISORDER. Record review of Resident #43's medication administration for August of 2024 revealed he received Ariprazole every day from 08/17/24-08/31/24. During an observation and interview on 10/29/24 at 10:24 AM Resident #43 was seated in his w/c in his room. He stated he was pleased with the care and services he received through hospice. An interview was attempted with MDS LVN on 10/30/24 at 08:17 AM by telephone. She did not answer the call. During an interview on 10/30/24 at 08:24 AM ADON stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN looked at resident charts to determine what medication and care they were receiving before completing the MDS. ADON stated MDS-LVN also gathered information regarding residents during the staff morning meeting. She stated an inaccurate MDS would negatively affect the rates the facility was paid to provide treatment to the resident. She stated that would negatively impact a resident because the facility would not have the funds needed to care correctly for the resident. During an interview on 10/30/24 at 08:31 AM ADM-IT stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN used the RAI as her policy when completing the assessments. ADM-IT stated MDS-LVN runs the medication list to find out what medications a resident is receiving before completing the MDS. She stated she did not think an inaccurate MDS would negatively affect a resident's care because nursing would still take care of the resident as needed. During an interview on 10/30/24 at 08:37 AM ADM stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN reads doctor's orders to assist in MDS completion. ADM stated an inaccurate MDS might result in the resident not receiving proper care plus I don't get the proper money. During an interview on 10/30/24 at 08:50 AM DON stated MDS-LVN was responsible for completing MDS assessments. She stated MDS-LVN looked in resident charts to find which cares and medications they were receiving. She stated an inaccurate MDS could negative impact a resident's care because the plan of care might be incorrect. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 2 of 16 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 10/30/2024 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 0641 2023 revealed the following: Level of Harm - Minimal harm or potential for actual harm . Section N: MEDICATIONS Intent: The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of . select medications were received by the resident. In addition, two medication sections have been added. The first is an Antipsychotic Medication Review. Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications. Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look-back period . Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period . Residents Affected - Few Section O SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Coding Instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. If no treatments, procedures or programs were received by, performed on, or participated in by the resident within the last 14 days or since admission/entry or reentry, check Z, None of the above. Hospice care Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 3 of 16 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 10/30/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 3 (Resident #2, Resident #26, and Resident #39) of 15 residents reviewed for accidents and hazards. The facility failed to perform quarterly safe smoking assessments on Resident #2, Resident #26, and Resident #39. These failures could place residents at risk of burns and/or injury. Findings Included: Record review of Resident #2's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diffuse traumatic brain injury with loss of consciousness of unspecified duration (a severe type of traumatic brain injury that occurs when the brain rapidly shifts inside the skull), lack of coordination, unspecified convulsions (a sudden, violent, irregular movement of a limb or of the body caused by involuntary contraction of the muscles and associated especially with brain disorders such as epilepsy), and parkinsonism (conditions that affect the ability to move and live independently). Record review of Resident #2's Quarterly MDS completed on 08/21/24 revealed the following: Section B: Resident #2's vision was impaired. Section C: Resident #2 had a BIMS score of 15, which indicated intact cognition. Section E: Resident #2 experienced delusions (misconceptions or beliefs that are firmly held, contrary to reality) and displayed behavioral symptoms directed toward others as well as himself. Section GG: Resident #2 had impairment to upper extremities on one side. He required supervision or touching assistance for eating, bathing, lower body dressing, transfers and bed mobility. He required set up or clean up assistance for oral hygiene, personal hygiene, upper body dressing, footwear (removal and application), and walking. He was independent in toileting. Record review of Resident #2's care plan completed on 09/09/24 revealed he was a smoker and required supervision while smoking due to a lack of coordination and impaired cognition. Record review of Resident #2's assessment tab in his EHR revealed a retired safe smoking assessment was completed on the following dates: 05/04/2019 10/10/2020 05/11/2021 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 4 of 16 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 10/30/2024 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 08/11/2021 Level of Harm - Minimal harm or potential for actual harm 11/10/2021 07/03/2023 Residents Affected - Some The assessment tab in his EHR revealed a new safe smoking assessment was completed on 10/29/2024. There were no safe smoking assessments performed for Resident #2 from 07/03/23 to 10/29/24. Record review of Resident #2's safe smoking assessment dated [DATE] revealed he required supervision while smoking, smoked 5-10 cigarettes per day, and smoked in the morning, afternoon, and evening of each day. Record review of Resident # 26's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a serious mental health disease that causes altered perception of reality), bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings), muscle weakness, syncope (dizziness) and collapse, and lack of coordination. Record review of Resident #26's quarterly MDS completed on 10/08/24 revealed the following: Section C: Resident #26 had a BIMS score of 3 which indicated severely impaired cognition. Section E: Resident #26 rejected care and wandered 1-3 days of the 7-day look back period. Section GG: Resident #26 had lower extremity impairment on one side and used a w/c. He required supervision or touching assistance across all ADLs except taking off and putting on footwear and personal hygiene where he required partial/moderate assistance. Record review of Resident #26's care plan completed on 09/10/24 revealed he was at risk for injury while smoking due to poor safety awareness and cognitive impairment. Resident #26 required supervision while smoking. Record review of Resident #26's assessment tab in his EHR revealed a retired safe smoking assessment was completed on the following dates: 11/17/2022 02/27/2023 07/03/2023 The assessment tab in his EHR revealed a new safe smoking assessment was completed on 10/29/2024. There were no safe smoking assessments performed for Resident #26 from 07/03/23 to 10/29/24. Record review of Resident #26's safe smoking assessment dated [DATE] revealed he had cognitive loss, required supervision while smoking, smoked 5-10 cigarettes per day, and smoked in the morning, afternoon, and evening of each day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 5 of 16 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 10/30/2024 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 - Minimal harm or potential for actual harm Record review of Resident #39's admission record dated 10/29/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, apraxia (difficulty in performing daily tasks), lack of coordination, dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle weakness, ataxia (poor muscle control causing clumsy movements), and need for assistance with personal care. Residents Affected - Some Record review of Resident #39's quarterly MDS completed on 09/12/24 revealed the following: Section C: Resident #39 had a BIMS score of 12 which indicated moderate cognitive impairment. Section E: Resident #39 rejected care 1-3 days during the 7-day look back period. Section GG: Resident #39 required supervision or touching assistance across all ADLs. Record review of Resident #39's care plan completed on 09/11/24 revealed he was at risk for injury while smoking related to a lack of coordination. He required supervision while smoking. Record review of Resident #39's assessment tab in his EHR revealed a retired safe smoking assessment was completed on the following dates: 04/13/2023 07/03/2023 10/03/2023 01/03/2024 The assessment tab in his EHR revealed a new safe smoking assessment was completed on 10/29/2024. There were no safe smoking assessments performed for Resident #39 from 01/03/24 to 10/29/24. Record review of Resident #39's safe smoking assessment dated [DATE] revealed he required supervision while smoking, smoked 5-10 cigarettes per day, and smoked in the morning, afternoon, and evening of each day. During an interview on 10/30/24 at 08:28 AM ADON stated DON was responsible for completing safe smoking assessments. She said the assessments were to be completed quarterly on each resident who smoked. She said the safe smoking assessments were stored under the assessment tab in the resident's EHR. ADON stated the assessments were not done quarterly because one safe smoking assessment form was retired and the new one failed to trigger in the system when it was due. She stated a possible negative outcome of not assessing residents for safe smoking on a quarterly basis was the facility would not know if the resident needed special equipment to smoke and the residents might burn themselves. During an interview on 10/30/24 at 08:35 AM ADM-IT stated all charge nurses were responsible for completing safe smoking assessments quarterly on all smoking residents. She said the assessments were kept under the assessment tab in the EHR. ADM-IT said a possible negative outcome of not assessing residents for safe smoking quarterly was, We are a nursing home, and the residents will decline eventually, they could be burned, or they could eat their cigarette. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 6 of 16 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 10/30/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/30/24 at 08:39 AM ADM stated charge nurses were responsible for completing safe smoking assessments. She said the assessments were supposed to be done quarterly and were kept under the assessments tab in the resident's EHR. She said if assessments were not completed quarterly residents could be unsafe to smoke due to disease progression. During an interview on 10/30/24 at 08:54 AM DON stated the nurses were responsible to complete safe smoking assessments and she and ADON were responsible to ensure the assessments were completed. She stated safe smoking assessments were not done for a period of time because corporate made a new one (safe smoking assessment) and it did not trigger to be done. DON stated safe smoking assessments were to be completed quarterly and were kept in the assessments tab in the resident's EHR. She said a possible negative outcome of not completing safe smoking assessments quarterly was residents might require enhanced supervision or not be able to smoke anymore and the facility would not know. Record review of facility policy titled Smoking Policy and dated 01/15/2021 revealed the following: . A smoking safety evaluation will be completed for all residents who smoke on admission change of condition, and quarterly. Record review of facility policy titled Smoking Policy-Residents and dated 2001 revealed the following: This facility has established and maintains safe resident smoking practices. 7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 7 of 16 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 10/30/2024 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 professional standards for food service safety in 1 of 1 kitchen reviewed for food service safety. The facility failed to label and date food in the refrigerator, freezer, and pantry. The facility failed to keep food in the refrigerator and freezer sealed. The facility failed to maintain cleanliness in the pantry. The facility failed to store all food at least 6 inches off the floor in the pantry. These failures could put residents at risk of food and pest borne illnesses. Findings Included: An observation of refrigerator 1 on 10/28/24 at 09:12 AM revealed the following: 1 clear plastic bag open to air containing what appeared to be lunch meat with no label or date. 1 square, opaque, plastic tub with a green lid containing what appeared to be jelly with no label or date. 1 box containing 6 sealed plastic bags of what appeared to be guacamole with brown spots throughout and a date printed on the plastic of 02/03/24. 1 square, opaque, plastic tub with a green lid containing what appeared to be slices of cheese with no label or date. 1 resealable plastic bag containing what appeared to be pasta and marinara sauce with no label and a date of 10/26. 1 bag of shredded mozzarella cheese in original packaging inside resealable plastic bag with no date and green specks throughout. 1 bag of shredded Parmesan cheese in original packaging inside resealable plastic bag with no date. 1 box of cream cheese, one third full with no date. 1 plastic tub with lid full of stacked sandwiches with no label and no date. An observation of refrigerator 2 on 10/28/24 at 09:21 AM revealed the following 1 square, opaque, plastic tub with green lid of jalapeno slices labeled and dated 10/04-10/19. 1 tray with small plastic cups with what appeared to be butter in each one. Covered with plastic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 8 of 16 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 10/30/2024 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 wrap. No label or date. Level of Harm - Minimal harm or potential for actual harm 1 opaque, plastic pitcher with red lid containing reddish liquid about 1/4 inch in bottom and some stuck to sides of pitcher with no label or date. Residents Affected - Many 1 square, opaque, plastic tub with green lid full of whitish substance with no label and no date. 1 large metal bowl covered with plastic wrap full of orange substance with no label no and date. An observation of Freezer 1 on 10/28/24 at 09:26 AM revealed the following: 1 box of egg patties open to air. An observation of the pantry on 10/28/24 at 09:27 AM revealed the following: A 5-pound tub of peanut butter with peanut butter smeared all around the outside of the lid and along the bottom edge of the tub in places. 1 5-gallon tub of what appeared to be corn flakes cereal 1/4 full with no label and no date. 1 5-gallon tub of what appeared to be bran flake and raisin cereal 1/3 full with no label and no date. 1 5-gallon tub of what appeared to be crispy rice cereal 3/4 full with no label and no date open to air. 1 5-gallon tub of what appeared to be O-shaped cereal 1/2 full with no label and no date. 1 5-pound buttermilk biscuit mix in bag with no date. 1 bag of powered sugar half full inside a resealable plastic bag with no date. 1/3 loaf of bread with best by date of 10/23. 1 and 3/4 bags of hamburger buns with best by date of 10/24. 1 shelf full of loaves of bread and bags of large tortillas 3 off the floor. 1 grocery bag containing 12 individual serving size resealable plastic bags containing what appeared to be animal crackers with no label and no date. 1 5-gallon tub 1/4 full of what appears to be flour with no label and no date 1 resealable gallon-size plastic bag full of what appears to be vanilla wafers with no label and no date. 1 large sealed bag of what appeared to be vanilla wafers with no label and no date. An observation of Freezer 2 on 10/28/24 at 09:36 AM revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 9 of 16 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 10/30/2024 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 1 large bag of what appeared to be tater tots with no label and no date. Level of Harm - Minimal harm or potential for actual harm 1 bag of lumpy whitish substance that appeared to be melted into a solid block on one end with no label and no date. Residents Affected - Many 1 bag of what appeared to be biscuit dough with no label and no date. 1 bag of what appeared to be chicken nuggets with no label and no date. An observation of Freezer 3 on 10/28/24 at 09:40 AM revealed the following: 2 resealable bags of what appeared to be raw chicken with no label and no date. During an interview on 10/28/24 at 09:10 AM DM stated she started her job as DM and had zero training. She stated she had her food manager license but had not received dietary management training. She stated the kitchen had been too short-staffed for her to be trained since she started as DM. She stated she had just recently been able to have days off. During an interview on 10/30/2024 at 08:26 AM ADON stated a possible negative outcome of undated, unlabeled food in the kitchen was residents could get some kind of illness or bacteria. She said a possible negative outcome for residents of food in the freezer being left open to air was residents not having a good, decent, proper meal to eat. During an interview on 10/30/2024 at 08:33 AM ADM-IT stated improperly labeled and dated food in the kitchen could result in residents having food poisoning. She stated food open to air in the freezer was just gross and residents might notice the taste of freezer burn or might not eat the food due to dryness and that could result in weight loss. She stated kitchen staff were responsible for ensuring food was labeled and dated and stored correctly. During an interview on 10/30/2024 at 08:39 AM ADM stated food that was not labelled and dated correctly could result in residents being served something that does not need to be served. During an interview on 10/30/2024 at 08:52 AM DON stated food that was not labelled and dated correctly could make residents sick. During an interview on 10/30/24 at 09:17 AM DM stated she dated food when it came into the kitchen. She stated, I just found out I am supposed to date it when it gets opened. She stated she learned that information during a mock survey. DM stated leftovers were dated by all kitchen staff with two dates, they day they go into the refrigerator and three days later, which is when they are to be thrown away. DM stated food in the refrigerator and in the freezer was to be sealed, no open to air. She stated food in the pantry should not be accessible to pests and the containers should be cleaned if they get dirty. DM stated all staff were responsible for labelling and dating food in the kitchen. She stated she trained her staff regularly one-on-one. DM stated if food was not labelled and dated correctly in the refrigerator or the pantry people can get sick. She stated peanut butter on the outside of the container in the pantry could result in pests. DM stated she did not know food had to be stored at least 6 inches off the floor. Record review of facility policy titled Refrigerators and Freezers and dated 2001 revealed the following: . This facility will ensure safe refrigerator and freezer maintenance, temperatures, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 10 of 16 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 10/30/2024 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 sanitation, and will observe food expiration guidelines. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. 'Use by' dates will be completed with expiration dates. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Residents Affected - Many Record review of facility policy titled Food Receiving and Storage and dated 2001 revealed the following: . Foods shall be received and stored in a manner that complies with safe food handling practices. 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 5. Non-refrigerated foods, . will be stored in a designated 'dry storage' unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) . 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). 11. Wrappers of frozen foods must stay intact until thawing. Record review of US Food and Drug Administration Food Code dated 2022 revealed the following: . Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: . 3) At least 15 cm (6 inches) above the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 11 of 16 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 10/30/2024 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 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 (CNA B) of 5 staff observed for resident care. Residents Affected - Few -CNA B did not perform the proper process, wash her hands, change gloves, or place a residents brief properly while performing incontinent care. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: During an observation on 10/29/24 at 10:59 AM of incontinent care performed by CNA B, CNA B cleaned the resident's rectal area first removing several wipes covered with BM, changed her gloves, used ABHR, placed new gloves, sprayed the resident's rectal area with moisture wipe, then wiped his rectal area with two more wipes. CNA B then picked up the new brief with her contaminated gloves and placed it under the residents. The resident was then rolled to his back. CNA B wiped the resident's penis with one wipe then pulled the new brief in place with her contaminated gloves and secured it. CNA B then removed her contaminated gloves and used ABHR. During an interview on 10/29/24 at 11:34 AM CNA B verified that she did remove her gloves and use ABHR then spray the resident's rectal area with moisture wipe, then use two more wipes to clean his rectal area, and then placed his new brief without removing her gloves or washing her hands. CNA B reported that she should have changed her gloves and washed her hands before putting on the clean brief. CNA B reported that if there had been any sign of feces on her gloves she would have had a problem but she did not see anything on her gloves, so she did not feel that not changing her gloves was an issue. CNA B did verify that she cleaned the resident's rectal area first before cleaning his peri area, that due to the residents having pooped she needed to clean his rectal area first. CNA B reported that she understood and had been instructed that a resident who had a BM was supposed to have that cleaned first before cleaning the peri area. CNA B stated, If you clean the back first when it's got poop you have that cleaned and then you won't get the front dirty. CNA B verified that the DON was the current infection control instructor and that she had been instructed on handwashing and glove changes. During an interview on 10/30/24 at 09:00 AM the DON with the ADON present reported that she expects her staff to complete all incontinent care with cleaning the peri area first then the rectal area before placing the new brief. The DON said this was done to prevent bacteria from the rectal area getting in the urethra and causing a UTI/infection. The DON reported that she also expected that infections could develop with glove changes and handwashing that are not done correctly because bacteria could be introduced. The DON expects glove changes/handwashing and/or sanitizer use frequently, anytime a staff member goes from dirty to clean, and before placing any new supplies such as briefs. The DON reported that if this process was not followed then a resident would be placed at risk for infection due to bacteria that would be on the dirty gloves that could be passed to the hands. The DON verified that she did teach staff on infection control, handwashing, and glove changes and that all direct care staff were instructed on the proper process for incontinent care and when to change gloves (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 12 of 16 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 10/30/2024 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 and use handwashing or ABHR/sanitizer. Level of Harm - Minimal harm or potential for actual harm Record review of the facility provided policy titled Handwashing/Hand Hygiene revised October 2023, revealed the following: Residents Affected - Few Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene f. before moving from work on a soiled body site to a clean body site on the same resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 13 of 16 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 10/30/2024 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 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 to maintain an effective pest control program so that the facility is free of pests for one of one facility reviewed for environment for 3 out of 3 days. Residents Affected - Some -The facility failed to prevent an infestation of flies and gnats based on observations at varied times over a 3-day period from 10-28-2024 to 10-30-2024. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings include: During an observation of room [ROOM NUMBER] on 10/28/24 at 09:45 AM with no resident present, observed was a partially eaten tray of food in the room on a bedside table with a meal ticket dated Supper: Sunday 10-27-2024 with Salisbury steak, garlic mash potatoes, and green beans listed on the meal ticket with the noted corresponding food partially eaten on the tray. Also noted were multiple flies and gnats on the tray, curtain, wall, and bed. During an observation and interview on 10/28/24 at 10:00 AM revealed Resident #2 was in his room laying on top of his bed. The resident was observed attempting to keep flies off his person. Five flies were observed to be either on him or his bed. The resident reported that the flies were a problem and verified that they were an issue when he eats. During an observation on 10/28/24 at 10:31 AM revealed four flies were noted on the PPE station outside of room [ROOM NUMBER], one fly on the hallway wall and one fly on the hallway floor. During an observation and interview on 10/28/24 at 10:33 AM revealed Resident #10 was observed in his room lying on top of his bed dressed in sweats and a t-shirt. Noted were several flies on his person and bed and he verified that the flies were an issue especially when he eats. During an interview on 10/28/24 at 11:58 AM LVN A verified that she found the resident tray in room [ROOM NUMBER] Bed B this am and removed it (at 10:07 AM observed by the surveyor). LVN A reported that she was aware that a tray left in a resident's room from the previous evening was an issue and stated, I'm sure you (this surveyor) saw the number of flies that were on that tray. LVN A reported that all trays should be removed from the resident's room within one hour of completing a meal. During the noon meal observation on 10/28/24 the following was revealed: 10/28/24 12:10 PM 2 flies on a table with two residents present. 10/28/24 12:12 PM Resident attempts to shoo fly from his coffee cup. 10/28/24 12:12 PM 5 flies on a table with three residents present. 10/28/24 12:23 PM A resident attempts to shoo a fly from his coffee cup. 10/28/24 12:26 PM A fly landed on a resident's food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 14 of 16 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 10/30/2024 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 0925 10/28/24 12:27 PM A fly landed on rim of a resident's coffee cup. Level of Harm - Minimal harm or potential for actual harm 10/28/24 12:30 PM A fly landed on a resident's fork. Residents Affected - Some During an observation on 10/28/24 at 02:21 PM revealed Resident #27 was in his bed sleeping on top of his covers. Observed were 5 flies on the resident while sleeping. The resident was observed changing positions several times. During an observation on 10/29/24 at 08:45 AM five flies were noted on the Resident #27's bed. The Resident was not present. During an observation and interview on 10/29/24 at 02:03 PM revealed wound care was performed for Resident #10 who was in his room sitting at the side of his bed. Noted were multiple flies in the room. Before the care started the resident made a statement that something needed to be done about the flies. LVN A reported that she would report the issue to the maintenance supervisor. During an interview on 10/28/24 at 03:03 PM the DON reported that a tray being left out was an issue and that all trays should be picked up within one hour of the meal being completed. The DON reported that it could result in an infestation such as the flies that were noted with this incident. The DON reported that she did not know why the staff did not pick up the tray for this resident the previous evening. The DON verified that staff were supposed to complete rounds every two hours. The DON reported that the Resident in room [ROOM NUMBER] could talk but that he will not make sense with his conversations, he will not remember anything, and he will become verbally aggressive if someone tries to talk to him for any length of time. During an interview on 10/29/24 at 08:48 AM and 08:59 AM this surveyor attempted to interview Resident #22 (the resident assigned to room [ROOM NUMBER]) and he did not respond to introduction or questions. He just starred at this surveyor and then started to become agitated. During an interview on 10/29/24 at 10:30 AM in a resident council meeting 19 of 20 anonymous residents stated the flies in the building bother them. There were loud exclamations and groans following the answer. One of the residents spoke up and said, They drive me crazy flying around my face and my ears all the time. During an interview on 10/29/24 at 02:14 PM LVN A reported that the situation with the flies was horrible mostly due to the resident's behavioral issues especially with urinating and defecating everywhere to include the outside courtyard. LVN A reported that the facility has tried multitude different approaches to deal with the flies and could not get the situation under control. LVN A reported that the flies could cause issues with infections such as with a wound. During an interview on 10/29/24 at 02:49 PM the Maintenance Supervisor reported that the facility has had a second pest control fly service completed outside of the usual monthly pest control service, that he spays with permethrin twice weekly; and he sweeps, and power washes the patio twice weekly due to the resident's constant urination and defecation. He stated the facility was looking into getting and automatic closing door for the patio due to the resident will not close the doors to keep out the flies. He stated the facility has added 12 fly lights, and he has automatic fly sprayers around the facility with food grade spray to address the issue. During an interview on 10/29/24 at 03:16 PM the DON reported that the flies were definitely and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 15 of 16 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 10/30/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm issue but that they did not know what they could do that they have not done already. The DON reported they have purchased $3000 dollars' worth of fly lights to increase the current fly lights, they have increased housekeeping hours to hopefully address the incontinence issues, and they were currently pricing the replacement cost of the back patio doors with automatic doors. The DON reported that flies could cause an issue with infection. Residents Affected - Some During an interview on 10/30/24 at 08:31 AM the Administrator reported that all meal trays delivered to resident rooms should be delivered as soon and the kitchen gets them ready, they should be covered, and they should be picked up 1 hour after the meal is completed. The Administrator reported that a meal tray left in the resident's room could result in issues such as flies and bugs. Record review of the facility provided Pest Control Statements revealed the facility received pest control service on the following dates: 8-16-2024 9-25-2024 10-23-2024 Record review of the facility provided policy titled Statement of Resident Rights undated, revealed the following: You have the right to: 1. all care necessary for you to have the highest possible level of health, 2. safe, decent, and clean conditions, Record review of the facility provided policy titled Quality of Life-Homelike Environment undated, revealed the following: Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment . 2. The facility staff and management shall maximize . a. Clean, sanitary, and orderly environment. Record review of the facility provided policy titled Food Preparation and Service revised November 2021, revealed the following: Food Distribution and Service: 12. Food that has been served to resident without temperature controls (e.g. trays, snacks, etc.) will be discarded if not eaten withing two hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 16 of 16