Health inspection·April 15, 2025

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete An interview with the Administrator on [DATE] at 5:27PM reflected monthly in-service trainings did not count as competency training in the aforementioned subjects, due to the fact that monthly in-services did not have a pre- or post-test and had no measure of staff competency but were informational and meant as a refresher course to keep vital information at the forefront of staff decision-making and resident care. There was no facility policy for the review of employee files by the BOM/HR or for the oversight of certificates by the DON. Event ID: Facility ID: 676411 If continuation sheet Page 2 of 4 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 04/15/2025 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for 4 out of 5 employees (LVN A, CNA B, CNA C and PTA) reviewed for required training. Residents Affected - Some The facility failed to ensure staff were properly trained in Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures and Dementia for 4 of 5 employees (LVN A, CNA B, CNA C, and the PTA) reviewed for training at hire and annually. This failure could place residents at risk of receiving care from individuals who did not have the knowledge and skills to properly provide safety from adverse events or other resident life and health complications. Findings included: Record review of employee records for LVN A reflected LVN A was hired at the facility on 03/18/2022 and had not received annual training through the facility on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since 09/24/2023. Record review of employee records for CNA B reflected CNA B was hired at the facility on 06/09/2023 and had not received annual training through the facility on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since 02/24/2024. Record review of employee records for CNA C reflected CNA C was hired at the facility on 02/28/2023 and had not received annual training through the facility on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since 02/28/2024. Record review of employee records for the PTA reflected the PTA was hired at the facility on an unknown date and had not received any training through the facility, on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia since hire. An interview with the BOM/HR on 04/15/2025 at 3:27PM reflected she was unaware LVN A, CNA's B and C, and the PTA were not up to date on their trainings. She stated she had spoken with the corporate office about trainings being provided to the facility staff, but nothing had been done at the corporate level. She stated she had asked the corporate office about the required instructional material of trainings, not the timing of trainings. The BOM/HR stated the PTA did not have trainings for Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, HIV, Restrains, Emergency Procedures, and Dementia on file with the facility because she assumed the PTA had done them through her contracted company. The BOM/HR had not asked the company for verification of the trainings for the PTA prior to hire and was unable to provide the telephone number for the contracted company, so the trainings for the PTA could have been verified. The BOM/HR stated LVN A, CNA B and CNA C should have been trained on Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia care through the facility, and could not explain why their training records were not up to date. The BOM/HR stated these trainings were done when an individual was hired and again (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676411 If continuation sheet Page 3 of 4 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 04/15/2025 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 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete annually. She stated the negative outcome of caring for residents without training could have been residents received incorrect or incomplete care by the untrained individual. Record Review of undated facility policy for required training reflected the following: There are certain in-service training courses that are required by State such as Blood Borne Pathogens, Restraints, Abuse and Neglect, Slip and Fall, Emergency Preparedness and Resident Rights upon hire and will vary by position and therefore some employees may be required to complete a minimum of courses while others will have a greater amount of training to be completed. Event ID: Facility ID: 676411 If continuation sheet Page 4 of 4