Health inspection·April 14, 2023

F 0760 and personal hygiene. The MDS indicated Resident #1 required assistance with eating. Level of Harm - Immediate jeopardy to resident health or safety Record review of the care plan last revised [DATE] indicted Resident #1 had and increased risk for injury related to hypertension with a goal of maintaining blood pressure range of 110-135 systolic and 70-85 diastolic. Residents Affected - Few Record review of a nursing progress note dated [DATE] at 9:41 p.m. written by LVN A indicated she received a call from nursing management that there had been a medication error with Resident #1 receiving another resident's nighttime medication along with her own. The nursing progress note indicated LVN A assessed Resident #1 and found her with a blood pressure 65/34 and very lethargic. The nursing progress note indicated Resident #1 asked LVN A to just let her sleep. The nursing progress noted indicated LVN A attempted to call the physician with no answer. The nursing progress note indicated Resident #1 was transferred to the emergency room. Record review of the hospital records dated [DATE] through [DATE] indicated Resident #1 was admitted to the hospital with diagnoses of hypotension and medication overdose, accidental or unintentional. Record review of the Medication Error Investigation Worksheet dated [DATE] indicated Resident #1 had received approximately half of another resident's crushed bedtime medications along with her own crushed bedtime medications. The Medication Error Investigation Worksheet indicated the reasons for the error was failure to check medication administration record, failure to follow procedure, failure to identify patient, and misread order/dose. The Medication Error Investigation Worksheet indicated Resident #1 was assessed and sent to the emergency room due to decreased blood pressure. The Medication Error Investigation Worksheet indicated MA B was suspended pending investigation and staff were re-educated regarding medication administration policies and procedures. Record review of the Corrective Action Form dated [DATE] indicated MA B was suspended on [DATE]. The Corrective Action Form indicated the reason for suspension was dispensing wrong medication to Resident #1 resulting in the resident being sent to the hospital. Record review of the Termination Form dated [DATE] indicated MA B last worked on [DATE]. The Termination Form indicated MA B was terminated due to gross misconduct. During an interview on [DATE] at 8:58 a.m. MA B said she had crushed both Resident #1's and her roommate's bedtime medication and entered the room with both cups of medication. MA B said Resident #1 was not receiving blood pressure medication during this medication pass. MA B said she administered half of Resident #1's roommate's medication to Resident #1. MA B said when she realized what she was doing she panicked, then administered Resident #1 her correct medications. MA B said with the medications being crushed there was no way to determine how much of each medication that Resident #1 had received. MA B said she administered 2 other residents their medication following the error before contacting the DON. MA B said she asked to be relieved by another medication aide and left the building. MA B said she did not notify the charge nurse of the medication error, and that the DON made the notification of the medication error to the charge nurse. MA B said she should have prepared, crushed, and administered the resident's medication one at a time to prevent the medication error. During an interview on [DATE] at 10:11 a.m. the physician said he was notified of the medication error involving Resident #1. The physician said the medications Resident #1 received caused her blood pressure to drop significantly below her baseline. The physician said preparing one resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676300 If continuation sheet Page 2 of 6 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 676300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Oaks 1901 S Trade Days Blvd Canton, TX 75103 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 0760 medication at time cuts down on medication errors and the opportunity for errors. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 10:18 a.m. LVN C said staff should never prepare more than one resident's medication at a time. LVN C said preparing one resident's medication at a time prevented medication errors. LVN C said in the event of a medication error the Administrator, DON, physician, and family should be notified immediately and the resident should be assessed. LVN C said if the resident had an adverse reaction the physician should be notified and depending on the severity of the reaction the resident should be sent to the emergency room. Residents Affected - Few During an interview on [DATE] at 10:21 a.m. MA D was able to name the 8 rights of medication administration. MA D said staff should not ever prepare more than one resident's medication at a time. MA D said preparing more than one resident's medication at a time could lead to a medication error. MA D said in the event of the medication error she would report to the charge nurse (her immediate supervisor) immediately. During an interview on [DATE] at 10:27 a.m. Resident #1 said she was doing well. Resident #1 said she had recently gotten out of the hospital and was feeling much better. Resident #1 said she had been hospitalized due to receiving the wrong medications. Resident #1 said it was scary. Resident #1 said things are better now. During an interview on [DATE] at 10:41 a.m. the DON said she expected staff to not pre-prepare medications and only prepare and administer on resident's medication at a time. The DON said MA B immediately suspended, and another MA took her place. The DON said MA B was eventually terminated due to the medication error. The DON said to prevent further medication errors nursing management was performing random audits, weekly medication cart checks, and random observations of medication pass. During an interview on [DATE] at 12:30 p.m. LVN A said on [DATE] she received a call from the DON regarding the medication error for Resident #1. LVN A said the DON told her Resident #1 had received approximately 1/2 a cup of crushed medication that were not her own including 4 blood pressure medications. LVN A said she could not confirm what medication Resident #1 actually received due to the medication being crushed. LVN A said an in-service was done following the incident regarding proper medication administration and not preparing/administering more than one resident's medication at a time. LVN A said if a medication error occurred it should be reported immediately. During an interview [DATE] at 12:42 p.m. MA E worked at the facility as a medication aide Monday through Friday 2:00 p.m.-10:00 p.m. and double weekends. MA E said they had recently received an in-service regarding medication administration. MA E said the in-service included not preparing/administering more than one resident's medication at a time and reporting a medication error immediately. MA E said the importance of not preparing/administering more than one resident's medication at a time was to prevent medication errors. During an observation of medication pass on [DATE] at 12:23 p.m. MA D checked medication against MAR to ensure right medication and dosage was given to the right resident. No issues noted during medication pass. No other medications were noted already prepared sitting in the medication cart and no other residents medication were prepared/administered at the same time. During interview on [DATE] at 11:15 a.m. the DON said the recent medication error was discussed in a QAA Committee Meeting on [DATE]. The DON said currently, she is and has been conducting unexpected spot checks of CMA's and nurses, during medication pass. She said going forward, the spot checks (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676300 If continuation sheet Page 3 of 6 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 676300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Oaks 1901 S Trade Days Blvd Canton, TX 75103 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few will continue, and she will be conducting weekly medication cart audits. She said she will be updating all competencies for CMA's first and then carry over to all nurses. All competencies will be repeated every 6 months. Any medication error, during times of completing competencies, will result in re-education with that staff member. She said egregious medications errors may result in disciplinary actions. Record review of the facility's Medical Management Program policy last revised [DATE] indicated, The facility implements a medication management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements Authorized staff must understand The 8 Rights for administering medication: 1. The Right Patient/Resident, 2. The Right Drug, 3. The Right Dose, 4. The Right Time, 5. The Right Route, 6. The Right Charting, 7. The Right Results, 8. The Right Reason .medications supplies for an individual patient/resident are not administered to another patient/resident .The authorized staff member or licensed nurse will only prepare one resident's medications at a time. Pre-pouring medication is NOT an acceptable or safe practice . The Administrator was notified on [DATE] at 4:06 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:09 p.m. The facility's Plan of Removal was accepted on [DATE] at 3:07p.m. and included: The identified resident has returned to the facility and is at baseline with no further concerns. The identified employee was suspended on [DATE] pending the outcome of the investigation. All residents who reside in the facility and receive medications have the potential to be affected by the alleged deficient practice. The Facility Activity report and the 24- hour report for the past 24 hours was reviewed by the Director of Nursing/designee to validate that no change of condition was identified that could be the result of a medication error. There were none identified. Facility wide audit conducted of all non-crushable medications on [DATE] at 8:00 p.m. any non-crushable medications orders have been updated to read do no crush. Licensed Nurses and Certified Medication Aides were re-educated on Medication Administration including the 8 Rights for administering medication. Education included: that under no circumstances do we ever set up medication pass in advance, pull medications for med pass 1 resident at a time, performing the 3-way check, monitoring and reporting. The Right Patient/Resident The Right Drug The Right Dose The Right Time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676300 If continuation sheet Page 4 of 6 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 676300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Oaks 1901 S Trade Days Blvd Canton, TX 75103 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 0760 The Right Route Level of Harm - Immediate jeopardy to resident health or safety The Right Charting Residents Affected - Few The Right Reason The Right Results Medication administration competencies completed with Licensed nurses and Certified Medication Aides using the Medication Administration Competency tool from the staff education orientation policy and procedure manual. Competencies completed by the Director of Nursing/designee. This was completed on [DATE] at 8:00 PM. This Re-education and competencies began on [DATE] and will be completed on [DATE] at 8:00 PM. Anyone not receiving this re-education by this time will receive prior to next scheduled shift. This will be included in new hire orientation and for agency staff. The 24-hour report and the Facility Activity report will be reviewed in clinical morning meeting to identify any change of condition that may be related to a potential medication error. The resident will be assessed and physician notified for further direction. The Medical Director was notified on [DATE] at 4:09 PM by telephone of the Immediate Jeopardy and the contents. An Ad Hoc Quality Assurance Performance Improvement meeting was held on [DATE] at 5:06 PM to discuss the contents of this plan. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the Nursing Medication Administration competencies for licensed nurses dated [DATE] through [DATE] indicated all licensed nurse who had been observed for medication administration competencies had been checked off by the DON as performing medication administration competencies accurately with no issues. Record review of the Nursing Medication Administration competencies for the MAs dated [DATE] through [DATE] indicated all MAs who had been observed for medication administration competencies had been checked off by the DON as performing medication administration competencies accurately with no issues. Record review of the Pharmacy Services audits dated [DATE], [DATE], and [DATE] indicated medication cart audits were being performed to ensure the medication cart were locked when unattended, there were no preset/pre-prepared medications in or on top of the cart, there were no loose pills in the cart, the carts were free of expired products and medications, and all items were properly dated when opened. Record review of a random sample of 5 resident's medication orders indicated medications not to be crushed included special instruction in the physician orders included DO NOT CRUSH starting [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676300 If continuation sheet Page 5 of 6 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 676300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Oaks 1901 S Trade Days Blvd Canton, TX 75103 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interviews with staff on [DATE] between 9:08 a.m. and 10:36 a.m. (LVN F, MA G, LVN H, RN J, LVN K, LVN C, MA L, MA D, LVN M, LVN N, the MDS nurse, LVN P, MA E, LVN A, and the DON) were performed. During the interviews the staff were able to list the 8 rights of medication administration, said resident's medications should not be pre-prepared, and medications should be administered to one resident at a time. Record review of the QAPI meeting sign in-sheet dated [DATE] indicated the facility had held a QAPI meeting and all required attendees were in attendance including the Medical Director, Administrator, DON, ADON, Dietary supervisor, Maintenance Supervisor, SW, Nurse Assessment Coordinator, Staff Development Coordinator, Human Resources Manager, and Director of Rehab. Event ID: Facility ID: 676300 If continuation sheet Page 6 of 6