Health inspection·May 24, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on his vent but could not recall to whom. Resident #1 said he did not want to be breathing that stuff in and wished the facility staff would clean it. Resident #1 said the vent had looked that way for several months. 2. Record review of the face sheet dated 5/24/25 indicated Resident #2 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including Coronary atherosclerosis (damage or disease in the heart's major blood vessels usually caused by the buildup of plaque, resulting in the narrowing of the coronary arteries, limiting blood flow to the heart), high blood pressure, and chronic kidney disease (progressive condition where the kidneys are damaged and can't filter waste and excess fluid from the blood efficiently). Record review of the MDS dated [DATE] indicated Resident #2 made herself understood and understood others. The MDS indicated Resident #2 had severe cognitive impairment (BIMS of 03). The MDS indicated Resident #2 was mostly independent with ADL activities and required Supervision/ stand by assistance only with bathing. The MDS also indicated she independently performed repositioning and transfers with the exception of transfer into a tub/shower for which she required supervision or touching assistance. The MDS indicated Resident #2 had no Pulmonary diagnoses (respiratory conditions or diagnoses). Record review of the care plan revised on 2/22/25 did not indicate Resident #2 had no respiratory diagnoses/issues or address ensuring a clean environment. During an observation and interview on 5/24/25 at 12:55 p.m., Resident #2 laid in her bed. Resident #2's heating and cooling vent to the wall on the right side of the far wall was covered in a black mold like substance. The black substance was also faintly noticed on the ceiling tiles adjacent to the vent. Resident #2 denied having any breathing issues or conditions such as asthma, COPD, or other pulomonary issues. Resident #2 said she had no trouble breathing at all and had not noticed the black substance on the vent. 3. Record review of the face sheet dated 5/24/25 indicated Resident #3 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including traumatic brain injury, type II diabetes, and dementia. Record review of the MDS dated [DATE] indicated Resident #3 made himself understood and understood others. The MDS indicated Resident #3 had no cognitive impairment (BIMS of 13). The MDS indicated Resident #3 was mostly independent with ADL activities and required set/up or clean up assistance only with eating and oral hygiene. The MDS also indicated he independently performed repositioning and transfers with the exception of transfer into a tub/shower for which he required supervision or touching assistance. The MDS indicated Resident #3 had no Pulmonary diagnoses (respiratory conditions or diagnoses). Record review of the care plan revised on 2/25/25 did not indicate Resident #3 had a respiratory diagnoses/issues or address ensuring a clean environment. During an observation and interview on 5/24/25 at 1:10 p.m., Resident #3 laid in his bed. Resident #3's heating and cooling vent to the wall on his right side, just above the doorway, was covered in a black mold like substance. Resident #3 denied having any breathing issues or conditions such as asthma, COPD, or other pulomonary issues. Resident #3 said he had no trouble breathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2025 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 4. Record review of the face sheet dated 5/24/25 indicated Resident #4 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including spina bifida (a congenital defect of the spine in which part of the spinal cord and its meninges are exposed through a gap in the backbone, often causing paralysis of the lower limbs), type II diabetes, and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease). Residents Affected - Some Record review of the MDS dated [DATE] indicated Resident #4 made himself understood and understood others. The MDS indicated Resident #4 had no cognitive impairment (BIMS of 15). The MDS indicated Resident #4 was dependent on staff for toileting, personal hygiene and showering/bathing. MDS also indicated he could turn side to side in his bed independently but transfers and position changes from sit to lying and lying to sitting on the side of bed were not attempted due to medical condition or safety concerns. The MDS indicated Resident #4 had no Pulmonary diagnoses (respiratory conditions or diagnoses). Record review of the care plan revised on 4/4/25 did not indicate Resident #4 had a respiratory diagnoses/issue nor did the care plan address ensuring a clean environment. During an observation and interview on 5/24/25 at 1:12 p.m., Resident #4 laid in his bed. Resident #4's heating and cooling vent to the far-right wall, just above the doorway, was covered in a black mold like substance. Resident #4 indicated his roommate (Resident #3) and was not sure if he was aware of the black substance on the vent. Resident #4 denied having any breathing issues or conditions such as asthma, COPD, or other pulomonary issues. Resident #4 said he had no trouble breathing but did think the vent should be cleaned. Resident #4 said the vent had been covered in the black substance for a long time. Resident #4 said he had never seen anyone clean the vent. During an interview and observation on 5/24/25 at 2:00 p.m., LVN A indicated she was the nurse for Resident's #1, #2 #3 and #4. LVN A said she was regularly assigned the hall the Residents resided on (#1, #2, #3 and #4) but had not noticed the black substance on the vents. LVN A said it was important for the vents to be cleaned to promote cleanliness of the resident home environment and prevent respiratory infections and health complications for residents with pulmonary disorders. LVN A said no residents had reported or displayed increased respiratory signs/symptoms of any chronic conditions nor had any resident reported/displayed signs/symptoms of respiratory infection. LVN A said she was not sure if housekeeping cleaned the heating/cooling vents in the residents' rooms regularly. During an interview on 5/24/25 at 2:15 p.m., CNA B said she was regularly assigned the hall the Residents resided on (#1, #2, #3 and #4) but had not noticed the black substance on the vents. CNA B said no residents had reported increased breathing problems or signs of respiratory infection. CNA B said it was important for the vents to be clean and free of mold. CNA B said the black substance on the vents was an infection control issue, CNA B said she was not sure if housekeeping cleaned the vents in Resident rooms or if it was something maintenance addressed. During an interview on 5/24/25 at 2:20 p.m., housekeeper C said she regularly worked at the facility and cleaning resident rooms was part of her duties. Housekeeper C said however cleaning the vents was not something the housekeeping staff did and she believed maintenance staff addressed them. During an interview on 5/24/25 at 2:35 p.m., the maintenance director said the cleaning the heating and cleaning vents was something he noticed needed to be done during the winter months. The maintenance director said he noticed when the vents kicked on during the winter the soot was blowing out of the vents. The maintenance director said he has been slowly getting around to cleaning all of them but had not yet completed the task. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2025 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 During an interview on 5/24/25 at 3:00 p.m., the ADON said the facility had a new DON starting at the facility next week. The ADON said the Administrator was not on sight and had returned to his home during the weekend (several hours away from the facility). The ADON said maintenance was responsible for ensuring the vents were clean. The ADON said it was important for the vents to be clean to prevent increased respiratory issues for residents with chronic pulmonary conditions and to prevent acute respiratory issues. Record review of the facility policy and procedure titled, Homelike environment, revised in February 2021, stated, .Residents are provided with a safe, clean, comfortable and homelike environment .(2) The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect .homelike 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 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 7 resident (Resident #1) reviewed for medications at their bedside. The facility did not ensure Resident #1's was administered his Protonix pill (a proton pump inhibitor used to treat GERD [gastroesophageal reflux disease a common digestive disease in which stomach acid or bile irritates the food pipe lining]) during his morning medication pass on 5/24/25 and left the unlabeled, unsecured medication on Resident #1's bedside table for several hours. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. Findings included: Record review of the face sheet dated 5/24/25 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive movement disorder of the nervous system characterized by a loss of nerve cells in the brain that produce dopamine. The disorder leads to the manifestation of motor symptoms like tremors, muscle stiffness, and slow movement), type II diabetes, history of fracture of the left fibula, GERD (gastroesophageal reflux disease a common digestive disease in which stomach acid or bile irritates the food pipe lining) and history of chronic pulmonary embolism (blood clots in the lungs). Record review of the MDS dated [DATE] indicated Resident #1 made himself understood and understood others. The MDS indicated Resident #1 had no cognitive impairment (BIMS of 15). The MDS indicated Resident #1 required Supervision or moderate assistance with most ADL activities. The MDS also indicated he independently performed repositioning and transfers with the exception of transfer into a tub/shower for which he was dependent on staff. Record review of Resident #1's care plan revised on 9/6/24 indicated he had impaired thought processes due to Parkinson's disease. The care plan interventions included administer medications as ordered by the physician. Record review of the physician order summary dated 5/24/25 for Resident #1 indicated he was to be administered the following: *Protonix (medication to treat GERD) 40 mg 1 tablet by mouth daily at 7:00 a.m.; *Eliquis ( a medication to prevent blood clots) 5 mg I tablet by mouth two times a day; *Gabapentin ( a medication used to treat nerve pain) 100 mg - two capsules for a dose of 200 mg two times a day; *hydralazine 25 mg (commonly used to treat high blood pressure) 1 tablet two times a day, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675471 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2025 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 0761 *Tylenol 325 mg, two tablets two times daily for pain. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 5/24/25 at 12:45 p.m., Resident #1 laid in his bed. On his bedside table sat a clear plastic medicine cup with single yellow oval pill. Resident #1 said the pill was for his reflux. Resident #1 said the pill had been brought to him with his morning meds but he decided he did not want to take the medication and stated he might take it and may take it later. Residents Affected - Few During an interview and observation on 5/24/25 at 12:54 p.m., LVN A said she was the nurse for Resident #1. LVN A said she had not passed Resident #1's morning medications and the meds had been passed by MA D. LVN A said the pill should not have been left at Resident #1's bedside. LVN A said the pill appeared to be Protonix (is a proton pump inhibitor used to treat GERD [gastroesophageal reflux disease a common digestive disease in which stomach acid or bile irritates the food pipe lining]). LVN A said MA D should have ensured Resident #1 took all of his medications during the morning pass and that any medication he refused to take should have been discarded appropriately. LVN A said another Resident could have wondered into his room and taken the medication. During an interview on 5/24/25 at 2:40 p.m., MA D said she did not ensure Resident #1 took all of his medications during the morning medication administration pass between 6:00 a.m. - 8:00 a.m. and she should have done so. MA D said medications should not be left at the resident bedside and should have been removed and disposed of properly if Resident #1 refused to take the medication. MA D said she thought Resident #1 took all the pills in the medication cup she had prepared for him and should have ensured he had done so before leaving the room. During an interview on 5/24/25 at 3:00 p.m., the ADON said the facility had a new DON starting at the facility next week. The ADON said MA D should have ensured Resident #1 took all of his medications during the morning pass and that any medication he refused to take should have been discarded appropriately. The ADON said another Resident could have wondered into his room and taken the medication. Record review of the facility policy and procedure titled Medication Administration, dated 7/8/24, stated, medications are administered in a safe and timely manner and as prescribed .(4) medications are administered in accordance with prescriber orders, (5) medication administration times are determined by the resident need and benefit , not staff convenience .(7) medications are administered within 1 hour of their prescribed time .(21) if the drug is withheld , refused .the individual administering the medication shall initial and circle the MAR . (27) Residents may self- administer their own medications only if the attending physician . has determined they have the decision making capacity to do so . The facility policy and procedure did not address leaving unlabeled medications at the resident bedside. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675471 If continuation sheet Page 6 of 6