Health inspection·March 6, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of the urine odor because this was the resident's home and she tried to ensure they were cleaned good for the residents. During an interview on 3/6/24 at 11:58 a.m., the Administrator stated the facility did run out in the house keeping cleaning supplies on the wall, and he refilled the chemicals on the same day. The Administrator stated he did not smell the urine odor on the 200 hall on 3/4/24, 3/5/24, or 3/6/24. The Administrator stated in the past he informed the housekeeping aides that a resident's room needed to be addressed and he also told the housekeeping aides to clean the resident's rooms every day. The Administrator stated he oversaw housekeeping because the facility did not have a housekeeping supervisor. The Administrator stated deep cleaning was to be done every day in at least two random rooms. The Administrator stated regular cleaning of the residents' rooms was done every day. The Administrator stated he had not received any complaints from the residents about their rooms not being cleaned. The Administrator stated, It was important for the resident's rooms to be cleaned for homelike environment and so the resident can be comfortable and free from inspections. 2. During an observation on 03/04/24 at 1:00 p.m., several room floors on hall 100 during the initial tour looked unclean with several light and dark spots on their floors. During an observation and interview on 03/05/24 at 9:31 a.m., Housekeeper G was observed cleaning room [ROOM NUMBER] on hall 100. Housekeeper G said she was cleaning the floor of the rooms on hall 100 with the product provided but the floors were still dirty with different shades of color and light and dark spots on them. She said she wished she knew how to make them look cleaner but she did not know how. During an interview on 03/05/24 at 9:48 a.m., the DON said the maintenance supervisor oversaw the floors. She said they did not have a deep cleaning schedule but cleaned all rooms daily. She said the rooms needed to be deep cleaned and or waxed because they looked like they had not been cleaned. During an interview on 03/05/24 at 12:45 p.m., Housekeeper G said she started working at the facility on 2/24/24. She said when she started, they were out of the chemical they were supposed to use so they were using something from the store. She said she did not remember the name, but it had been replaced with the correct chemicals today (03/05/24). She said she did not have a deep cleaning schedule, but they cleaned the rooms daily including the floors with the products they had. She said she wanted the floors and the rooms to be clean for the residents. During an interview on 03/05/24 at 2:00 p.m., the Administrator said he was the housekeeping supervisor and was aware the floors looked like they needed to be cleaned because of the different colors of the room's floors. He said they had a PIP (Performance Improvement Project) in place for the floors. We reviewed the PIP together and he started the PIP on 02/12/24 which indicated they would deep clean 2 rooms a day. The Administrator could not produce the schedule for the rooms that were supposed to be deep cleaned. He said he was responsible for ensuring the floors had been deep cleaned. He said they could not start the deep cleaning process because he had not hired any staff to do the deep cleaning until last week. He said that he had not made the deep cleaning schedule since he had hired the new staff. He said he wanted the floors cleaned for the resident's home. 3. Record review of Resident #45's face sheet, dated 03/06/24, indicated Resident #45 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had diagnoses which included Parkinson's (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), high blood pressure, and diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 2 of 33 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 03/06/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #45's quarterly MDS assessment, dated 02/05/24, indicated Resident #45 usually understood and understood others. Resident #45's BIMS score was 15, which indicated he was cognitively intact. Resident #45 required assistance with toileting, personal hygiene, transfer, dressing, and bed mobility. During an observation and interview on 03/05/24 at 8:45 a.m., Resident #45 was in his bed and said he had chipped/peeling wallpaper. He said anyone with eyes could see it coming from the wall and he would like it fixed. During an interview on 03/06/24 at 8:44 a.m., CNA F looked at the wallpaper in Resident #45's room and said she would not like her wallpaper to be peeling in her home. She said she was not aware of how long the wallpaper had been peeling but was aware. She said she would go put it in the maintenance book so that it would be fixed. During an observation on 03/06/24 at 8:46 a.m., Resident #45's peeling/torn wallpaper was placed in the maintenance book. During an interview on 03/06/24 at 8:445 a.m., LVN D said she was aware of the wallpaper in Resident #45's room but had not placed it in the maintenance book. She said she knew she should have placed it in the maintenance book but did not. She said she would not like peeling wallpaper in her house or the resident's home. During an interview on 03/06/24 at 4:55 p.m., the Maintenance Supervisor said he had someone from their regional office who came yesterday (03/05/24) and they planned for him to remove the wallpaper and replace it with textured paint. He said they discussed it only but had no written plans. He said the wallpaper should or replaced for the beautification of the room. During an interview on 03/06/24 at 2:58 p.m., the DON said all staff should report and place anything in the maintenance book that needed to be fixed. She said all staff was aware of this process. She said she would not want her house wallpaper to be peeling nor does she want it for the residents. During an interview on 03/06/24 at 3:38 p.m., the Administrator said he was not aware of the wallpaper in Resident #45's room but would see what he could do to have the wallpaper repaired. He said all staff should report anything that needed to be fixed to the maintenance supervisor and place it in his book. He said if things were not placed in the maintenance book, then they could be missed. He said he had been at the facility for 6 months and he was working on things and systems throughout the facility to make it better overall for everyone. Record review of the facility policy titled, Homelike Environment, dated 02/21 indicated, Residents are provided with a safe, clean, comfortable, and home life environment and are encouraged to use personal belongings to the extent possible. #2 The facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, home-like setting. These characteristics include A. clean, sanitary, and orderly environment F. Pleasant, neutral scents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 3 of 33 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 03/06/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 16 residents (Resident #36) reviewed for MDS transmittal. Residents Affected - Few The facility did not ensure Resident # 36's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted and accepted as required as of 03/06/2024. This deficient practice could place residents at risk of not having their assessments transmitted and accepted in a timely manner and causing a delay in payments for the facility. The findings included: Record review of Resident #36's face sheet dated 03/06/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #36 had diagnoses including Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), heart disease, anxiety (an unpleasant state of inner turmoil), and diabetes mellitus (a disease in which the body has trouble controlling blood sugars). Record review of Resident # 36's quarterly MDS assessment dated [DATE] indicated Resident #36 had a BIMS score of 5, which indicated severe cognitive impairment. Resident #36 was dependent on staff for assistance with ADLs. During an interview on 03/06/24 at 12:14 p.m. the MDS nurse said she was responsible for creating, completing, and transmitting all MDSs in the facility. The MDS nurse said that all MDS assessments were required to be transmitted to CMS in a timely manner. She said she when she completed the MDS for Resident #36 she accidentally checked the section not to transmit the assessment to CMS. The MDS nurse said that the MDS not being transmitted in a timely manner could cause a delay in payment. During an interview on 03/06/24 at 04:15 p.m. the DON said the MDS for Resident #36 should have been transmitted to CMS in a timely manner. She said the MDS nurse was responsible for ensuring the MDS's are submitted in a timely manner. The DON said the MDS nurse should have caught the error because MDSs are monitored in a meeting weekly by the MDS nurse and the corporate nurse, so it was just missed. The DON said the failure placed the resident at risk of loss of benefits and/or the facility to have had loss of payment. During an interview on 03/06/24 at 04:42 p.m. the Administrator said he expected the MDS assessments to have been completed and transmitted to CMS in a timely manner. He said the MDS nurse was responsible for ensuring the assessments were completed and transmitted on time. The Administrator said the failure could have caused a risk of Resident #36's information not being updated with CMS and payment issues for the facility. Review of the facility policy, MDS Completion and Submission Timeframes revised September 2010 indicated Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 4 of 33 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 03/06/2024 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 0640 Policy Interpretation and Implementation Level of Harm - Minimal harm or potential for actual harm 1. The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to CMS QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. Residents Affected - Few 2. The following timeframes will be observed by this facility . Quarterly (Non-Comprehensive) MDS should be transmitted by Completion Date + 14 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 5 of 33 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 03/06/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 3 of 4 (Resident #9, Resident #16, and Resident #43) residents reviewed. 1. The facility failed to care plan Resident #9's fall and/or intervention, diagnoses, and medication use of Xanax (a medication used for generalized anxiety disorder). 2. The facility failed to care plan Resident #16's intervention, diagnoses, and medication use of diagnosis Eliquis {Apixaban} (an anticoagulant medication used to help prevent blood clots). 3. The facility failed to have a care plan related to Resident #43's [NAME] button and extension used for enteral feedings. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1.Record review of Resident #9's face sheet, dated 03/06/24, indicated Resident #9 was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #9 had diagnoses which included anxiety, high blood pressure, heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and diabetes. Record review of Resident #9's quarterly MDS assessment, dated 01/15/24, indicated Resident #9 understood and understood others. Resident #9's BIMS score was 07, which indicated she was moderately cognitively impaired. Resident #9 was independent with eating and required extensive assistance with toileting, personal hygiene, transfer, dressing, and bed mobility. The MDS indicated she used antianxiety medications but had no falls. Record review of Resident #9's physician orders dated 10/18/23, indicated Xanax Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth three times a day for Anxiety. Record review of Resident # 9's medical records incident report dated 2/25/24 at noon, indicated Resident #9 had fallen on the floor in the shower room. LVN E was called to the shower room and assessed Resident #9 and no injuries were observed. LVN E ordered an X-ray (used to generate images of tissues and structures inside the body) of the right knee and lower back. X-ray results were negative. Record review of Resident #9's comprehensive care plan dated 09/22/21 did not indicate any plan of care or interventions for medication use of Xanax or a fall that occurred on 02/25/24. Record review of Resident #9's comprehensive care plan, dated 03/06/24 after the state surveyor intervention indicated: Resident #16 was on antianxiety medication for Xanax related to anxiety disorder. The interventions were for staff to administer antianxiety medications as ordered by the physician and monitor for side effects and effectiveness every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 6 of 33 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 03/06/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/05/24 at 8:48 a.m., Resident #9 said she remembered falling but could not remember what happened. 2. Record review of Resident #16's face sheet, dated 03/06/24, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anxiety (persistent and excessive worry that interferes with daily activities), sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), chronic obstructive pulmonary disease or COPD, ( a group of diseases that cause airflow blockage and breathing-related problems), and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart). Record review of Resident #16's quarterly MDS assessment, dated 02/02/24, indicated Resident #16 was understood and understood by others. The MDS assessment indicated she had a BIMS score of 15 indicating cognitively intact. The MDS indicated she took anticoagulant medication. Resident #16 required assistance with bathing, dressing, bed mobility, personal hygiene, toileting, and setting up for eating. Record review of Resident #16's physician orders dated 01/26/24, indicated: Eliquis (Apixaban) 5MG, give 1 tablet by mouth two times a day related to secondary pulmonary hypertension. Record review of Resident #16's comprehensive care plan, dated 02/02/24, did not indicate any plan of care or interventions for the medication use of Eliquis. Record review of Resident #16's comprehensive care plan, dated 03/06/24 after surveyor intervention indicated: Resident #16 was on anticoagulant therapy of Eliquis (Apixaban) related to a disease process of pulmonary hypertension resulting in decreased mobility. The interventions were for staff to administer anticoagulant medications as ordered by the physician and monitor for side effects and effectiveness every shift. During an observation and interview on 03/06/24 at 9:00 a.m., the MDS nurse said she was responsible for the comprehensive care plans, but all the department heads do their acute care plans. The MDS nurse looked at Resident #9's care plan and said she did not see her fall or use of the Xanax on the care plan. She also looked at Resident #16's care plan and said she did not see the use of Eliquis care planned. The MDS nurse said the fall, diagnoses, and interventions should have been listed on Resident #9's care plan and the diagnoses, and interventions should have been listed on Resident #16's care plan. She said the omissions on both were an oversight. She said care plans were done to address concerns and for continuity of care so that the residents could have the best possible outcome for their care. During an interview on 03/06/24 at 2:58 p.m., the DON said the MDS nurse was responsible for completing the care plans. She said she was the overseer. The DON said she was not aware that Resident #16's medication use of Eliquis and Resident #9's fall on 02/24/24 or her medication use of Xanax was not care planned. She said care plans reflected residents' care and needs and should be complete and accurate to ensure the residents received the care they needed. During an interview on 03/06/24 at 3:38 p.m., the Administrator said all disciplinaries should work together to complete a resident's care plan. He said the DON was the overseer. He said Residents #9 and #16 should have had intervention, diagnoses, and medication indicated on their care plan and Resident #9's fall. He said care plans were generated to provide each resident with the best care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 7 of 33 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 03/06/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Record review of Resident #43's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses cerebral palsy (a group of movement disorders that appear in early childhood), high blood pressure, dysphasia (difficulty swallowing), epilepsy (neurological disorder characterized by recurrent seizures), and a need for assistance with personal care. Record review of Resident #43's admission MDS assessment dated [DATE] indicated she had a BIMS score of 0 which indicated severely impaired cognition. The MDS also indicated she required total assistance with all ADL's and required a feeding tube for more than 51% of her calorie intake. Record review of Resident #43's order summary report dated 03/06/24 indicated she had orders as followed, after state surveyor intervention: 1.Change [NAME] button extension tubing every other week on Tuesday. Every 14 days dated 03/05/24 and a start date of 03/19/24. Record review of Resident #43's care plan dated 04/21/23 indicated resident required a feeding tube with no indication of the use of the [NAME] button to be used for feedings and to be changed out every 14 days. During an interview on 03/05/24 at 11:18 a.m. LVN D said the [NAME] extension bag should have been dated and the [NAME] extensions were required to be changed out every 14 days but without the date she could not say when it was changed out. LVN D said the charge nurses were responsible for changing the [NAME] button extensions out. She said the risk to the resident was infection. During an interview on 03/06/24 at 04:17 p.m. the DON said the [NAME] extension should have been changed every other week and it should have been added to the care plan. The charge nurse was responsible for ensuring there was an order in place for changing the [NAME] button extension out and the ADON should have followed up on the orders. The DON said the MDS nurse was responsible for ensuring the care plan included the [NAME] button along with the enteral feedings. The DON said the failure placed a risk for the extension and the bag not being changed properly. She said with the [NAME] extension not being on the care plan, the nurses would not know how to care for the [NAME] extension. She said the facility did not have a policy for the [NAME] extension in detail, but provided an enteral tube policy and the facility would update the care plan and policy to include the [NAME] extension. During an interview on 03/06/24 at 04:32 p.m. the Administrator said the extension should have been placed as a physician order as well as on the care plan. He said the charge nurse was responsible for ensuring the order was placed and the MDS nurse was responsible for the care plan being updated. The Administrator said the failure placed Resident #43 at risk for the nurse taking care of her not using the [NAME] extension or not using it correctly. Record review of the facility policy titled Care plans, Comprehensive Person-Centered, dated March 2022 indicated a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT) in conjunction with residents and his or her family develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment no more than 21 days after admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 8 of 33 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 03/06/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as possible to prevent accidents for 1 of 2 hallways (Hall 100) and 1 of 1 oxygen storage areas reviewed for accidents. 1. The facility did not ensure the flooring on Hall 100 was even and free of cracked/broken floor tiles. 2. The facility failed to ensure 1 oxygen cylinder was secured in the oxygen storage area. These failures could place residents at risk for injury. Findings included: 1.During an observation on 03/04/24 at 1:00 p.m., the hallway on Hall 100 had cracked and uneven flooring approximately 3 feet across the floor (side to side). An observation included an ambulatory resident walking over the uneven area. During an observation and interview on 03/05/24 at 9:24 a.m., CNA F said the floor between hall 100 nurses' station and the dining room had been cracked/broken for an unknown amount of time. She said 1 broken spot just occurred about 2-3 weeks ago. She said it could be a trip hazard because she does have residents who walk. She said she was not aware of any falls. She said she could see and feel a hump underneath the floor and said it could be a hazard because it was uneven. She said the administration staff was aware but did not know if the facility had a plan to fix the floor. During an interview on 03/06/24 at 8:49 a.m., LVN D said the floor had been coming apart for an unknown time but was not aware of any falls. She said she could see the potential for falls because the floor was unleveled and had cracks. During an interview on 03/06/24 at 4:55 p.m., the Maintenance Supervisor said he was hired in October 2023. He said he had no set schedule to monitor or check flooring routinely. The Maintenance Supervisor said he had someone from their regional office who came yesterday (03/05/24) and looked at the floors. He said he had to get with the corporate office to approve major repairs to the flooring. He said it was important to ensure the flooring was in good repair for the safety of the residents. 2.During an observation on 03/06/24 at 10:05 a.m., the oxygen storage area outside had 1 oxygen cylinder free-standing without being stored in the oxygen holding rack. During an observation and interview on 03/06/24 at 10:15 a.m., the Activity Director indicated there was 1 free-standing oxygen tank on the outside oxygen storage area. The Activity Director said the oxygen cylinders should be stored in the available rack or holder for the safety of everyone. During an interview on 03/06/24 at 2:58 p.m., the DON said everyone was responsible for oxygen storage. The DON indicated the oxygen cylinders should be stored in the oxygen storage rack for safety. The DON said she was aware of the uneven floor on hall 100 but the holes were new (unknown time) and could be seen as a fall risk. She said all staff were responsible for safety, but the maintenance supervisor was the overseer. The DON said it was important to report uneven flooring and cracked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 9 of 33 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 03/06/2024 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 flooring to the Maintenance supervisor to prevent injuries or falls. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/06/24 at 3:38 p.m., the Administrator indicated all staff were aware of how the oxygen cylinders should be stored. He said every staff member was responsible for ensuring oxygen cylinders were stored correctly. He said they should be secured for safety. The administrator said he was aware of the uneven floors and some holes in the floor on hall 100. He said the holes were supposed to be covered already. He had been working on a plan for the last month or so to fix the uneven floors but had not made a specific plan yet. He said he expected all staff if they saw any safety issues for them to fill out a maintenance slip and to notify him. He said the holes and the uneven floors on hall 100 could be a safety issue for the residents. Residents Affected - Few Record review of the facility policy titled, Oxygen Safety, dated 08/16/22 indicated, Oxygen cylinder must be stored in racks with chain, steady portable carts, or approve stands. No oxygen cylinders should ever be left freestanding. Record review of the facility policy titled, Homelike Environment, dated 02/21 indicated, Residents are provided with a safe, clean, comfortable, and home life environment and are encouraged to use personal belongings to the extent possible. #2 The facility staff and management maximize to the extent possible, the characteristics of the facility that reflect a personalized, home-like setting. These characteristics include: A. clean, sanitary, and orderly environment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 10 of 33 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 03/06/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 4 (Resident #16) who were reviewed for respiratory care. Residents Affected - Some The facility failed to ensure Resident #16 had orders for her Bipap machine (a type of ventilator-a device that helps with breathing). This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #16's face sheet, dated 03/06/24, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anxiety (persistent and excessive worry that interferes with daily activities), sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), chronic obstructive pulmonary disease or COPD, ( a group of diseases that cause airflow blockage and breathing-related problems), and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart). Record review of Resident #16's quarterly MDS assessment, dated 02/02/24, indicated Resident #16 was understood and understood by others. The MDS assessment indicated she had a BIMS score of 15 indicating she was cognitively intact. Resident #16 required assistance with bathing, dressing, bed mobility, personal hygiene, toileting, and setting up for eating. The MDS indicated she used a Bipap. Record review of Resident #16's physician orders dated 03/06/24, did not indicate any orders for her Bipap. Record review of Resident #16's comprehensive care plan, dated 02/05/24 indicated Resident #16 used Trilogy BIPAP at night related to Pulmonary hypertension The intervention was for staff to assist the resident in applying a mask at hours of sleep as needed, ensuring proper fit of mask, maintain settings as per physicians orders, and monitor and document signs and symptoms of respiratory difficulties. During an observation on 03/05/24 at 08:41 a.m., Resident #16 was in her bed with her eyes closed on a Bipap machine. During an observation and interview on 03/06/24 at 08:29 a.m., LVN D said Resident #16 had an order for her Bipap settings. LVN D looked into their electronic medical records and did not see an order for Resident #16's Bipap machine. She said the nurses were responsible for ensuring orders were placed in their electronic system. She said Resident #16 usually had on her Bipap when she came on shift. She said she did not know Resident #16's Bipap settings. She said it was important to know the setting to ensure correct airflow and prevent respiratory issues. During an interview on 03/06/24 at 2:58 p.m., the DON said Resident #16 should have had an order for her Bipap. She said she was unaware why Resident #16 did not have a physician order for her Bipap. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 11 of 33 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 03/06/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The DON said the nurses were responsible for writing orders in the electronic records when they received orders. She said Resident #16 should have orders for her Bipap so staff would know the correct settings. She said failure to have an order or know the correct settings could lead to respiratory issues. During an interview on 03/06/24 at 3:38 p.m., the Administrator said everyone should have orders so the nurses would know how to take care of the residents. He said the DON was to ensure all residents had orders. He said he was not clinical but failure to know or have the correct setting for a Bipap machine could cause staff to deliver the wrong amount of air which could lead to respiratory problems. Record review of the facility policy titled, Medication orders dated February 2014 indicated, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders #2 A current list of orders must be maintained in a clinical record of each resident; recording orders: #2 oxygen orders when recording orders for oxygen specify the rate of flow the route and rationale. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 12 of 33 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 03/06/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for 1 of 1 resident reviewed (Resident #16) for respiratory care. The facility failed to ensure nurses were trained on the use of a Bipap machine (a machine that helps you breathe) for Resident #16. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize respiratory issues. The findings included: Record review of Resident #16's face sheet, dated 03/06/24, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anxiety (persistent and excessive worry that interferes with daily activities), sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), chronic obstructive pulmonary disease or COPD, ( a group of diseases that cause airflow blockage and breathing-related problems), and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart). Record review of Resident #16's quarterly MDS assessment, dated 02/02/24, indicated Resident #16 was understood and understood by others. The MDS assessment indicated she had a BIMS score of 15 indicating she was cognitively intact. Resident #16 required assistance with bathing, dressing, bed mobility, personal hygiene, toileting, and setting up for eating. The MDS indicated she used a Bipap. Record review of Resident #16's physician orders dated 03/06/24, did not indicate any orders for her Bipap. Record review of Resident #16's comprehensive care plan, dated 02/05/24 indicated Resident #16 used Trilogy BIPAP at night related to Pulmonary hypertension The intervention was for staff to assist the resident in applying a mask at hours of sleep as needed, ensuring proper fit of mask, maintain settings as per physicians orders, and monitor and document signs and symptoms of respiratory difficulties. During an observation on 03/05/24 at 08:41 a.m., Resident #16 was in her bed with her eyes closed on a Bipap machine. During an attempted phone interview on 03/05/24 at 9:47 p.m., LVN E (night nurse on hall 100) did not answer the phone. During an interview on 03/06/24 at 08:29 a.m., LVN D said Resident #16 usually had on her Bipap when she came on shift. She said she did not know Resident #16's Bipap settings. She said she could not remember any training on Resident #16's Bipap. She said it was important to know how to operate her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 13 of 33 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 03/06/2024 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 0726 Bipap machine to ensure correct airflow and prevent respiratory issues. Level of Harm - Minimal harm or potential for actual harm During an attempted phone interview on 03/06/24 at 2:10 p.m., LVN K (weekend nurse for hall 100) did not answer the phone. Residents Affected - Some During an interview on 03/06/24 at 2:58 p.m., the DON said they had Bipap training but could not remember when or locate the training. She said the ADON gave the training but was not sure if the ADON had been trained by a respiratory therapist or another nurse who was trained. She said nurses should be trained on Bipap function, orders, and settings. She said they should have done competencies on hire, yearly, and as needed. She said it was important for nurses to know what the Bipap needed to be set on to ensure adequate breathing function and not knowing could lead to respiratory problems. During an interview on 03/06/24 at 3:38 p.m., the Administrator said he expected nurses to have the training they needed for a Bipap machine. He said the DON/ADON was responsible for ensuring nurses were competent in their skill set. The administrator said without proper training someone could mess up and have a negative outcome. Record review of competencies skills did not reveal LVN D had been checked off on Bipap assessments or settings. Record review of the facility policy titled, Staffing, Sufficient and Competent Nursing, dated August 2022, indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 4. Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting, and reporting resident changes of condition consistent with their scope of practice and responsibilities. 5. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: a. programming for staff training results in nursing competency; b. gaps in education are identified and addressed; c. education topics and skills needed are determined based on the resident population; d. tracking or other mechanisms are in place to evaluate the effectiveness of training, and e. training includes critical thinking skills and managing care in a complex environment with multiple interruptions. Record review of the facility policy titled, CPAP/BIPAP Support, dated March 2015, indicated, Purpose: #1. To provide the spontaneous breathing residents with continuous positive air pressure with or without supplemental accident #2. To improve arterial oxygenation (PAO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive obstructive lung disease. #3. To promote resident comfort and safety. Preparation: #1. Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. #4 Review and follow manufacturer instructions for the CPAP/Bipap machine to set up an oxygen delivery. General guidelines: #2 Bipap delivers CPAP but allows separate pressure settings for expiration and inspiration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 14 of 33 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 03/06/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: During an observation and interview on [DATE] at 09:50 a.m., the following medications were observed in the controlled medication storage cabinet awaiting to be disposed: *Alprazolam 0.5mg- 60 tablets *Alprazolam 0.5mg- 1 tablet *Tramadol 50mg- 30 tablets The DON said the controlled medications awaiting to be disposed were kept in the locked cabinet behind a locked door. The DON said she was responsible for the discontinued medications, and she was the only one with the key to the door and the cabinet. The DON said when she reconciled medications that need to be disposed of the medications were brought to her, she checked the narcotic medication count, verified the count with the nurse, logged the medication on the destruction log that was kept in a binder, and then placed the medication in the locked cabinet. The DON was not able to find the current log of the medications to be disposed and said she must have misplaced it and she would usually log them as she received the medications. The DON said the risk of her not logging the medications would be if someone broke in, she would not know which medications were not accounted for. Record review of the facility's medication destruction binder on [DATE], indicated the last medication destruction was completed on [DATE]. During an interview on [DATE] 04:28 p.m. the Administrator said when narcotic medications were discontinued, they were given to the DON with the narcotic count sheet and kept locked. The Administrator said the narcotic medication should be logged as the DON received them. The Administrator said if the narcotic medications were not reconciled then medications could come up missing and be unaccounted for. The Administrator said the DON and the pharmacy consultant were responsible for ensuring the narcotic medications were accurately reconciled. Record review of the facility's policy Medication Storage and Disposal revised [DATE], indicated Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 15 of 33 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 03/06/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete accordance with federal and state laws and regulations .3. All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of: A. In the facility by the Director of Nursing .4. Disposition is documented on the individual controlled substance accountability record/book . Event ID: Facility ID: 675471 If continuation sheet Page 16 of 33 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 03/06/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, interviews, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy, as evidenced by: 1.) The facility failed to serve hot spiced apples as part of the noon-time (lunch) meal on 3/5/24 for all residents. The residents were served sherbert ice cream instead. 2) The facility failed to follow puree recipe for chicken fettuccine alfredo served on 3/5/24 (lunch meal) for residents on a puree diet. This failure could affect all residents in the facility who required pureed food consistency by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record Review of the facility week 1 menu received on 3/04/24, indicated the lunch meal items included chicken fettuccine alfredo, green beans, dinner roll, hot spiced apples, margarine, salt/pepper packets, choice of beverage, and water. Record Review of the recipe for the chicken fettuccine alfredo for 5 or less residents on puree indicated to mix 1/3 pound of milk whole gallon and 1 7/8 pound of regular chicken fettuccine alfredo. The recipe instructions for the chicken fettuccine alfredo indicated Step #1 note: The serving size as shown on this recipe and on the diet, spreadsheet is an estimate. The fluid amount listed in the recipe is also an estimate that is based on industry standards. To get the actual serving size, puree the number of portions needed, adding adequate liquid needed to achieve desired consistency as appropriate for resident, then divide the total amount equally by the number of portions pureed. Wash hands before beginning preparation, sanitize all surfaces and equipment; place portions to be pureed into blender or food processor; add adequate amount of liquid needed to achieve the consistency as appropriate for resident(s) and puree until smooth; Reheat to an internal temperature of > 165F held for 15 seconds; measure the resulting total amount of pureed product prepared; Serve: 6 ounce Spoodle (a versatile kitchen utensil that combines the design elements of a spoon and a ladle); maintain at an internal temperature of >140F for only 4 hours and discard unused portion(s). During an interview 3/4/24 at 4:11 p.m., Resident #2 stated the facility served the same foods and the food had no flavor. Resident #2 stated he had not eaten at the facility in months. Resident #2 stated he had been living at the facility for a year. During observation and interview on 3/5/24 at 11:37 a.m., of puree preparation for the noon meal prepared on 3/5/24, Dietary aide B stated she liked for the puree foods to be firm. Dietary aide B was observed not following the recipe book for the puree chicken alfredo. Dietary aide B added ½ cup of water with the 2 cups regular chicken alfredo in the blender. The dietary aide stated she had looked at the recipe book prior to the state surveyor coming in the kitchen. During observation, the state surveyor asked to review the recipe book with the dietary aide. During observation of the food recipe book, the recipe book for the chicken alfredo indicated to add milk and not water to puree the chicken alfredo. During an interview, Dietary aide B said she always added some water because the Dietician told her she could. Dietary aide B stated she had been employed at the facility for a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 17 of 33 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 03/06/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few few months. Dietary aide B stated when the recipe was not followed it could alter the flavor of the foods served to the residents. Dietary aide B stated the dietary manager oversaw her. Dietary Aide B stated the Dietary manager was responsible for ensuring the puree recipe was being followed by the dietary staff. During observation of the preparation of the puree foods on 3/5/24 at 11:37 a.m., the Dietary manager yelled at Dietary aide B and stated, The consistency for puree should be pudding like texture and that they had been over this over and over. During observation on 3/5/24 at 1:10 p.m., Residents were served sherbet ice cream instead of hot spiced apples for the lunch meal on 3/5/24. During an interview on 3/6/24 at 8:15 a.m., [NAME] C stated she had been employed at the facility for a little over a year. [NAME] C stated she alternated shifts between other dietary staff but mostly worked the morning shifts. [NAME] C stated sometimes the kitchen did not have foods selected on the menu. [NAME] C stated when the facility did not have the selected food for the menu, she and or the Dietary Manager would go to the store and buy the foods needed to serve the residents. [NAME] C stated the dietary staff were supposed to follow the menu daily. [NAME] C stated the Dietary Manager was notified the Administrator and the dietician if the kitchen was not able to follow the menu. [NAME] C stated the Dietary Manager over saw her. [NAME] C stated, It was important follow the menu to ensure the residents were aware of what was for breakfast, lunch, and dinner and for nutrition needs for the residents. [NAME] C stated she also used water to thin the puree foods and sometimes milk. [NAME] C stated the Dietician indicated the staff could use apple juice for the puree bread to give the food flavor and a little bit of water. [NAME] C said the dietary staff were supposed to follow the recipe book. [NAME] C stated, Sometimes she looked at the recipe book and sometimes she just prepped the foods without looking at the recipe book. [NAME] C stated the dietary staff completed in-services on the recipe book a few weeks ago for her only and not the entire dietary staff. [NAME] C stated, It would be important to ensure the dietary staff was following the recipe book to ensure the food tastes good. During an interview on 3/6/24 at 9:47 a.m., the Dietitian stated if there were any substitutions, the Dietary Manager should fill out a form so she can approve the form when the facility did not have items listed on the menu. The Dietitian stated, For all substitutes changes, the category had to be the same for substitution for an example a, meat for meat and a dessert for dessert. The Dietitian stated she was not aware of the Dietary Manager not following the recipe book. The Dietitian stated she was not aware that the Dietary Manager served sherbet ice cream instead of hot spiced apples for the lunch meal on the lunch meal on 3/5/24. The Dietician stated she did not approve of sherbet ice cream to be served on 3/5/24 for lunch. The Dietitian stated depending on the recipe that apple juice would enhance the flavor for bread on puree and she did inform the dietary staff that they could use apple juice for the puree bread. The Dietitian stated unless the recipe specified water then the dietary staff were not to use water for the recipes. The Dietitian stated It was important for the dietary staff to follow the menu and the recipe book to provide the proper nutrition to the residents and ensure the residents received the total calories and nutrition for the day. During an interview at 3/6/24 at 11:42 a.m., the Administrator stated he was not aware of the dietary staff not following the menu. The Administrator stated he was not aware of the dietary staff not following the recipes in the kitchen for the meals. The Administrator stated, It was important for the dietary staff to follow the menu to ensure the residents received a complete diet and so the residents do eat the same foods. The Administrator stated, It was important for the dietary staff to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 18 of 33 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 03/06/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few follow the recipes, so it tastes good, and so the foods have good quality. The Administrator stated he oversaw the Dietary Manager. During an interview on 3/6/24 at 4:40 p.m., the Dietary Manager stated she had been the Dietary manager for a year. The Dietary Manager stated she had not had a lot of training at the facility for the Dietary Manager position since being employed as the Dietary Manager at the facility. The Dietary Manager stated the Administrator oversaw her. The Dietary Manager stated she tried following the menu and much as possible, but she did fill out a form to have the sherbet ice cream approved after the lunch meal on 3/5/24 was served. The Dietary Manager stated the Dietitian approved the sherbet ice cream after the lunch meal was served on 3/5/24. The Dietary Manager stated she had meant to send the approval substitute form earlier to the Dietician, but she got preoccupied with the state surveyor and did not send the approval for the substitute change until after the lunch meal was served on 3/5/24. The Dietary Manager stated she was required to have approval for the substitutions prior to serving the substitutes to the residents. The Dietary Manager stated she was also to inform the Administrator of the menu changes, but she did not know that she was supposed to inform the Administrator of menu changes until today 3/6/24. The Dietary Manager stated she was informed on 3/6/24 to notify the Administrator of any changes to the menu immediately. The Dietary Manager stated It is important to follow the menu and to report menu changes to ensure if one item was substituted that the substituted items equaled the same nutritional value as the initial food item on listed on the menu. The Dietary Manager stated, It was important to follow the recipe to ensure the resident received nutritional their needs. The Dietary Manager stated the Dietary aide was not supposed to mix water with when prepping for puree chicken alfredo. The Dietary Manager stated the cooks and dietary aides had not been in-serviced on how to puree foods. The Dietary Manager stated not all dietary staff had been in-serviced on how to puree foods. The Dietary Manager stated she had never told her staff to use water when pureeing foods for the residents. The Dietary Manager stated she informed her staff to use milk to puree foods. The Dietary Manager stated the Dietitian did inform the dietary staff that they could use apple juice for the puree bread for more flavor but not water. The Dietary Manager stated the Dietitian had informed the dietary staff to follow the recipe. The Dietary Manager stated, It was important to follow the recipe to ensure the foods tastes good to the residents. The Dietary Manager stated she was responsible for overseeing the cooks and dietary aides. Record review of facility's menu policy dated indicated October 2022, indicated, Menus are developed and prepared to meet residents choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy . (4) The Dietitian reviews and approves all menu (5) Input from the resident is considered in menu planning . (9) If a food group is missing from a resident's daily diet (e.g., dairy products), the residents is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplements or fortified non-diary alternatives.) . A policy for following the recipe guidelines was requested on 3/5/24 from the Dietary Manager and was not received before exit on 3/6/24 at 6:30 p.m. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 19 of 33 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 03/06/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability, attractiveness, and appetizing . Residents Affected - Few The dietary staff failed to provide food that was palatable and appetizing temperature for 1 of 3 meals observed on 3/5/24 (lunch) meal for all residents. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During an interview on 3/4/24 at 4:10 p.m., Resident #44 stated he did not like the food and the food was not seasoned. During an interview 3/4/24 at 4:11 p.m., Resident #2 stated the facility served the same foods and the food had no flavor. Resident #2 stated he had not eaten at the facility in months. Resident #2 stated he had been living at the facility for a year. During an interview on 3/4/24 at 1:49 p.m., Resident #4 stated the food could be better. Resident#4 stated he wanted his food hot but received the food cold sometimes. Record Review of the facility week 1 menu received on 3/04/24, indicated the lunch meal items included chicken fettuccine alfredo, green beans, dinner roll, hot spiced apples, margarine, salt/pepper packets, choice of beverage, and water. During an observation on 3/5/24 at 11:21 a.m., observations of food temperatures were made on the steam table by [NAME] N. The results were as followed, regular chicken fettuccine alfredo 171°F, regular green beans 139°F, dinner roll was room temperature. The puree chicken fettuccine alfredo tempted 140°F, puree green beans tempted 130°F, and the puree dinner roll tempted 134°F. During an observation, interview, and test tray testing on 3/5/24 at 1:28 p.m., the Dietician Manager indicated the following responses for lunch meal served on 3/5/24, The green beans were seasoned and warm; the chicken fettuccine alfredo needed more sauce, was dry tasting but was good in flavor; the bread was good, and the sherbet ice cream was good. During an interview on 3/6/24 at 8:31 a.m., [NAME] C stated she had been employed at the facility for a little over a year. [NAME] C stated she alternated shifts between other dietary staff but worked mostly morning shifts. [NAME] C stated she tasted the foods every time she cooked at the facility. [NAME] C stated she had complaints about the food cooked at the facility when she first started working at the facility but was not aware of any recent food complaints. [NAME] C said the chicken alfredo could have been [NAME] or creamier and she thought the taste was fine. [NAME] C stated, It was important to ensure the foods were palatable, attractive, and appetizing to ensure the residents did not lose weight and the food won't be bland foods. [NAME] C stated the Dietary Manager oversaw her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 20 of 33 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 03/06/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/6/24 at 4:33 p.m., the Dietary Manager stated she had been the Dietary Manager for a year. The Dietary Manager said she had not had much training at the facility for the Dietary Manager position. The Dietary Manager stated the Administrator oversaw her. The Dietary Manager stated she tasted the foods every week and she tried to test the food every day. The Dietary Manager said when the chicken alfredo came out of the oven, it was creamy, but when it sat on the steam table, the sauce dried out. The Dietary Manager stated it was important to ensure the food was palatable to prevent putting the residents at risk for not eating the foods. The Dietary Manager stated the Administrator never ordered test trays. The Dietary Manager stated she randomly brought the Administrator food for him to personally eat at the facility and not for a test tray. The Dietary Manager said the Administrator never gave her constructive criticism about the food cooked from the kitchen. The Dietary Manager stated she had received food complaints about bread being too hard and food complaints when the dietary staff served foods that had been fried too hard. The Dietary Manager stated she in serviced the cooks about how to cook the meals with bread and fried foods. The Dietary Manager stated, It was important to ensure the foods was palatable, attractive, and appetizing to ensure the residents get the nutrition that they need. During an interview on 3/6/24 11:37 a.m., the Administrator stated he oversaw the dietary manager. The Administrator stated he ordered a test tray last week of puree meal and the puree meal was good. The Administrator said he would get a test tray and ask other staff to test the kitchen food. The Administrator stated staff did not complain about the test tray foods. The Administrator stated, It was important that food as palatable, attractive, and appetizing to ensure the residents would eat; the food should look appetizing. Record review of facility's Menu policy dated indicated October 2022, indicated, Menus are developed and prepared to meet residents choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy . (4) The Dietitian reviews and approves all menu (5) Input from the resident is considered in menu planning . (9) If a food group is missing from a resident's daily diet (e.g., dairy products), the residents is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplements or fortified non-diary alternatives.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 21 of 33 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 03/06/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to label and date all food items in the refrigerator and freezer #1. 2) Dietary staff failed to dispose of expired food items. 3) Dietary Staff failed to store (1) dented cans in a separate area. 4) Dietary Staff failed to effectively reseal, label and date frozen food items. 5) The dietary staff failed to maintain safe temperatures at or above 135 degrees F for hot foods. 6) The facility failed to store raw foods (ground turkey) in a manner to reduce the risk of contamination of cooked or ready-to-eat foods. 7) The dietary staff failed to clean the microwave after use. 8) The dietary staff failed to properly dispose of used gloves and used hair net. 9) The dietary staff failed to clean the toaster after use. 10) The dietary staff failed to clean the utensil drawer. 11) The dietary staff failed to clean the clean the floors daily. 12) The dietary staff failed to remove the scoop from the sugar container and corn meal. 13) The dietary staff failed to clean the can opener. 14) The dietary staff failed to clean the countertops. 15) The facility failed to have the cracks in the floor repaired in the kitchen. 16) The dietary staff failed to log water temperature and chemical sanitation levels for the 3 compartment sinks on 2/27/24, 2/28/24, 2/29/24 3/1/24, 3/2/24 and 3/3/24. 17) The dietary staff failed to follow manufacturers instruction for cleaning the pastry brushes. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observation with [NAME] C on 03/04/24 at 10:15 a.m., the following were indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 22 of 33 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 03/06/2024 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 0812 -(1) 1/5- quart container of white cheese expired 2/20/24, had no open date, no receive date Level of Harm - Minimal harm or potential for actual harm -(1) 1/5 pound bag of lettuce not sealed, received 2/14/24, had no open date and no expiration -(1) 1/5-pound bag of lettuce unopened was brown in color received on 2/14/24, had no receive date. Residents Affected - Many -(3) 12-ounce pack of cheese unopened had no received date. -(1) ½-quart of caramel had no open date and expired on 2/28/24. -(1) gallon of salad dressing received on 1/3/24 had no open date. -(1) bag of parmesan cheese had an open date of 12/11/24 and no expiration date. -(1) 4-pound container of pimento cheese expired on 2/5/24 had no open date and no receive date. -(1) 2-quarts of pineapples expired on 2/28/24 had no open date. -(1) ½--quart of banana pudding expired on 2/28/24. -(1) 2-quarts of sliced turkey had no open date, no receive date, and no expiration date. -(2) avocados not labeled, had no open date, no receive date and no expiration date. -(1) gallon of soy sauce opened 12/13/23 and had no receive date. -(1) container of baking soda fridge in freezer indicated on label to change every 30 days expired on 8/16/23. -(1) 2-pound containers of chopped garlic received on 1/17/24 had no open date. -(1) 1-pound container of base beef had no open date, no expiration date, and was received on 1/17/24. -(1) 1-pound container of ham base received on 2/28/24 had no open date and no expiration date. -(2) 5-pound container of sour cream received on 2/14/24 had no open date. -(1) 1-gallon of barbecue sauce received on12/13/23 had no open date. -(1) 4-pound of maraschino cherries received on 10/11/24 had no open date and no received date. -(2) 1-gallon ranch dressing received on 2/14/24 had no open date and no expiration date. -(1) 1-gallon yellow mustard received on 12/27/23 had no open date and no expiration date. -(1) 2-quart container of Jell-O opened on 2/14/24 had no expiration date and received date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 23 of 33 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 03/06/2024 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 0812 -(1) 4-quart container of shredded cheese opened 2/23/24 had no received date and no open date. Level of Harm - Minimal harm or potential for actual harm -(1) 2-quart container of broccoli opened 2/29/24 had no expiration date and no prep date. -(1) 3-pound bag of bacon received on 2/21/24 had no open date. Residents Affected - Many -(1) bag of uncured turkey bacon opened 2/29/24, had no receive date. -(1) zip lock bag of baked ham was not labeled, had no open date, no receive date, and no expiration date. -(1) roll unopened roll of turkey sausage was leaking blood, had no received date, and was placed on the second shelf over the boiled eggs. -(2) zip lock bag of pepperoni opened 1/23/24 had no expiration date and no received date. -(1) 1- gallon of Tuscan gold Italian dressing opened 2/2/24 had no expiration date. -(1) box of cream cheese received on 2/28/24 had no open date. -(1) gallon of tea expired on 3/2/24. -(1) 1/2-quart pitcher of tea expired 3/3/24. -(1) 1-gallon of 2 percent milk had no open date and no receive date. -(2) 1-gallon of 2 percent milk had no receive date. -(1) pitcher of lemonade not labeled, had no expiration, and prep date. During observation of Freezer #1 on 03/04/24 at 11:28a.m., the following were indicated: -(1) box of beef patties fritter received on 2/28/24, bag was not sealed, and had no open date. -(1) 10-pound box of chicken fried bread beef patties had no open date, bag no sealed, and received on 2/7/24. During an interview with the Dietary Manager and observation on 03/04/24 11:28a.m., the following were indicated in the Dry Storage area: -(1) 3-pound can of cream of chicken dented found in dry storage area. Dietary Manager stated the dented cans were to be stored in her office and she missed the dent on the side of the can. During an observation with the Dietary Manager of the kitchen on 03/04/24 11:28a.m., the following were indicated: -(1) 19-ounce garden seasoning received on 11/1/23 had no open date and no expiration date. -(1) 18-ounce salt seasoning had no open date, no receive date, and no expiration date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 24 of 33 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 03/06/2024 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 0812 -(1) chives seasoning received on 2/28/24 had no open date and no expiration date. Level of Harm - Minimal harm or potential for actual harm -(1) 20-ounce granulated onion seasoning received on 2/28/24 had no open date and no expiration date. -(1) 10-ounce poultry seasoning had no open date, no receive date, and no expiration date. Residents Affected - Many -(1) 19-ounce garlic bread sprinkle seasoning had no open date, no expiration date, and was received on 11/29/23. -(1) 18-ounce black pepper seasoning had no open date and received on 1/31/24. -(1) 19-ounce garlic bread sprinkle seasoning had no open date, no expiration date, and was received on 10/25/23. -(1) 24-ounce granulated garlic seasoning had no open date and was received on 1/17/24. -(1) 28-ounce lemon pepper seasoning had no open date and was received on 12/13/23. -(1) 16-ounce whole celery seed seasoning received on 11/8/23 and no open date. -(1) 6-ounce rubbed sage seasoning received 11/16/22 (expired), opened 11/18/22. -(1) 12-ounce ground thyme seasoning received on 3/8/23 had no open date and no receive date. -(1) container of paprika seasoning received on 10/13/20 (expired) and 10/13/20 open date. -(1) 12-ounce of ground oregano seasoning had no open date, no expiration date, and was received on 3/30/22. -(2) 17-ounce of oil base with lecithin cooking spray had no received date, and no open date. -(1) 17-ounce white pepper seasoning had no open date, no receive date, and no expiration date. -(1) 12 ounce of crushed red pepper seasoning had an expiration date of 12/2023 (expired) and no open date, no received date. -(1) 32 ounce of celery salt seasoning received on 11.8/23 had no open date or expiration date. -(1) 16 ounce of ground nutmeg seasoning had no open date, no expiration date, and was received on 3/30/22. -(1) 14 ounce of ground mustard seed seasoning received on 6/21/23 had no open date and no expiration date. - (1) 18 ounce of chili powder seasoning received on 3/30/22 had no expiration date and no open date. (expired) -(1) 6-ounce Italian seasoning received on 12/27/23 had no expiration date and no open date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 25 of 33 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 03/06/2024 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 0812 -(1) 18-ounce chili powder seasoning received on 3/1/20 had no open date and no expiration date. (expired) Level of Harm - Minimal harm or potential for actual harm During an interview on with [NAME] C on 03/04/24 at 10:15 a.m., [NAME] C stated, [NAME] C sated the lettuce should have been thrown out. Residents Affected - Many During an interview on 03/04/24 11:28a.m., the Dietary Manager stated all seasoning was good for 6 months and seasoning should have been thrown in the trash. During an interview and observation with the Dietary Manager on 3/4/24 at 12:07 p.m., the dishwashing 3 compartment sink was missing 3/3/24 dishwashing temperatures. The Dietary manager stated she was not aware the water temperatures and chemical sanitation levels for 2/27/24 (breakfast, lunch, and dinner), 2/28/24 (breakfast and lunch), 2/29/24 (lunch and dinner) 3/1/24 (lunch), 3/2/24 (lunch and dinner), and 3/3/24 (breakfast, lunch, and dinner). had not been recorded. The Dietary Manager stated the dietary staff used the 3 compartment sinks every day. The Dietary Manager was not aware the dietary staff logged water temperature and chemical sanitation level on 2/29/24, 2/30/24, and 2/31/24 despite the month of February ending on 2/29/24. During an interview and observation with the Dietary Manager of the kitchen on 03/04/24 at 12:17 a.m., the can opener was observed with a brown substance all over the handle of the can opener, the knife, and the handle of the can opener was greasy. During an interview with the Dietary Manager, the dietary staff should have had the can opener cleaned. During observation, the utensil drawers had white crumbs inside the utensil drawers. During an interview, the Dietary Manager stated the utensil drawer did not appear clean and needed to be cleaned. The Dietary Manager stated she would get the utensil drawer taken care of. During an interview on 03/5/24 at 8:27 a.m., [NAME] C stated she had been employed at the facility for a year and her position was dietary aide and cook. [NAME] C stated the pastry brushes were opened and had been used in the kitchen for the past 3 months. [NAME] C stated she thought the pastry brushes were paint brushes. [NAME] C stated the facility had rubber pastry brushes, but it had been months since the facility had used rubber pastry brushes. [NAME] C stated she had seen other staff run the pastry brushes through the high temperature water chemical dishwasher. [NAME] C stated she had not had any in-service training on how to clean the pastry brushes. [NAME] C stated she was not informed that the manufacture indicated that the pastry brushes were not dishwasher safe. [NAME] C stated staff had been cleaning the pastry brushes in the high temperature washer for the past 3 months. [NAME] C stated she was not aware that the dietary staff were to hand wash the pastry brushes according to the manufacturer. [NAME] C stated the Dietary Manager was responsible for overseeing her. [NAME] C stated, It was important to ensure the dietary staff was following the manufacture instructions for cleaning the brushes to ensure the residents do not get bristles in their food and to prevent the residents from getting sick. During an interview on 3/5/24 at 9:25 a.m., the Dietary Manager stated she had been the dietary manager at the facility for one year. The Dietary Manager stated she was responsible for overseeing the kitchen. The Dietary Manager stated the facility used silicone pastry brushes in the past, but those pastry brushes kept falling apart so the facility used a different manufacture pastry brush. The Dietary Manager stated the brushes currently used in the kitchen were purchased 3 months ago. The Dietary Manager stated she purchased 4 pastry brushes and then 2 of those pastry brushes went bad quickly so the kitchen was down to only two pastry brushes. The Dietary Manager stated the pastry brushes were cleaned in the high temperature dishwasher and sometimes the 3-compartment sink was used to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 26 of 33 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 03/06/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many clean the pastry brushes. The Dietary Manager stated she did not conduct in-service training for the dietary staff on how to properly clean the pastry brushes. The Dietary Manager stated that she was not aware that according to the manufacturer's instruction the pastry brushes were not dishwasher safe, and the brushes were to be hand washed only. The Dietary Manager stated the two pastry brushes used in the facility were thrown out. The Dietary Manager stated the Administrator oversaw her. The Dietary Manager stated, It was important to follow the manufactures instructions on cleaning the pastry brushes to ensure the bristle on the brushes were not breaking off into the resident's food. During an interview on 3/6/24 at 8:43 a.m., [NAME] C stated she had been employed at the facility for a little over a year. [NAME] C stated she alternated shifts between other dietary staff but worked mostly morning shifts. [NAME] C stated when the dietary staff received foods from the food truck that the dietary staff were to label the foods, include a receive date, and when the foods were open it was supposed to have an expiration date and open date. [NAME] C stated she did not know how long the seasonings were good for. [NAME] C stated she was not aware the policy stated the seasonings were good for only 6 months. [NAME] C stated she was not aware of the expired seasoning and the expired foods found in the refrigerator prior to survey. [NAME] C stated all dietary staff were responsible for cleaning out the refrigerator, labeling, and dating all food items. [NAME] C stated the Dietary Manager went through the refrigerator every other day, and the Dietary Manager informed the dietary staff every day to throw out expired items. [NAME] C stated the dented cans were to be stored in the Dietary Managers office. [NAME] C stated she took the temperatures of the foods served every day. [NAME] C stated hot foods were supposed to be 165-degree Fahrenheit. [NAME] C stated the cold foods were supposed to be 38- degrees and below. [NAME] C stated the Dietary Manager conducted in-services on water temperature and chemical sanitation a few months ago. [NAME] C stated raw meats were not supposed to be stored on the second shelf above the ready to eat boiled eggs. [NAME] C stated raw meats should be stored on the bottom of the refrigerator to prevent the blood leaking in other food items. [NAME] C stated the microwave was to be cleaned on every shift but if a dietary staff messed up the microwave that the dietary staff were to clean the microwave immediately and not wait until the second shift. [NAME] C stated that if a dietary staff member left the kitchen with a hair net on, the hair net should be thrown away in the trash can. Stated used gloves were to be disposed in the trash can. Stated she had witnessed other dietary staff members putting used gloves on the countertop. [NAME] C stated she had informed staff members to throw used gloves and hair nets in the trash can. [NAME] C stated the dietary staff were to clean the toaster immediately after use. [NAME] C stated in the past she had gotten busy and forgot to clean the toaster immediately. [NAME] C stated deep cleaning was supposed to be done weekly. [NAME] C stated mopping and sweeping the floor was supposed to be done every shift. [NAME] C stated she was the main dietary staff member who swept and mopped through the day in the kitchen. [NAME] C stated on every shift the dietary staff were to ensure the floors had been cleaned and if the previous shift did not clean the floors, then the next shift was responsible for cleaning the floors. [NAME] C stated the second shift did not clean the floors often and she informed the Dietary Manager every time the floors were left dirty. [NAME] C said the crack in the floor near the steam table and drains had been there since she was employed. [NAME] C stated the Dietary Manager, and the Administrator were aware of the cracks in the kitchen floor. [NAME] C stated that a floor repair company came out and made some repairs to the kitchen floor 4 months ago but that repair company did not repair the entire kitchen floor. [NAME] C stated the scoop in the sugar container was not to be left inside the containers. [NAME] C stated the scoops in the sugar could contaminate the sugar. [NAME] C stated she did not throw out the sugar because she was not told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 27 of 33 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 03/06/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many to throw the sugar out. [NAME] C stated the can opener was to be cleaned every day and to be cleaned after each use. [NAME] C stated, It was important food items were labeled and dated to ensure expired foods items did not get the resident sick. [NAME] C stated, It was important for the dented can be stored in a separate storage area to prevent contamination. [NAME] C stated, It was important to ensure food items were resealed in the freezer to prevent food bacteria and freezer burn. [NAME] C stated, It was important to dispose of used gloves and hair nets in the trash to prevent cross contamination. [NAME] C stated, It was important for the kitchen to be cleaned to prevent pest, rodents, and for the residents health and safety. [NAME] C stated, It was important for the kitchen floors to be repaired to prevent trip hazard. During an interview on 3/6/24 at 12:00 p.m., the Administrator stated he had been the Administrator since August 7 of 2023. The Administrator stated he was not aware of the issues found in the kitchen. The Administrator stated staff were to dispose of all expired food items. The Administrator stated staff were to label food items with a receive date, open date, and expiration date. The Administrator stated the dented cans were to be stored in the dietary manager's office. The Administrator stated staff were supposed to ensure they were resealing the food in their freezer and include an open date, expiration, and receive date. The Administrator stated the dietary staff should not have served the puree green beans at 130-degrees and it should have been served at 135 and above. The Administrator stated, It was important for staff to ensure they are serving foods at the right temperature to prevent bacteria growth. The Administrator stated the dietary staff should have put the freezer frozen items to thaw out on the lower shelf to prevent contamination. The Administrator stated the dietary staff should have cleaned the toaster, can opener, and the microwave after each use to prevent contamination. The Administrator stated, It was important for staff to clean the utensil drawer daily to prevent contamination. The Administrator stated the dietary staff were not to leave the scoop inside the sugar bid. The Administrator stated, It was important to ensure that staff were removing the scoop from the bid to prevent contamination. The Administrator stated the dietary staff should be cleaning the floors and countertops daily and after each meal. The Administrator stated he was aware of the cracks in the kitchen floor and He was working on it. The Administrator stated, It was important to address the cracks in the floor because it was trip hazard for the dietary staff. The Administrator stated, It was important for dietary staff to follow the manufactures instruction on the pastry brushes to ensure the bristles did not fall into the resident's foods. The Administrator stated he conducted walk through in the kitchen daily. The Administrator stated he had informed the dietary to deep clean the kitchen. The Administrator stated he had extra staff come in to help deep clean the kitchen. During an interview on 3/6/24 at 4:07 p.m., the Dietary Manager stated she had been the Dietary manager for a year. The Dietary Manager stated she had not had a lot of training at the facility for the Dietary Manager position at the facility. The Dietary Manager stated she oversaw the kitchen. The Dietary Manager stated items in the refrigerator were to be labelled with a received and opened date. The Dietary Manager stated the expiration date was usually on most items received on the truck and for the food items without one, the dietary staff was responsible for including the expiration date. The Dietary Manager stated on Monday, Wednesday, and Fridays that she conducted walk throughs in the kitchen. The Dietary Manager stated on last Friday (3/1/24) that she was sick and did not have a chance to go through the kitchen, and the dietary staff had been trained to go through the kitchen to check for expired food items. The Dietary Manager stated the dietary staff should have resealed and closed the bag on the open freezer foods. The Dietary Manager stated the dietary staff should have included open date on the frozen foods that was opened. The Dietary Manager stated, It was important for staff to reseal the freezer food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 28 of 33 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 03/06/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many items to prevent cross contamination and no spoiled food products. The Dietary Manager stated, It was important to maintain 135-degree Fahrenheit for hot foods to prevent bacteria growth. The Dietary Manager stated, It was important to have the frozen food items thaw out at the bottom of the refrigerator to prevent cross contamination. The Dietary Manager stated the microwave, toaster, and the can opener should be cleaned daily and after each use. The Dietary Manager stated she did not know why the kitchen was not cleaned because she had been on vacation. The Dietary Manager stated the floors in the kitchen did look rough and it needed to be cleaned. The Dietary Manager stated the floors should be cleaned after every shift. The Dietary Manager stated the dietary staff used a bleach product to clean the countertops. The Dietary Manager stated the bleach used on the counter left a white residue that appeared like the counter tops had not cleaned. The Dietary Manager stated staff should be wiping with disinfectant and sanitizer, not bleach products. The Dietary Manager said she saw a cook wiping the countertops with bleach and instructed that staff member not to wipe them with bleach products. The Dietary Manager stated she had conducted staff in-service training on cleaning the can opener, cleaning the ovens, temperatures on dishwasher, and chemical sanitization a few months ago. The Dietary Manager stated she was not aware that water temperature and chemical sanitation level for 2/27/24 (breakfast, lunch, and dinner), 2/28/24 (breakfast and lunch), 2/29/24 (lunch and dinner), 3/1/24 ( lunch), 3/2/24 lunch and dinner), and 3/3/24 (breakfast, lunch and dinner) .had not been recorded. Temperature checks for the 3 compartment sinks were not completed. The Dietary Manager stated staff was cleaning the pastry brushes in the high temp dishwasher, but she was not aware that the manufacture instructions indicated that the pastry brushes were not dish washer safe. The Dietary Manager stated, It was important to follow the manufactures instruction on the brushes to ensure the brushes were sanitized and cleaned properly, and to prevent the potential hazards of the bristles breaking off the pastry brushes. The Dietary Manager stated the Administrator oversaw her at the facility. Record Review of the facility dry storage policy dated on October 2022 indicated, (3) All items must be dated with the date that the food was delivered; (4) If a food is taken out of the original container (what the manufacture placed the product in) it must be labeled and dated; (5) All expired foods must be removed from the storeroom. (6) All dented cans must be removed from the storeroom or marked do not use until it is picked up;(7) Food is dated so the food that is delivered can be used first. This is called FIFO-First in First out; (10) Lids on spices should be closed. Spice should be discarded after 6 months; (14) No scoops in the dry storage bins. Record Review of the facility receiving a storage policy dated October 2022 indicated, (8) All foods in the refrigerator or freezer will be covered labeled and dated (use by date). Record Review of the facility's sanitation policy revise dated on January 2024 indicated, the food service area shall be maintained in a clean and sanitary manner (1) All kitchens, kitchen and dining area shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects; (2) All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped area that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair; (3) All equipment, food contact surfaces shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions;(9) Manual washing and sanitizing will employ a three step process for washing, rinsing and sanitizing:(c) Sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solutions may consist of: (1) chlorine 50 parts per million or 10 seconds. (2) Iodine 12.5 parts per million or (3) Quaternary ammonium compound 150-200 parts per million for time designated by the manufacturer; (16) The Food Service Manager (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 29 of 33 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 03/06/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the facility's pastry brush Manufacture's recommendations for product # 5768 and model #HL9116W indicated, the pastry brushed was not dishwasher safe and to hand wash only. Event ID: Facility ID: 675471 If continuation sheet Page 30 of 33 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 03/06/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #43) and 1 of 3 shower rooms (hall 100 shower room) reviewed for infection control practices. Residents Affected - Few 1) Facility failed to ensure [NAME] button extension for Resident #43 was bagged and dated. 2) LVN D failed to wash or sanitize hands and change gloves between dirty and clean while providing bolus feeding for Resident #43. 3) The facility failed to store clean linen away from dirty. These failures could place residents and staff at risk for cross contamination and the spread of infection. Findings included: 1. Record review of Resident #43's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses cerebral palsy (a group of movement disorders that appear in early childhood), high blood pressure, dysphasia (difficulty swallowing), epilepsy (neurological disorder characterized by recurrent seizures), and a need for assistance with personal care. Record review of Resident #43's admission MDS assessment dated [DATE] indicated she had a BIMS score of 0 which indicated severely impaired cognition. The MDS also indicated she required total assistance with all ADL's and required a feeding tube for more than 51% of her calorie intake. Record review of Resident #43's order summary report dated 06/06/24 indicated she had orders as followed, after the state surveyor intervention: 1.Change [NAME] button extension tubing every other week on Tuesday. Every 14 days dated 03/05/24 and a start date of 03/19/24. Record review of Resident #43's care plan dated 04/21/23 indicated resident required a feeding tube with no indication of the use of the [NAME] button to be used for feedings and to be changed out every 14 days. During an observation on 03/05/24 at 11:18 a.m. LVN D washed her hands applied gloves and setup a table with supplies to give medications and bolus feeding to Resident #43. She then removed her gloves, sanitized her hands, and donned new gloves. LVN D prepared medication and bolus feeding and went into Resident #43's room and placed medication and bolus feeding on the table. LVN D checked for placement, she grabbed a dirty dressing (4X4 gauze with dark yellow drainage on it) from resident's [NAME] button, and threw it in the trash. LVN D then failed to remove contaminated gloves, use hand hygiene, and donn new gloves. LVN D then grabbed the [NAME] button extension from the undated Ziploc bag and attached it to the resident's [NAME] button and continued the procedure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 31 of 33 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 03/06/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/05/24 at 11:35 a.m. LVN D said she realized after she completed the procedure that she should have removed her gloves after touching the dirty dressing, sanitized her hands, and donned clean gloves. She said the failure placed Resident #43 at risk for infection. She said she had been employed by the facility for almost 3 years, she had been checked off on enteral feeding skills, hand washing upon hire, and several times since then. LVN D said the [NAME] button extension should be changed out every 2 weeks and should be bagged and dated. During an interview on 03/06/24 at 04:17 p.m. the DON said the [NAME] button extension should have been changed every other week and the charge nurses were responsible for changing it out and dating the bag when it was changed. She said the failure placed Resident #43 at risk for infection when it sat in the bag and was not being changed properly. During an interview on 03/06/24 at 04:22 p.m. the DON said she expected the nurses to wash hands and change gloves any time after touching a dirty surface or object. She said the failure placed Resident #43 at risk for contamination of the feeding tube and infection related to the growth from the soiled dressing. The DON said the infection control preventionist which was the ADON was responsible for ensuring the staff performed proper hand washing. The DON said the facility had completed the handwashing proficiency check offs and it should be completed upon hire and quarterly as well as if a problem arose. During an interview on 03/06/24 at 04:32 p.m. the Administrator said the extension should have been bagged and dated when the new extension was placed in the resident's room. He said the charge nurse was responsible for ensuring the dates were placed on the bag. The Administrator said the failure placed Resident #43 at risk for infection. During an interview on 03/06/24 at 04:36 p.m. the Administrator said the nurse was expected to remove gloves when touching a dirty surface and perform hand hygiene and donn new gloves. He said the failure placed Resident #43 at risk for infection. The Administrator said the DON and the ADON were responsible for ensuring proper handwashing with all staff. The Administrator said the handwashing check offs were performed upon hire and quarterly and when problems arose. 2. During an observation on 03/04/24 at 11:00 a.m., observed a linen cart with clean laundry and 2 dirty barrels in the shower room next to each other on hall 100. During an observation and interview on 03/06/24 at 8:41 a.m., observed a linen cart with clean laundry and 2 dirty barrels in the shower room next to each other on hall 100. CNA-F said they usually kept the dirty barrels and the clean linen cart in the hall 100 shower room. She said she saw the dirty barrels were not far from the clean linen and said they should be apart. CNA F said she would move them. She said they should be apart to prevent cross-contamination. During an interview on 03/06/24 at 2:58 p.m., the DON said the linen cart and the barrels should not be close together. She said staff should be aware to keep them apart. She said clean and dirty should be separate to prevent cross-contamination. During an interview on 03/06/24 at 3:38 p.m., the Administrator said dirty and clean should not be stored together. He said staff should be aware to keep them separate for the spread of infection. Record review of the facility policy titled Environmental services-laundry and Linen, revised 1/23, indicated, The purpose of this procedure is to provide a process for the safe and a septic handling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 32 of 33 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 03/06/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few washing and storage of linen. General guidelines: #1 Separate soiled and clean linen at all times . #6 Keep soiled and clean linen in their respective hampers and laundry carts separate at all times. #7 Clean linen will remain hygienically clean through measures designed to protect it from environmental contamination such as covering clean linen cart . Record review of the Handwashing-Hand Hygiene Policy and Procedure revised 10-2020 indicated Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. before and after coming on duty .k. after handling used dressings, contaminated equipment . Record review of the facility policy titled Infection Prevention and Control Program, dated 01/23, indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. transmission of healthcare-associated infections.2. The Infection Preventionist and Administrator will identify those disciplines or individuals who need task or job-specific infection control training beyond that provided by initial orientation or policies and procedures. 3. Infection control training topics will include at least: A. Standard Precautions, including hand hygiene, B Transmission-Based Precautions (airborne, droplet, contact). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 33 of 33