Health inspection·June 5, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #6's PASRR Level 1 Screening completed on 05/30/2019 indicated in section C0100 there was no evidence of this individual having mental illness. Further review of the medical records indicated there was no action taken after the facility identified Resident # 6 as having diagnoses of mental illness. Record review of Resident #48's undated face sheet indicated she was a [AGE] year-old female who originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder (feeling of dread, fear, and uneasiness), visual hallucinations (seeing things that are not there), and psychotic disorder with hallucinations (a mental disorder characterized by a disconnection from reality). Record review of the Comprehensive (admission) MDS assessment dated [DATE] in the section, Preadmission Screening and Resident Review, indicated Resident #48 did not have a serious mental illness. The MDS section I, Active Diagnoses, indicated Resident #48 had diagnoses of anxiety disorder and psychotic disorder. MDS section N indicated the resident received antipsychotic and antianxiety medications all 7 days of the review. Record review of the Comprehensive (quarterly) MDS assessment dated [DATE] in the section I, Active Diagnoses, indicated Resident #48 had diagnoses which included anxiety disorder and psychotic disorder. Section N indicated the resident received antipsychotic and antianxiety medications all 7 days of the review. Record review of the Comprehensive(annual) MDS Assessment, dated 08/12/2023, in section, Preadmission Screening and Resident Review, indicated Resident #48 did not have a serious mental illness. Section I, Active Diagnoses, indicated Resident #48 had diagnoses which included anxiety disorder and psychotic disorder. Section N indicated the resident received antidepressant and antianiety medications all 7 days of the review. Record review of the physician's orders dated June 2024 indicated an order dated 09/21/2023 for Resident #48 to receive buspirone (a medication for anxiety) for treatment of anxiety disorder three times a day and an order dated 12/18/2023 for Resident #48 to receive Risperdal (an antipsychotic medication) for treatment of psychotic disorder twice a day. Record review of Resident #48's PASRR Level 1 Screening completed on 08/03/2022 indicated in section C0100 this resident did not have evidence of having a mental illness. During an interview with MDS/LVN A on 06/05/2024 at 9:25 AM, she said she was responsible for tasks related to PASRR and MDS processes. She said she was hired in 2020 and was not aware a corrected Form 1012 to correct the original PASRR Level 1 had not been completed. She said she would contact the local authority and address it immediately. During an interview with the DON on 06/05/2024 at 09:50 AM, she said the MDS Nurses were responsible for MDs and PASRR tasks. She said she expected the PASRR tasks to be done correctly and timely. During an interview on 06/05/2024 at 10:45 AM MDS/LVN A said she would contact the local authority concerning the inaccurate PASRR and get it corrected. During an interview with MDS/RN on 06/05/2024 at 04:00 PM, she said she and MDS/LVN A use the Long-Term Care (LTC) User Guide for Preadmission Screening and Resident Review (PASRR) as their reference (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676300 If continuation sheet Page 2 of 3 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 06/05/2024 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 0644 for PASRR associated tasks. She said a failure to notify the local authority of residents with diagnoses of mental illnesses could result in a resident not receiving services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676300 If continuation sheet Page 3 of 3