Health inspection·January 12, 2024

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few gangrene (the death or decay of body tissues), and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) Record review of the consolidated physician's orders dated 1/09/2024 indicated Resident #1 had an ordered referral for psychiatric services on 4/14/2022, and on 8/29/2023. There were no antipsychotic or antidepressant medications ordered on Resident #1's consolidated physician's orders. Record review of Quarterly MDS dated [DATE] indicated Resident #1 understood and was understood by others. The MDS in the section of Cognition Pattern C0100 had a (-) meaning unable to determine the response, in the section for the BIMS assessment C0200 also had a (-), in the section Recall C0400 there was also a (-). The MDS in section C0700 indicated Resident #1's memory short-term and long-term both indicated her memory was intact. The MDS in the section C1310 indicated there was no evidence of an acute change in mental status, and no behaviors of inattention, or disorganized thinking. The MDS in the section Mood D0100 indicated a (-). The MDS section D0150 Resident Mood Interview indicated (-) in column 1 and blank in column 2. The MDS in section D0160 a (-) was documented. The MDS section D Mood the staff assessment of Resident #1's mood indicated she had no symptoms of little interest or pleasures, feeling down or depressed, feeling tired, poo appetite, indicating they feel bad about self, trouble concentrating, moving, or speaking slowly or fast, stating life not worth living. The MDS reflected in Mood J being short-tempered, easily annoyed marked yes and 12-14 days in column 2. Section E Behaviors of the MDS indicated Resident #1 had no hallucinations or delusions. The MDS indicated in E0200 Behavioral Symptoms indicated physical behaviors directed toward others occurred 1-3 days, verbal behavior symptoms directed at others occurred 4-6 days, and other behavioral symptoms not directed at others (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds). The MDS in section E0800 Rejection of care indicated Resident #1 displayed this behavior 4-6 days but less than daily. The MDS indicated in Section GG Resident #1 was independent with eating, dependent with toileting and personal hygiene, and refused bathing, dressing. The MDS in section I Active Diagnosis indicated Resident #1 had depression other than bipolar, and psychotic disorder other than schizophrenia. The MDS assessment did not indicate Resident #1 had a diagnosis of schizophrenia. The MDS in section M indicated Resident #1 had no skin conditions. Section M of the MDS indicated Resident #1 was not receiving any antipsychotic or antidepressant medications. The MDS indicated in Section Q the family, significant other, legal guardian, and other legally authorized representative participated in the assessment and goal setting. The MDS indicated Resident #1's assessments in sections B, C, E, and Q were completed by the social service staff. Record review of the care plan dated 9/21/2021 and revised on 9/25/2023 indicated Resident #1 makes poor safety choices as evidenced by refusal of wound care to foot, hospitalization, and hospice. The goal of the care plan was Resident #1 wound not have adverse effects related to the refusal of care. The interventions of the care plan were to attempt to monitor resident in regard to safety choices; notify the doctor, administrator, DON, and supervisor in regard to poor safety choices that place resident at risk implemented on 8/19/2021 and educated Resident on risks associated with poor safety choices implemented on 8/19/2021 this care plan failed to implement any current interventions. The care plan indicated Resident #1 was at risk for infections related to refusal to allow her room to be cleaned. The goal of the care plan was Resident #1 would not have any adverse effects related to her refusal. The interventions included attempt to clean the room throughout the day by housekeeping and nursing dated 10/28/2022, attempt to tidy the room when care provided dated 10/28/2022, and educate Resident #1 on the risks of living in unclean environment dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 2 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 10/28/2022 there care plan failed to implement current interventions. The care plan dated 8/19/2021 and revised on 11/30/2022 indicated Resident #1 had a behavior problem as evidenced by yelling and cursing at staff, demeaning and derogatory comments to staff, allowing only limited staff members to provide care, calling 911, refuse to allow trays to be removed from room, making false accusations, refusing to allow call light to be turned off the goal of the care plan was Resident #1 would have fewer episodes of outbursts. Resident #1's care plan interventions included 2 persons to offer and provide care at all times, anticipate and meet the resident needs allowed reviewed on 8/31/2023, anticipate and meet the resident's needs as allowed revised on 8/31/2023, assist the resident to develop more appropriate methods of coping and interacting and encouraged Resident #1 to express feeling appropriately revised on 8/19/2021. Resident #1's care plan interventions indicated she would have all procedure explained before starting and allow time for adjustment to change dated 8/19/2021. Resident #1's care plan intervention included to monitor behavior episodes and attempt to determine underlying cause and document dated 8/19/2021. Resident #1's care plan interventions indicated to refer Resident #1 to psychological services dated 8/30/2023. Resident #1's care plan failed to address her behaviors with new interventions and revise with interventions that promoted stability with her mental illness. Record review of a Comprehensive Care Plan Conference Summary dated 8/30/2023 indicated Resident #1 refused environmental care, refuses care, yells, curses, calls 911, verbal outbursts, and was at high risk for impaired skin. The care plan conference was signed by the AD, occupational therapist, the social services staff person, dietary manager, and the DON. The care plan conference was not signed by Resident #1 or the responsible party. Record review of an undated Comprehensive Care Plan Conference Summary indicated Resident #1 had multiple behaviors, unavoidable skin issues, and Buerger's disease. The conference was signed by the MDS nurse, the activity director, and social services staff person. Resident #1 or the responsible party signature area was left blank. Record review of a Wound-Weekly Observation Tool dated 2/16/2023 indicated Resident #1's left toes wound site was acquired since admission with a date of 11/21/2022. Resident #1's wound measured 0x0x0, with no undermining, no tunneling, 100 % skin intact, no eschar, no drainage, an odor was present, but the wound was determined to be healed . Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 2/21/2023 indicated Resident #1 scored a 0 due to not being assessed. Resident #1 refused to participate in the assessment and the assessment indicated Resident #1 said close the door when you leave. Record review of a BIMS (Brief Interview for Mental Status) assessment dated [DATE] indicated Resident #1 score was a 10 indicating moderately impairment. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of a Psychotherapy Intake Note dated 4/20/2022 indicated Resident #1 was seen by a therapist for 1 hour. The therapist indicated Resident #1 was referred due to a history of depression and psychosis. The note indicated Resident #1 was oriented to person, place, and time. The note indicated Resident #1's mood was euthymic (normal display of emotion), affect was congruent with Resident #1's mood, Resident #1 had good attention, and appropriate thought content. The note indicated Resident #1 denied any mental health issues and indicated her health records were falsified to keep her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 3 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in the facility against her will. The note indicated she believed the staff were trying to murder her and the only way to get help was to meet her fiancé. The note indicated Resident #1 believed the business office had stolen money and the claim was validated by the state agency even though she had not found a letter stating so. Resident #1 discussed previous traumas at other nursing facilities and alluded to some abuse when growing up. The note indicated Resident #1 believed she was in a relationship with a famous musician. The note indicated Resident #1 hoped to buy a gift card to purchase a fan club membership in so that she could spend time with the musician in person. The therapist documented the diagnosis of Major depressive disorder, single episode severe, and schizophrenia spectrum and other psychotic disorders. The note indicated Resident #1's presented with depression and psychosis. The goal of Resident #1's treatment was to reduce depression, psychosis, and improve sense of well-being in the facility. The estimated completion was 12 months for Resident #1. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress Note dated 5/04/2022 indicated the session lasted 53 minutes with Resident #1. The note indicated Resident #1 had the diagnosis of Major Depressive Disorder, single episode severe, and Schizophrenia Spectrum and other psychotic disorder. The note indicated Resident #1 was alert oriented to person, place, and time. The note indicated her mood was normal, and her affect was congruent with her mood. The note indicated Resident #1 was not having a good week. The note indicated Resident #1 continued to believe she was held against her will and they were still trying to kill her. The note indicated Resident #1 continues to hope to see her fiancé soon and believed he was trying to come and visit with her. The note indicated Resident #1 was unable to call the person because he was in Europe and her phone does not call Internationally. The note indicated Resident #1 continues to be upset no one will purchase her a $2000 gift cared for her. Resident #1 said she could not notify the ombudsman or the state agency as they hang up on her. The note indicated Resident #1's interventions included rapport building, exploration of coping patterns, exploration of emotion, exploration of relationship patters, supportive reflection and symptom management. The note indicated there was no progress in the reduction of symptoms of depression, symptoms of psychosis, or an improved sense of well-being. The note indicated Resident #1 would be treated weekly. Record review of a Psychotherapy Progress Note dated 5/11/2022 indicated the therapist was with Resident #1 53 minutes. The note indicated Resident #1 oriented to person, place, and time. The note indicated Resident #1's mood and affect were congruent, attention was good, thought content appropriate. The resident reported she is not having a good week. The note indicated Resident #1 continues to believe she is held against her will and they were trying to kill her. The note indicated Resident #1 believes her fiancé would be able to visit. Resident #1 said she had been able to speak with her fiancé some this week but had not mentioned to issues of international calling. According to the note Resident #1 continued to be upset with not being able to purchase the $2000 gift card. The note indicated Resident #1 was hoping to see the orthopedic surgeon to strengthen her leg. The note indicated Resident #1 believed she needed someone in Dallas as they provide better care. Resident #1 was noted as indicating she would need physical therapy after the surgery. The note indicated Resident #1 does not want to stay in any nursing facility. Staff had reported Resident #1 called 911 twice last week and left the line open. Resident #1 reported a police officer had come to the facility and called her crazy in front of the staff. The note indicated Resident #1 indicated the police officer threatened to take her to court and make the facility her guardian. The note indicated Resident #1 believed this was a violation of her rights. The notes indicated the progress in reduction of symptoms of depression, reduction of symptoms of psychosis, and the reduction of sense of well-being was maintained. The note indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 4 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 called the therapist's office on 5/13/2022. The note indicated Resident #1 wanted to inform the therapist of her big toe on her bad foot was infected. The note indicated Resident #1 indicated the staff were not helping or treating her foot. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress note dated 6/01/2022 indicated the therapist was with Resident #1 60 minutes. The note indicated Resident #1's diagnoses were Major Depressive Disorder, single episode, severe, and Schizophrenia Spectrum and other Psychotic Disorder. The note indicted Resident #1 was oriented to person, place and time. The note indicated Resident #1 continued to report not having a good week, as indicated by expressing she believed she was held against her will, and they were trying to kill her. Resident #1 indicated to the therapist had found some new orthopedic surgeons in a hospital in Dallas. The note indicated Resident #1 hoped the therapist called all the physician's and to explain her emergency situation so they will quickly take her. The note indicated Resident #1 attempted to message one of the surgeons on an App, but never received a response. The note indicated Resident #1 hoped the FBI would find her friends in Arizona who would loan her some money so she could leave with her fiancé's manager. The note indicated Resident #1 had spoken of suicide attempts but had promised God she would never try gain. The note indicated Resident #1 denied any current suicidal ideation, plan, means, or intent. The note indicated the treatment progress for Resident #1 continued to be maintained. The note indicated Resident #1 called the therapist's office indicating she had something urgent to discuss. The therapist indicated Resident #1 had not mentioned this concern during the therapy session. The note indicated Resident #1 would continue to be seen weekly. Record review of a Psychotherapy Progress Note dated 6/22/2022 indicated Resident #1 was seen by the therapists for 46 minutes. The therapist indicated Resident #1 was angry this week. The note indicated Resident #1 was upset with the therapist since the therapist had not provided an envelope and stamps for Resident #1 to mail money to her fiancé. The note indicated the therapist indicated the dangers of mailing cash as well as the therapeutic boundaries. The note indicated Resident #1 attempted to switch places and tried to provide therapy to the therapist and become frustrated when the therapist would not allow this to occur. The note indicated Resident #1 believed the therapist was there to get easy blood money from Medicare and does not believe the therapeutic relationship was what she needed at present. The note indicated Resident #1 was placed on an as needed status. The note indicated Resident #1 had no progress in the reduction of depressive symptoms, psychosis symptoms or in the sense of well-being . Record review of Resident #1's clinical record revealed there were no further treatments noted from a psychotherapist after 6/22/2022. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 8/03/2023 indicated Resident #1 scored an 8 indicating she was mildly depressed. Record review of a Unavoidable Wound Documentation assessment dated [DATE] indicated Resident #1 had peripheral vascular disease, chronic bowel incontinence, thyroid disease, impaired mobility, and cognitive impairment. The assessment indicated Resident #1 had the head of her bed elevated the majority of the day. The assessment in Resident Compliance indicated Resident #1 refuses care and has psychosis this form was signed by the physician on 9/21/2023. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 10/23/2023 indicated Resident #1 was not assessed for depression due to her refusal to participate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 5 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of the medication administration record dated December 2023 (a seperate treatment administration record was not avaiable) indicated Resident #1 had an order dated 9/22/2022 for the application of Betadine to the left great toe redness three times daily as needed. The medicaton administration had no indications this treatment was offered, refused, or performed. Record review of the electronic medication administration record dated December 2023 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of the electronic medication administration record dated January 2024 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of a physician's progress note dated 12/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for her high blood pressure, and reflux disease (stomach acid or bile irritates the food pipe lining). The physician's progress note indicated the past medical history of psychosis and major depressive disorder (recurrent and moderate). The physician's progress note failed to address a psychological examination and indicated Resident #1's skin was warm, dry, no rashes, and no suspicious lesions. The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a physician's progress note dated 7/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for coronary artery disease (damage or disease in the heart's major blood vessels) and weakness. Resident #1's past medical history included psychosis and major depressive disorder. The assessment indicated Resident #1 had warm and dry skin with no suspicious lesions. The neurological assessment indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a physician's progress note dated 8/09/2023 completed by the nurse practitioner indicated Resident #1 was seen for neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet) and reflux disease. The note indicated the nature of the neuralgia was general neuralgia affecting both legs with a moderate severity. The note indicated Resident #1's skin was warm, dry, no suspicious lesions, and no rashes. The note failed to mention Resident #1's left foot condition, and the neurological exam indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression . Record review of a Social Determinants of Health assessment dated [DATE] completed by the social worker designee/marketer indicated Resident #1's assessment included her ethnicity, race, language, need of interpreter to communicate with a doctor or health team, lack of transportation, how often does she require assistance with reading, and how often does she feel lonely or isolated. The social health assessment failed to ascertain information regarding Resident #1's current or past behavioral health needs, assess the on-going behaviors and identify triggers and interventions, provide in-sight on the need of outside resources. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 6 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0684 Record review of Resident #1's progress notes dated 9/12/2023 to 1/11/2024 indicated: Level of Harm - Immediate jeopardy to resident health or safety Progress note dated 9/12/2023 at 2:57 p.m., LVN G documented the psychiatric nurse practitioner was present for a psychological exam and Resident #1 refused. The progress note failed to reflect Resident #1's physician was notified of the refusal for psychiatric services. Residents Affected - Few Progress note dated 9/23/2023 at 11:21 p.m., LVN C documented he offered incontinent care and Resident #1 started yelling get out, get out, you murderers! The progress note failed to denote Resident #1's physician was notified of the delusions. Progress note dated 9/26/2023 at 4:00 a.m., LVN C documented Resident #1 cursed loudly and yelled obscenities at the nursing staff when offering incontinent care. The note failed to indicate LVN C notified the physician of the verbal aggressive behaviors. Progress note dated 9/26/2023 at 7:30 a.m., LVN A documented Resident #1 indicated she need a brief change. LVN A indicated she offered a total bed bath. LVN A indicated Resident #1 refused and stated, I don't want you tearing my flesh apart more than you already have. LVN A documented Resident #1 stated during repositioning stating, you both are going to hell, [NAME]. God does me justice and you will both rot in hell and burn for eternity. The note failed to indicate LVN A notified Resident #1's physician of the delusions (of being harmed) and religiosity thoughts. Progress note dated 10/02/2023 at 9:17 a.m., LVN A indicated, Resident #1 continued to refuse care and left foot continued to decline related to Bueger's Syndrome. The note indicated Resident #1 refused to allow staff to touch her foot, clean or treat. The note indicated staff had made multiple attempts. The note indicated the foot appeared to be black on the toes with crusty like covering up to ankles. The note indicated multiple attempts were made to send Resident #1 to the hospital as the foot had no circulation and become necrotic. Progress note dated 10/02/2023 at 1:14 p.m., LVN A indicated the wound care specialist visited and Resident #1 refused care and treatment. The progress note indicated Resident #1 commenced to yelling and screaming at staff. The note failed to indicate Resident #1's physician was notified of her refusal of care and verbally aggressive behaviors. Progress note dated 10/03/2023 at 5:05 a.m., LVN B documented Resident #1 refused incontinent care this shift. The progress noted failed to reflect the acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Progress note dated 10/13/2023 at 8:55 a.m., LVN A documented Resident #1 requested to have incontinent care performed. LVN A documented after Resident #1's medication administration, and a sip of water Resident #1 threw the remaining water on LVN A and said, cool off bitch and burn in hell. The note indicated the Administrator was informed. LVN A failed to document the notification of the physician related to the aggressive physical behaviors. Progress note dated 10/30/2023 at 10:25 a.m., LVN A documented Resident #1 continue to refuse care and her left foot continued to decline. The progress noted indicated Resident #1 refused to allow staff to touch foot, clean, or treat. The progress note indicated LVN A documented the foot has black toes with crusty like covering up to Resident #1's ankles. LVN A documented Resident #1's left foot had no circulation and was necrotic. LVN A failed to document to notify Resident #1's physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 7 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Progress note dated 11/03/2023 at 10:21 a.m., the DON documented during the weekly skin check Resident #1 refused care. The DON documented the Resident #1's left foot was withering and changing to a dark color with dry skin flaking off related to the diagnosis of Buerger's Syndrome. The DON documented the Resident #1's refusal of staff to touch the foot, clean or treat the foot. The DON documented Resident #1's left foot had black toes with a crusty like covering up to sock line. The DON documented Resident #1's fingertips had discolored areas on the middle of the fingers. The DON documented the physician was notified and the nurse practitioner was present for the offering of treatment, hospitalization, or hospice. The DON documented after extensive attempts Resident #1 was screaming get out of my room. The progress note failed to indicate any behavioral health care was offered. Progress note dated 11/05/2023 at 2:21 a.m., LVN C documented Resident #1 refused peri-care during each round and said, you all are bothering me so much on purpose. Progress note dated 11/06/2023 at 8:52 a.m., LVN A documented the weekly skin assessment was performed and Resident #1 has withering and callus with discoloration to the left great toe. LVN A documented Resident #1 refused care to the toe. LVN A documented Resident #1 stated it is a science project and staff shouldn't worry themselves about it. LVN A documented the physician had been notified. Progress note dated 11/09/2023 at 9:28 a.m., LVN B documented Resident #1 refused staff to assist with reposition or incontinent care. Progress note dated 11/11/2023 at 5:43 a.m., LVN C documented Resident #1 refused peri-care throughout the shift. Progress note dated 11/27/2023 at 3:37 p.m., LVN G documented Resident #1 asked to be changed. LVN G said Resident #1 had a strong body odor and a brown drainage coming from Resident #1's left foot. The note indicated LVN G documented Resident #1 refused the bath and refused a shower. LVN G documented Resident #1 stated I don't refuse care as they say, I refuse abuse, and no one has ever offered me a bath. LVN G documented she heard Resident #1 shouting and cursing a nurse aide. LVN G documented Resident #1 said nobody had ever tried to take care of her foot. LVN G indicated she advised Resident #1 the drainage from her foot was a sign of infection. LVN G documented Resident #1 said yes I know its infected, what do you expect? LVN G documented Resident #1 said, all of you are going to hell, you falsify my records, you abuse me if you touch me, it will be too late for you, and no one touches my flesh. LVN G said Resident #1 gets louder, cursing the nurse. LVN G documented she left the room to allow Resident #1 to calm down. The note failed to indicate LVN G notified the physician of these behaviors and the condition of the left foot and seek psychological care. Progress note dated 11/30/2023 at 1:10 a.m., LVN C documented Resident #1 refused peri-care during rounds. LVN C documented Resident #1 said just get out and leave me alone. Progress note dated 12/14/2023 at 9:00 a.m., LVN A documented performed care for Resident #1 when apple juice accidently spilled. The note indicated Resident #1 indicated the nurse spilled the juice on purpose and then threw the apple juice on the nurse. LVN A failed to document the physician was notified on the aggressive behavior. Progress note dated 12/17/2023 at 11:00 p.m., LVN C documented Resident #1 refused routine rounds from this nurse and attempts to ignore nursing staff. Resident #1 stated the only way for you to leave me alone is to answer your questions? LVN C documented Resident #1 refused repositioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 8 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Progress note dated 12/28/2023 at 1:35 a.m., LVN C documented Resident #1 refused routine peri-care and began yelling go to hell and just go to hell. LVN C documented Resident #1 was upset concerning not having a phone cord. The note failed to indicate LVN C notified the physician of the behavior refusing care and having verbal aggressive behaviors. Progress note dated 12/29/2023 at 5:05 a.m., LVN C documented Resident #1 refused incontinent care all shift. Progress note dated 12/29/2023 at 9:38 p.m., LVN G documented Resident #1 refused foot care from this nurse but allowed the nurse to trim her fingernails. LVN G documented Resident #1's left foot was withered with dead skin on the foot but Resident #1 refused care from the staff. Progress note dated 12/30/2023 at 11:22 p.m., LVN C indicated Resident #1 with the complaint her room was too hot and requested personal fan be turned on. The note indicated LVN C offered incontinent care and Resident #1 refused stating you can go now; you did all I needed you to do. The note indicated Resident #1 refused to allow the dinner tray to be removed from bedside. Progress note dated 1/01/2024 at 3:04 a.m., LVN B documented Resident #1 refused incontinent care. The progress note failed to reflect the physician was notified negative symptom of schizophrenia and seek psychological care. Progress note dated 1/04/2024 at 1:37 a.m., LVN C documented Resident #1 refused incontinent care by CNA F, and LVN C. The note indicated Resident #1 refused oral fluids and snacks offered. LVN C documented Resident #1 refused the removal of the dinner tray. Progress note dated 1/06/2024 at 8:30 p.m., LVN D documented she and CNA E were changing Resident #1. LVN D documented after providing peri-care she looked for barrier cream to apply in Resident #1's drawers. Resident #1 was noted to have said there was cream in the drawer. The note indicated LVN D obtained barrier cream returned to Resident #1. The note indicated LVN D rolled Resident #1 using the draw sheet when Resident #1 began screaming at the top of her lungs, Oh, my finger, you all hurt my finger. You are murdering me, and you are abusing me. LVN D said she left the room and obtained another CNA to assist with care. LVN D documented she notified the Administrator of Resident #1 accused LVN D of hurting her finger. Resident #1 was provided a phone and the Administrator spoke to Resident #1 where she alleged they're abusing me tonight. The note failed to indicate Resident #1's ph[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 9 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 3 (Resident #2) residents reviewed for accidents. The facility failed to ensure CNA F used two-person assistance to provide incontinent care for Resident #2 which resulted in a fall with injury. This failure could place residents at risk of injuries, falls and hospitalizations. Findings include: Record review of Order Summary Report dated 01/12/2024 indicated Resident #2 was a [AGE] year-old male, with an admission to the facility on [DATE] with diagnoses including dementia (decline in cognitive abilities that impacts a person's abilities to perform everyday activities), myocardial infarction (a blockage of blood flow to the heart muscle), hypertension (high blood pressure), cognitive communication deficit, abnormal posture, heart failure, chronic respiratory failure, diabetes mellitus type I (a chronic condition where the pancreas produces little to no insulin), diabetes insipidus (a disorder of salt and water metabolism marked by intense thirst and urination), stiffness of left knee. Record review of the care plan last revised 04/20/2023 indicated Resident #2 had an ADL (Activities of Daily Living) self-care performance deficit related to activity intolerance. The care plan indicated interventions included two - person staff assist for toileting. Record review of the quarterly MDS dated [DATE] indicated Resident #2 was able to understand and make himself understood. The MDS showed BIMS of 15 which indicated Resident #2 was cognitively intact. The MDS indicated that Resident #2 required extensive assistance by two-person staff for toileting, bed mobility, transferring, and personal hygiene. The MDS indicated Resident #2 had not sustained any falls. Record review of the provider investigation report, dated 11/04/2023, indicated Resident #2 fell from the bed during peri care provided by CNA F. The provider investigation report indicated CNA F yelled from Resident #2's bedside for help from LVN D. The provider investigation report revealed LVN D found Resident #2 on his knees on the floor. LVN D requested assistance from 911 to place Resident #2 back into the bed. LVN D assessed Resident #2's injuries of an abrasion 2cm x 2cm noted to the left knee, open area to the right groin and superficial skin tear noted to right posterio r forearm. Other information noted on the provider's investigation report was a bariatric (obesity) mattress on regular size bed and hangs off bedframe and CNA F changed resident by herself. The provider's investigation report indicated Resident #2 denied the need to go to the hospital. Record review of the Visual/IPAD [NAME] (a system that gives a brief overview of the resident's care with pictures) on 01/10/2023 used by the CNAs indicated Resident #2 required 2-person staff assist for toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 10 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 - Actual harm Residents Affected - Few During an interview on 01/09/2024 at 10:10 a.m. Resident #2 said CNA F entered his room on 11/05/2023 to change his brief alone . Resident #2 said CNA F instructed him to roll over to his left side. Resident #2 said I knew I was falling when my right leg came over and I yelled out to CNA F that I was going to fall. Resident #2 said his knees hit the floor and his neck was caught on the small grab bar on side of the bed. Resident #2 said sometimes two of the staff assisted him with toileting prior to the fall but most of the time it is just one. Resident #2 said LVN D and CNA F told him to attempt to get back into the bed, but he was not able to do that. Resident #2 said the LVN D finally called 911 for assistance to get him back into the bed. Resident #2 said I am a large man and weigh over 400 lbs. The weight of my leg due to gravity took me down into the floor because there was no one on the opposite side to catch my leg and I was too close to the edge of the bed. Attempted telephone call on 01/09/2024 at 11:30 a.m. to CNA F - not accepting calls and unable to leave a message. During an interview on 01/09/2024 at 02:19 p.m., CNA N said she recalled the incident involving Resident #2. CNA N said she was aware of how to take care of residents by the report the charge nurse gave to her or by the CNA that was on the previous shift would tell her what the resident required. CNA N said she did not look at the [NAME] on the electronic charting system to verify how to take care of the residents. CNA N said she did not recall before the incident any staff member telling her Resident #2 was a two person assist for toileting. CNA N said it was important for Resident #2 to have a two person staff assistance to prevent falls and injuries. During an interview on 01/09/2024 at 02:31 p.m., CNA O said she was aware of how to take care of residents by the report the charge nurse gave to her or by the CNA that was on the previous shift that would tell her what the resident required. CNA O said she did not look at the [NAME] on the electronic charting system to verify how to take care of the residents. CNA O said she did not recall before the incident any staff member telling her Resident #2 was a two person assist for toileting, but he can't help much with turning so she used another staff member to assist since the incident. CNA O said it was important for Resident #2 to have a two person staff assistance with toileting to prevent falls and injuries due to the Resident #2's weight and his inability to help turn. During an interview on 01/09/2024 at 03:03 p.m., LVN G said the CNA's got the information of how to take care of the resident from the charge nurse. LVN G said she gave the CNA's the information to take care of the residents during report prior to the start of the shift. LVN G said the CNAs should ask her what level of assistance a resident requires. LVN G said the CNA's can look at the [NAME] for the resident's plan of care located in the electronic charting system on their iPad but mainly the CNA's get all information from the charge nurse. LVN G said it was important to follow the resident's plan of care to prevent injuries and take care of the residents safely. During an interview on 01/09/2024 at 03:08 p.m., CNA P said she received all information on how to take care of the resident from the CNA on the previous shift. CNA P said if she had other questions regarding the resident's care, she asked the charge nurse. CNA P said she used the iPad to chart the residents' showers but had not ever got that far into the system to see any information on how to take care of the residents such as the required staff needed for performing an ADLs. CNA P said it was important to know how to toilet and transfer a resident to prevent falls. Attempted telephone call on 01/10/2023 at 2:29 p.m. to CNA F - not accepting calls and unable to leave a message. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 11 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 - Actual harm Residents Affected - Few During an interview on 01/10/2024 at 03:40 p.m., LVN D said she was the charge nurse working with CNA F who had attempted to provide toileting care when Resident #2 fell out of the bed. LVN D said she was aware that Resident #2 was a two person assist but some of the staff provided the care alone especially on night shift when no extra staff were available. LVN D stated that she educated all the CNA's to ask for assistance from her and not to move the residents by themselves after the incident with Resident #2. LVN D said the CNAs do have access to the [NAME] on the iPad but prefer to ask the charge nurse most of the time. LVN D said if a resident was newly admitted CNAs should check the [NAME], ask the nurse, or consult with therapy regarding the residents' status. LVN D said it was important to utilize the [NAME] for resident safety and prevent injuries and falls. Attempted telephone call on 01/10/2024 at 04:30 p.m. to CNA F - not accepting calls and unable to leave a message. During an interview and observation on 01/11/2024 at 03:30 p.m., the DON said the CNAs should have used the [NAME] which was located on the iPad for necessary information on how to take care of the residents. The DON said the ADON was responsible upon hiring to train the CNAs to use the electronic charting system which contained the [NAME] with the residents' plan of care. The DON said the new hire CNAs were placed with another trained CNA for further training after being educated on the electronic system. The DON demonstrated to surveyor how to utilize the [NAME] on the CNAs' iPad. The DON said it was important for the [NAME] to be used by all staff to prevent injuries and harm to the staff and residents while care was provided. During an interview on 01/11/2024 at 03:30 p.m., the ADON said the residents' status of a newly admitted resident was relayed in report from the discharging facility, found in the discharge paperwork, or relayed by the physician. The ADON said the status of a resident should be entered into the plan of care which populates into the iPad for the CNAs to access. The ADON said the CNAs were able to look in the iPad, ask the nurse, or should have been given report by the nurse to know how to take care of the resident. The ADON said she was responsible of hiring and training the CNAs. The ADON said the CNAs should use the [NAME] on the iPad to access the resident information to know how to take care of the resident properly. The ADON said she was shown today by the DON how to access the information from the CNA iPad, and she had not shown the newly hired CNA's how to utilize the system for resident information because she did not know how to access the [NAME] from the iPad herself before today's date. The ADON said there was not a process in place to monitor the CNA's knowledge to access the information on the iPad/[NAME]. The ADON said it was important to follow the plan of care which is listed on the [NAME] on the CNA's iPad to prevent injuries from occurring and ensure the residents were getting the proper care per their needs. During an interview on 01/11/2024 at 03:40 p.m., the Administrator said it was the responsibility of the DON to train the CNA staff which included the [NAME] on the iPad. The Administrator said the DON was good to know the needs of the residents and was good to verbally communicate the needs of the residents to the staff. The Administrator said the importance of staff knowing how to take care of the residents appropriately was to prevent falls and injuries. Record review of the facility's Fall Prevention Program revised 07/20/2021 indicated, The goal of fall prevention strategies is to design interventions that minimize fall risk by elimination or managing contributing factors while maintaining or improving the resident's mobility. After risk is assessed, individualized nursing care plans will be implemented to prevent falls . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 12 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received necessary behavioral health care services to maintain the highest practicable mental and psychosocial wellbeing for 1 of 6 residents (Resident #1) reviewed for behavioral services. The facility failed to have Resident #1 evaluated for decision making capacity. The facility failed to provide a psychological evaluation to determine if Resident #1 was a harm to herself. The facility failed to re-offer psychiatric services since 8/2023 for Resident #1. The facility failed to develop interventions to address the resident's acute schizophrenic behaviors. The facility failed to implement licensed social services to provide crises support, and coordination with the healthcare team. The facility failed to recognize and obtain Resident #1's schizophrenia diagnosis from behavioral health care. An IJ was identified on 1/11/2024 at 12:56 p.m. The IJ template was provided to the facility on 1/11/2024 at 1:11 p.m. While the IJ was removed on 1/12/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for [NAME] than minimal harm because all staff had not been trained on neglect. These failures could placed residents at risk for the lack of behavioral health services with the potential for serious injury and death. Findings included: Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old female, who admitted on [DATE] with the diagnosis of unspecified psychosis (Psychosis is when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions), motivational impairment, social withdrawal, flat emotions, negative symptoms worsen a person's quality of life and functioning (negative symptoms). It may also involve confused (disordered) thinking and speaking) not due to a substance or known physiological condition, Buerger's disease (also known as thromboangitis obliterans) affects blood vessels in the body, most commonly in the arms and legs. Blood vessels swell, which can prevent blood flow, causing clots to form. This can lead to pain, tissue damage, and even gangrene (the death or decay of body tissues), and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) Record review of the consolidated physician's orders dated 1/09/2024 indicated Resident #1 had an ordered referral for psychiatric services on 4/14/2022, and on 8/29/2023. There were no antipsychotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 13 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0740 or antidepressant medications ordered on Resident #1's consolidated physician's orders. Level of Harm - Immediate jeopardy to resident health or safety Record review of Quarterly MDS dated [DATE] indicated Resident #1 understood and was understood by others. The MDS in the section of Cognition Pattern C0100 had a (-) meaning unable to determine the response, in the section for the BIMS (Brief Interview Mental Status) assessment C0200 also had a (-), in the section Recall C0400 there was also a (-). The MDS in section C0700 indicated Resident #1's memory short-term and long-term both indicated her memory was intact. The MDS in the section C1310 indicated there was no evidence of an acute change in mental status, and no behaviors of inattention, or disorganized thinking. The MDS in the section Mood D0100 indicated a (-). The MDS section D0150 Resident Mood Interview indicated (-) in column 1 and blank in column 2. The MDS in section D0160 a (-) was documented. The MDS section D Mood the staff assessment of Resident #1's mood indicated she had no symptoms of little interest or pleasures, feeling down or depressed, feeling tired, poo appetite, indicating they feel bad about self, trouble concentrating, moving, or speaking slowly or fast, stating life not worth living. The MDS reflected in Mood J being short-tempered, easily annoyed marked yes and 12-14 days in column 2. Section E Behaviors of the MDS indicated Resident #1 had no hallucinations or delusions. The MDS indicated in E0200 Behavioral Symptoms indicated physical behaviors directed toward others occurred 1-3 days, verbal behavior symptoms directed at others occurred 4-6 days, and other behavioral symptoms not directed at others (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds). The MDS in section E0800 Rejection of care indicated Resident #1 displayed this behavior 4-6 days but less than daily. The MDS indicated in Section GG Resident #1 was independent with eating, dependent with toileting and personal hygiene, and refused bathing, dressing. The MDS in section I Active Diagnosis indicated Resident #1 had depression other than bipolar, and psychotic disorder other than schizophrenia. The MDS assessment did not indicate Resident #1 had a diagnosis of schizophrenia. The MDS in section M indicated Resident #1 had no skin conditions. Section M of the MDS indicated Resident #1 was not receiving any antipsychotic or antidepressant medications. Residents Affected - Few Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 2/21/2023 indicated Resident #1 scored a 0 due to not being assessed. Resident #1 refused to participate in the assessment and the assessment indicated Resident #1 said close the door when you leave. Record review of a BIMS (Brief Interview for Mental Status) assessment dated [DATE] indicated Resident #1 score was a 10 indicating moderately impairment. Record review of the care plan dated 9/21/2021 and revised on 9/25/2023 indicated Resident #1 makes poor safety choices as evidenced by refusal of wound care to foot, hospitalization, and hospice. The goal of the care plan was Resident #1 wound not have adverse effects related to the refusal of care. The interventions of the care plan were to attempt to monitor resident in regard to safety choices; notify the doctor, administrator, DON, and supervisor in regard to poor safety choices that place resident at risk implemented on 8/19/2021 and educated Resident on risks associated with poor safety choices implemented on 8/19/2021 this care plan failed to implement any current interventions. The care plan indicated Resident #1 was at risk for infections related to refusal to allow her room to be cleaned. The goal of the care plan was Resident #1 would not have any adverse effects related to her refusal. The interventions included attempt to clean the room throughout the day by housekeeping and nursing dated 10/28/2022, attempt to tidy the room when care provided dated 10/28/2022, and educate Resident #1 on the risks of living in unclean environment dated 10/28/2022 there care plan failed to implement current interventions. The care plan dated 8/19/2021 and revised on 11/30/2022 indicated Resident #1 had a behavior problem as evidenced by yelling and cursing at staff, demeaning and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 14 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few derogatory comments to staff, allowing only limited staff members to provide care, calling 911, refuse to allow trays to be removed from room, making false accusations, refusing to allow call light to be turned off; the goal of the care plan was Resident #1 would have fewer episodes of outbursts. Resident #1's care plan interventions included 2 persons to offer and provide care at all times, anticipate and meet the resident needs allowed reviewed on 8/31/2023, anticipate and meet the resident's needs as allowed revised on 8/31/2023, assist the resident to develop more appropriate methods of coping and interacting and encouraged Resident #1 to express feeling appropriately revised on 8/19/2021. Resident #1's care plan interventions indicated she would have all procedure explained before starting and allow time for adjustment to change dated 8/19/2021. Resident #1's care plan intervention included to monitor behavior episodes and attempt to determine underlying cause and document dated 8/19/2021. Resident #1's care plan interventions indicated to refer Resident #1 to psychological services dated 8/30/2023. Resident #1's care plan failed to address her behaviors with new interventions and revise with interventions that promoted stability with her mental illness. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 8/03/2023 indicated Resident #1 scored an 8 indicating she was mildly depressed. Record review of a Comprehensive Care Plan Conference Summary dated 8/30/2023 indicated Resident #1 refused environmental care, refuses care, yells, curses, calls 911, verbal outbursts, and was at high risk for impaired skin. The care plan conference was signed by the AD, occupational therapist, the social services staff person, dietary manager, and the DON. The care plan conference was not signed by Resident #1 or the responsible party. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 10/23/2023 indicated Resident #1 was not assessed for depression due to her refusal to participate. Record review of an undated Comprehensive Care Plan Conference Summary indicated Resident #1 had multiple behaviors, unavoidable skin issues, and Buerger's disease. The conference was signed by the MDS nurse, the activity director, and social services staff person. Resident #1 or the responsible party signature area was left blank. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of a Psychotherapy Intake Note dated 4/20/2022 indicated Resident #1 was seen by a therapist for 1 hour. The therapist indicated Resident #1 was referred due to a history of depression and psychosis. The note indicated Resident #1 was oriented to person, place, and time. The note indicated Resident #1's mood was euthymic (normal display of emotion), affect was congruent with Resident #1's mood, Resident #1 had good attention, and appropriate thought content. The note indicated Resident #1 denied any mental health issues and indicated her health records were falsified to keep her in the facility against her will. The note indicated she believed the staff were trying to murder her and the only way to get help was to meet her fiancé. The note indicated Resident #1 believed the business office had stolen money and the claim was validated by the state agency even though she had not found a letter stating so. Resident #1 discussed previous traumas at other nursing facilities and alluded to some abuse when growing up. The note indicated Resident #1 believed she was in a relationship with a famous musician. The note indicated Resident #1 hoped to buy a gift card to purchase a fan club membership in so that she could spend time with the musician in person. The therapist documented the diagnosis of Major depressive disorder, single episode severe, and schizophrenia spectrum and other psychotic disorders. The note indicated Resident #1's presented with depression (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 15 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and psychosis. The goal of Resident #1's treatment was to reduce depression, psychosis, and improve sense of well-being in the facility. The estimated completion was 12 months for Resident #1. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress Note dated 5/04/2022 indicated the session lasted 53 minutes with Resident #1. The note indicated Resident #1 had the diagnosis of Major Depressive Disorder, single episode severe, and Schizophrenia Spectrum and other psychotic disorder. The note indicated Resident #1 was alert oriented to person, place, and time. The note indicated her mood was normal, and her affect was congruent with her mood. The note indicated Resident #1 was not having a good week. The note indicated Resident #1 continued to believe she was held against her will and they were still trying to kill her. The note indicated Resident #1 continues to hope to see her fiancé soon and believed he was trying to come and visit with her. The note indicated Resident #1 was unable to call the person because he was in Europe and her phone does not call Internationally. The note indicated Resident #1 continues to be upset no one will purchase her a $2000 gift cared for her. Resident #1 said she could not notify the ombudsman or the state agency as they hang up on her. The note indicated Resident #1's interventions included rapport building, exploration of coping patterns, exploration of emotion, exploration of relationship patters, supportive reflection and symptom management. The note indicated there was no progress in the reduction of symptoms of depression, symptoms of psychosis, or an improved sense of well-being. The note indicated Resident #1 would be treated weekly. Record review of a Psychotherapy Progress Note dated 5/11/2022 indicated the therapist was with Resident #1 53 minutes. The note indicated Resident #1 oriented to person, place, and time. The note indicated Resident #1's mood and affect were congruent, attention was good, thought content appropriate. The resident reported she is not having a good week. The note indicated Resident #1 continues to believe she is held against her will and they were trying to kill her. The note indicated Resident #1 believes her fiancé would be able to visit. Resident #1 said she had been able to speak with her fiancé some this week but had not mentioned to issues of international calling. According to the note Resident #1 continued to be upset with not being able to purchase the $2000 gift card. The note indicated Resident #1 was hoping to see the orthopedic surgeon to strengthen her leg. The note indicated Resident #1 believed she needed someone in Dallas as they provide better care. Resident #1 was noted as indicating she would need physical therapy after the surgery. The note indicated Resident #1 does not want to stay in any nursing facility. Staff had reported Resident #1 called 911 twice last week and left the line open. Resident #1 reported a police officer had come to the facility and called her crazy in front of the staff. The note indicated Resident #1 indicated the police officer threatened to take her to court and make the facility her guardian. The note indicated Resident #1 believed this was a violation of her rights. The notes indicated the progress in reduction of symptoms of depression, reduction of symptoms of psychosis, and the reduction of sense of well-being was maintained. The note indicated Resident #1 called the therapist's office on 5/13/2022. The note indicated Resident #1 wanted to inform the therapist of her big toe on her bad foot was infected. The note indicated Resident #1 indicated the staff were not helping or treating her foot. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress note dated 6/01/2022 indicated the therapist was with Resident #1 60 minutes. The note indicated Resident #1's diagnoses were Major Depressive Disorder, single episode, severe, and Schizophrenia Spectrum and other Psychotic Disorder. The note indicted Resident #1 was oriented to person, place and time. The note indicated Resident #1 continued to report not having a good week, as indicated by expressing she believed she was held against her will, and they were trying to kill her. Resident #1 indicated to the therapist had found some new orthopedic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 16 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few surgeons in a hospital in Dallas. The note indicated Resident #1 hoped the therapist called all the physician's and to explain her emergency situation so they will quickly take her. The note indicated Resident #1 attempted to message one of the surgeons on an App, but never received a response. The note indicated Resident #1 hoped the FBI would find her friends in Arizona who would loan her some money so she could leave with her fiancé's manager. The note indicated Resident #1 had spoken of suicide attempts but had promised God she would never try gain. The note indicated Resident #1 denied any current suicidal ideation, plan, means, or intent. The note indicated the treatment progress for Resident #1 continued to be maintained. The note indicated Resident #1 called the therapist's office indicating she had something urgent to discuss. The therapist indicated Resident #1 had not mentioned this concern during the therapy session. The note indicated Resident #1 would continue to be seen weekly. Record review of a Psychotherapy Progress Note dated 6/22/2022 indicated Resident #1 was seen by the therapists for 46 minutes. The therapist indicated Resident #1 was angry this week. The note indicated Resident #1 was upset with the therapist since the therapist had not provided an envelope and stamps for Resident #1 to mail money to her fiancé. The note indicated the therapist indicated the dangers of mailing cash as well as the therapeutic boundaries. The note indicated Resident #1 attempted to switch places and tried to provide therapy to the therapist and become frustrated when the therapist would not allow this to occur. The note indicated Resident #1 believed the therapist was there to get easy blood money from Medicare and does not believe the therapeutic relationship was what she needed at present. The note indicated Resident #1 was placed on an as needed status. The note indicated Resident #1 had no progress in the reduction of depressive symptoms, psychosis symptoms or in the sense of well-being. Record review of Resident #1's clinical record revealed there were no further treatments noted from a psychotherapist after 6/22/2022. Record review of a Unavoidable Wound Documentation assessment dated [DATE] indicated Resident #1 had peripheral vascular disease, chronic bowel incontinence, thyroid disease, impaired mobility, and cognitive impairment. The assessment indicated Resident #1 had the head of her bed elevated the majority of the day. The assessment in Resident Compliance indicated Resident #1 refuses care and has psychosis this form was signed by the physician on 9/21/2023. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of the electronic medication administration record dated December 2023 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of a physician's progress note dated 12/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for her high blood pressure, and reflux disease (stomach acid or bile irritates the food pipe lining). The physician's progress note indicated the past medical history of psychosis and major depressive disorder (recurrent and moderate). The physician's progress note failed to address a psychological examination and indicated Resident #1's skin was warm, dry, no rashes, and no suspicious lesions. The note failed to mention the stability of Resident #1's psychosis and depression. Record review of the electronic medication administration record dated January 2024 indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 17 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of a physician's progress note dated 7/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for coronary artery disease (damage or disease in the heart's major blood vessels) and weakness. Resident #1's past medical history included psychosis and major depressive disorder. The assessment indicated Resident #1 had warm and dry skin with no suspicious lesions. The neurological assessment indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a physician's progress note dated 8/09/2023 completed by the nurse practitioner indicated Resident #1 was seen for neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet) and reflux disease. The note indicated the nature of the neuralgia was general neuralgia affecting both legs with a moderate severity. The note indicated Resident #1's skin was warm, dry, no suspicious lesions, and no rashes. The note failed to mention Resident #1's left foot condition, and the neurological exam indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a Social Determinants of Health assessment dated [DATE] completed by the social worker designee indicated Resident #1's assessment included her ethnicity, race, language, need of interpreter to communicate with a doctor or health team, lack of transportation, how often does she require assistance with reading, and how often does she feel lonely or isolated. The social health assessment failed to ascertain information regarding Resident #1's current or past behavioral health needs, assess the on-going behaviors and identify triggers and interventions, provide in-sight on the need of outside resources. Record review of Resident #1's progress notes dated 9/12/2023 to 1/11/2024 indicated: Progress note dated 9/12/2023 at 2:57 p.m., LVN G documented the psychiatric nurse practitioner was present for a psychological exam and Resident #1 refused. The progress note failed to reflect Resident #1's physician was notified of the refusal for psychiatric services. Progress note dated 9/23/2023 at 11:21 p.m., LVN C documented he offered incontinent care and Resident #1 started yelling get out, get out, you murderers! The progress note failed to denote Resident #1's physician was notified of the delusions. Progress note dated 9/26/2023 at 4:00 a.m., LVN C documented Resident #1 cursed loudly and yelled obscenities at the nursing staff when offering incontinent care. The note failed to indicate LVN C notified the physician of the verbal aggressive behaviors. Progress note dated 9/26/2023 at 7:30 a.m., LVN A documented Resident #1 indicated she needed a brief change. LVN A indicated she offered a total bed bath. LVN A indicated Resident #1 refused and stated, I don't want you tearing my flesh apart more than you already have. LVN A documented Resident #1 stated during repositioning , you both are going to hell, [NAME]. God does me justice and you will both rot in hell and burn for eternity. The note failed to indicate LVN A notified Resident #1's physician of the delusions (of being harmed) and religiosity thoughts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 18 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Progress note dated 10/02/2023 at 9:17 a.m., LVN A indicated, Resident #1 continued to refuse care and left foot continued to decline related to Buerger's Syndrome. The note indicated Resident #1 refused to allow staff to touch her foot, clean or treat. The note indicated staff had made multiple attempts. The note indicated the foot appeared to be black on the toes with crusty like covering up to ankles. The note indicated multiple attempts were made to send Resident #1 to the hospital as the foot had no circulation and become necrotic. The note failed to indicate Resident #1's physician was notified of the negative symptoms of psychosis/schizophrenia. Progress note dated 10/02/2023 at 1:14 p.m., LVN A indicated the wound care specialist visited and Resident #1 refused care and treatment. The progress note indicated Resident #1 commenced to yelling and screaming at staff. The note failed to indicate Resident #1's physician was notified of her refusal of care and verbally aggressive behaviors. Progress note dated 10/03/2023 at 5:05 a.m., LVN B documented Resident #1 refused incontinent care this shift. Progress note dated 10/13/2023 at 8:55 a.m., LVN A documented Resident #1 requested to have incontinent care performed. LVN A documented after Resident #1's medication administration, and a sip of water Resident #1 threw the remaining water on LVN A and said, cool off bitch and burn in hell. The note indicated the Administrator was informed. LVN A failed to document the notification of the physician related to the aggressive physical behaviors. Progress note dated 10/30/2023 at 10:25 a.m., LVN A documented Resident #1 continue to refuse care and her left foot continued to decline. The progress noted indicated Resident #1 refused to allow staff to touch foot, clean, or treat. The progress note indicated LVN A documented the foot has black toes with crusty like covering up to Resident #1's ankles. LVN A documented Resident #1's left foot had no circulation and was necrotic. LVN A failed to document to notify Resident #1's physician. Progress note dated 11/03/2023 at 10:21 a.m., the DON documented during the weekly skin check Resident #1 refused care. The DON documented the Resident #1's left foot was withering and changing to a dark color with dry skin flaking off related to the diagnosis of Buerger's Syndrome. The DON documented the Resident #1's refusal of staff to touch the foot, clean or treat the foot. The DON documented Resident #1's left foot had black toes with a crusty like covering up to sock line. The DON documented Resident #1's fingertips had discolored areas on the middle of the fingers. The DON documented the physician was notified and the nurse practitioner was present for the offering of treatment, hospitalization, or hospice. The DON documented after extensive attempts Resident #1 was screaming get out of my room. The progress note failed to indicate any behavioral health care was offered. Progress note dated 11/05/2023 at 2:21 a.m., LVN C documented Resident #1 refused peri-care during each round and said, you all are bothering me so much on purpose. The note failed to indicate Resident #1's physician was notified on the negative symptoms, and paranoid thoughts. Progress note dated 11/06/2023 at 8:52 a.m., LVN A documented the weekly skin assessment was performed and Resident #1 has withering and callus with discoloration to the left great toe. LVN A documented Resident #1 refused care to the toe. LVN A documented Resident #1 stated it is a science project and staff shouldn't worry themselves about it. LVN A documented the physician has been notified. The note failed to reflect Resident #1 was disconnected from reality related to her left toe condition and seek psychological care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 19 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Progress note dated 11/09/2023 at 9:28 a.m., LVN B documented Resident #1 refused staff to assist with reposition or incontinent care. The note failed to reflect acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Progress note dated 11/11/2023 at 5:43 a.m., LVN C documented Resident #1 refused peri-care throughout the shift. The note failed to reflect acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Progress note dated 11/27/2023 at 3:37 p.m., LVN G documented Resident #1 asked to be changed. LVN G said Resident #1 had a strong body odor and a brown drainage coming from Resident #1's left foot. The note indicated LVN G documented Resident #1 refused the bath and refused a shower. LVN G documented Resident #1 stated I don't refuse care as they say, I refuse abuse, and no one has ever offered me a bath. LVN G documented she heard Resident #1 shouting and cursing a nurse aide. LVN G documented Resident #1 said nobody had ever tried to take care of her foot. LVN G indicated she advised Resident #1 the drainage from her foot was a sign of infection. LVN G documented Resident #1 said yes I know its infected, what do you expect? LVN G documented Resident #1 said, all of you are going to hell, you falsify my records, you abuse me if you touch me, it will be too late for you, and no one touches my flesh. LVN G said Resident #1 gets louder, cursing the nurse. LVN G documented she left the room to allow Resident #1 to calm down. The note failed to indicate LVN G notified the physician of these behaviors including grandiose behavior, insight not appropriate for the situation, fabrication, and the condition of the left foot and seek psychological care. Progress note dated 11/30/2023 at 1:10 a.m., LVN C documented Resident #1 refused peri-care during rounds. LVN C documented Resident #1 said just get out and leave me alone. The note failed to reflect acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Record review of a skin check dated 12/07/2023 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Record review of a skin check dated 12/14/2023 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Progress note dated 12/14/2023 at 9:00 a.m., LVN A documented performed care for Resident #1 when apple juice accidently spilled. The note indicated Resident #1 indicated the nurse spilled the juice on purpose and then threw the apple juice on the nurse. LVN A failed to document the physician was notified on the aggressive behavior. Progress note dated 12/17/2023 at 11:00 p.m., LVN C documented Resident #1 refused routine rounds from this nurse and attempts to ignore nursing staff. Resident #1 stated the only way for you to leave me alone is to answer your questions? LVN C documented Resident #1 refused repositioning. Progress note dated 12/28/2023 at 1:35 a.m., LVN C documented Resident #1 refused routine peri-care and began yelling go to hell and just go to hell. LVN C documented Resident #1 was upset concerning not having a phone cord. The note failed to indicate LVN C notified the physician of the behavior refusing care and having verbal aggressive behaviors. Record review of a skin check dated 12/28/2023 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 20 of 21 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 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418 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 0740 Level of Harm - Immediate jeopardy to resident health or safety Progress note dated 12/29/2023 at 5:05 a.m., LVN C documented Resident #1 refused incontinent care all shift Progress note dated 12/29/2023 at 9:38 p.m., LVN G documented Resident #1 refused foot care from this nurse but allowed the nurse to trim her fingernails. LVN G documented Resident #1's left foot was withered with dead skin on the foot but Resident #1 refused care from the staff. Residents Affected - Few Progress note dated 12/30/2023 at 11:22 p.m., LVN C indicated Resident #1 with the complaint her room was too hot and requested personal fan be turned on. The note indicated LVN C offered incontinent care and Resident #1 refused stating you can go now; you did all I needed you to do. The note indicated Resident #1 refused to allow the dinner tray to be removed from bedside. The progress note failed to reflect the physician was notified of the behaviors and to seek psychological care. Progress note dated 1/01/2024 at 3:04 a.m., LVN B documented Resident #1 refused incontinent care. Progress note dated 1/04/2024 at 1:37 a.m., LVN C documented Resident #1 refused incontinent care by CNA F, and LVN C. The note indicated Resident #1 refused oral fluids and snacks offered. LVN C documented Resident #1 refused the removal of the dinner tray. Record review of a skin check dated 1/04/2024 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Progress note dated 1/06/2024 at 8:30 p.m., LVN D documented she and CNA E were changing Resident #1. LVN D documented after providing peri-care she looked for barrier cream to apply in Resident #1's drawers. Resident #1 was noted to have said there was cream in the drawer. The note indicated LVN D obtained barrier cream returned to Resident #1. The note indicated LVN D rolled Resident #1 using the draw sheet when Resident #1 began screaming at the top of her lungs, Oh, my finger, you all hurt my finger. You are murdering me, and you are abusing me. LVN D [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 21 of 21