Health inspection·April 15, 2025

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 2 CNAs (CNA C) reviewed for CNA certification. Residents Affected - Few The facility failed to ensure CNA C's certification was current before allowing her to care for residents. CNA C worked in the facility providing resident care, on a full-time basis, with an expired certification for the months of February and [DATE]. This failure could place residents who received care from CNA C in medical jeopardy, which could lead to the decreased physical, mental, and psychosocial well-being of each resident. Findings included: On [DATE] record review of employee records revealed CNA C's certification expired on [DATE]. An interview with the BOM/HR on [DATE] at 3:27PM revealed she was not aware CNA C's certification had expired. She stated she thought it was the responsibility of CNA C, not herself, to ensure the certification was up to date. CNA C had been on bereavement leave since [DATE] and was not interviewed. An interview on [DATE] at 3:30PM with the Admn., the DON, the ADON, and the BOM/HR revealed the DON was not aware CNA C's certification had expired. The DON stated the last day CNA C worked on the floor was [DATE] due to a death in the family. It was noted at that time, CNA C had been working for 2-months prior to [DATE] with an expired certification. The BOM/HR asked the DON if it was her responsibility to keep up with CNA certifications. The Admn stated it was both the responsibility of the DON and the BOM/HR, along with the employee to ensure all certifications were up to date. The Admn. stated the BOM/HR should have had a system for reviewing employee folders or files to ensure all HR paperwork was up to date. The DON should have had the dates of her employees' certifications and licenses in an electronic file on her computer where it was reviewed monthly. The Admin., the ADON, and the BOM/HR could not identify a negative outcome of having an uncertified CNA caring for residents. The DON stated CNA C had been a CNA for an exceptionally long time and she was competent in her skillset but could not give a negative outcome of CNA C providing care to residents with an expired certification. Page 1 of 4 676411 676411 04/15/2025 Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 676411 Page 2 of 4 676411 04/15/2025 Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226

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 676411 Page 3 of 4 676411 04/15/2025 Clarendon Nursing Home Ten Medical Center Dr Clarendon, TX 79226

F 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 676411 Page 4 of 4