Health inspection·December 1, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 9 residents (Resident #4) reviewed for quality of life. The facility failed to provide Resident #4's showers as scheduled on Saturdays. This failure could place residents at risk of not receiving the services and care needed, decreased self-esteem, and a decreased quality of life. Findings included: Record review of a face sheet dated 10/23/2025 indicated Resident #4 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included unspecified combined systolic and diastolic congestive heart failure (heart is unable to pump enough force to push enough blood into circulation) and schizoaffective disorder bipolar type (mood disorder that can include depression, delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #4's Comprehensive MDS assessment dated [DATE] indicated Resident #4 was understood by others and understood others. Resident #4 had a BIMS score of 15, which indicated her cognition was intact. Resident #4 required substantial/maximal assistance with showering/bathing herself. Record review of Resident #4's care plan dated 08/28/2024, indicated she had an ADL self-care performance deficit related to impaired balance. Resident #4's care plan indicated she was able to wash the upper front and lower front of her body and staff was to wash her back areas. Record review of Resident #4's Shower/Bathe Task Record for October 2025 indicated she received showers on Tuesday, Thursday, and Saturday on the 2 PM-10 PM shift. Resident #4's Shower/Bathe Task Record did not indicate she missed any showers. During an interview on 10/21/2025 at 4:04 PM, Resident #4 said she was not getting showers sometimes on Saturdays. Resident #4 said the staff told her they were short-handed, so they could not give her a shower. During an interview on 10/22/2025 at 11:27 AM, CNA E said there were some residents who complained about not receiving showers on the 2 PM-10 PM shift and on Saturdays. CNA E said Resident #4 was one of them. CNA E said the ADON and DON were aware of the missed showers. CNA E said when a resident reported to her they had not received a shower, she gave them one. CNA E said she had given Resident #4 a shower yesterday,10/21/2025. CNA E said Resident #4 requested a shower from her because she did not get one on Saturday,10/18/2025. CNA E said the residents not receiving showers as scheduled could result in skin breakdown, rashes, and make them feel down. During an interview on 10/22/2025 at 1:42 PM, LVN F said she worked the weekends (6 AM- 10PM) and a lot of times they were short staffed. LVN F said usually they had 1 CNA on each side of the building and 2 nurses. LVN F said the past weekend the ADON worked because they were short staffed. LVN F said she was not the nurse for Resident #4 over the weekend that LVN D was the nurse and MA H was the CNA on Saturday (10/21/2025) for Resident #4. LVN F said when they were short staffed it was not possible to provide the required care, and if they were not able to provide the required care due to being short staffed, this could be considered neglect. During an attempted phone Residents Affected - Few Page 1 of 12 675471 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview on 10/22/2025 at 1:51 PM, LVN D did not answer the phone. During an interview on 10/23/2025 at 10:38 AM, MA H said she worked Saturday, 10/18/2025. MA H said they were short and she worked all over the building, and she did not know if the residents' received showers. MA H said they were short staffed frequently, and sometimes they missed the showers. MA H said Saturdays were awful. MA H said she did not give any showers on 10/18/2025. MA H said the residents not receiving their showers as scheduled could affect their skin and them being clean. During an interview on 10/23/2025 at 11:39 AM, the ADON said she was aware showers were not given as scheduled. The ADON said Saturday, 10/18/2025, she worked and gave medications to the residents for 12 hours and then worked as a CNA the last 4 hours of her shift. The ADON said she did not give any showers on 10/18/2025. The ADON said she completed the charting for MA H on, 10/18/2025, and she was under the impression MA H had given Resident #4 her shower, so she signed it off as being completed. The ADON said the nurses were responsible for ensuring the residents received their showers. The ADON said if the residents did not receive their showers, it could cause skin breakdown and odors. During an interview on 10/23/2025 at 1:17 PM, the DON said the only person that had complained to her about not receiving showers was Resident #4. The DON said a couple weekends ago Resident #4 informed her she had not received a shower, and she gave her one herself. The DON said she monitored if the residents were getting their showers by checking the task records, and she had not noticed any issues. The DON said if the residents did not receive their showers it could result in low self-esteem, and they would not feel clean. During an attempted phone interview on 10/23/2025 at 1:50 PM, LVN D did not answer the phone. During an interview on 10/23/2025 at 2:21 PM, the Interim Administrator said Resident #4 reported to her several weekends ago she had not received a shower, but the DON had given her one. The Interim Administrator said she was not aware of Resident #4 not receiving a shower on 10/18/2025. The Interim Administrator said she expected the residents to get showers, and the nursing staff and everybody were responsible for ensuring this happened. The Interim Administrator said the residents not receiving their showers would mean they were dirty. Record review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing .). 675471 Page 2 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed and 3 of 20 residents (Resident #2, Resident #4, and Resident #5) for care and services. 1. The facility failed to ensure Resident #2 medications were administered during the scheduled time. 2. The facility failed to ensure sufficient staff was provided to ensure Resident #4 received her showers on Saturdays. 3. The facility failed to ensure sufficient staff was provided to ensure Resident #5 was able to get out of bed when requested. 4. The facility failed to provide sufficient nursing staff according to the facility assessment on 05/03/2025, 05/04/2025, 05/10/2025, 05/11/2025, 06/20/2025, 06/21/2025, 06/28/2025, 07/01/2025, 07/05/2025, 07/06/2025, 07/12/2025, 08/02/2025, 08/03/2025, 09/01/2025, 09/20/2025, 09/21/2025, 10/5/2025, 10/12/2025, and 10/18/2025. These failures placed residents at risk of not having sufficient staff to provide for their care/treatment needs.Findings included: 1. Record review of Resident #2's face sheet, dated 10/23/25, reflected Resident #2 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Parkinson's (a disorder that affects movement, balance, and coordination) with dyskinesia (involuntary, uncontrolled, and abnormal muscle movements). Record review of the order summary report dated 10/23/25 indicated Resident #2 was ordered: Carbidopa-Levodopa 25-100mg 1 tablet by mouth three times a day. Buspirone 5 mg 1 tablet by mouth three times a day. Record review of the Medication Administration Audit Report dated 10/23/25 reflected Resident #2 received her medications on 10/05/25 by MA B as listed: Carbidopa-Levodopa 25-100mg 1 tablet given at 11:06 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Buspirone 5 mg 1 tablet given at 11:06 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:46 a.m. of the scheduled medication pass 12:00 p.m. Buspirone 5 mg 1 tablet given at 11:46 a.m. of the scheduled medication pass 12:00 p.m. During an interview on 10/23/25 at 10:39 a.m., MA B stated medications should be administered one hour before or one hour after the scheduled time. MA B stated medications were given late due to short staff and her being the only MA that worked that day. MA B stated she did not remember given Resident #2 the second dose of Buspirone and Carbidopa-Levodopa that was scheduled at 12:00 p.m. MA B stated she probably just clicked it off on the MAR as given to show the task was completed. MA B stated she did not notify the physician or the DON about the second dose not given, or medications given late. MA B stated it was important medications were given on time to ensure the dose was effective and prevent an overdose. Record review of the Medication Administration Audit Report dated 10/23/25 reflected Resident #2 received her medications on 10/18/25 by the ADON as listed: Buspirone 5 mg 1 tablet given at 11:25 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:25 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:26 a.m. of the scheduled medication pass 12:00 p.m. Buspirone 5 mg 1 tablet given at 11:26 a.m. of the scheduled medication pass 12:00 p.m. During an interview on 10/23/25 at 11:27 a.m., the ADON stated medications should be given within the scheduled time. The ADON stated she rarely passed medications, and she did not know the medications like the staff that normally administered the medications. The ADON stated she did not notify the MD that the medications were given late nor the 12:00 p.m. dose of Buspirone or Carbidopa-Levodopa were not given. The ADON stated she guessed when she was clicking off the medications on the MAR, she did not realize it was duplicate. The ADON stated it was important medications were given as scheduled to prevent 675471 Page 3 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many overmedication and a medication error. During a telephone interview on 10/23/25 at 12:24 p.m., the MD stated staff should have notified him if the medications were given late or if the second dose was close to the first dose that was administered. The MD stated he had received text messages about medications been administered late but not frequently. The MD stated he did not know anything about culture time window just the one hour before and one hour after. The MD stated the risk of not administering medications on time was if the resident received a blood pressure medication it could affect their blood pressure. During an interview on 10/23/25 at 12:54 p.m., the DON stated medications can be given one hour before or one hour after. The DON stated the facility did have a culture time which means a window for medication administration. The DON stated if the first dose was given close to when the second dose should be given, the second dose should be held and the MD notified. The DON stated she was responsible for monitoring and overseeing by pulling the medication administration audit report in PCC randomly. The DON stated there have been issues in the past and when she investigated it the staff stated it was given on time just documented late. The DON stated it was important medications were given on time to ensure the residents received the accurate dose and decrease their risk of complications. During an interview on 10/23/25 at 2:08 p.m., the Administrator stated she expected the medications to be administered according to the schedule to ensure effectiveness. The Administrator stated the DON and the ADON were responsible for monitoring and overseeing medication administration. The Administrator stated it was important to ensure medications were given on time to prevent an adverse reaction.2. Record review of a face sheet dated 10/23/2025 indicated Resident #4 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included unspecified combined systolic and diastolic congestive heart failure (heart is unable to pump enough force to push enough blood into circulation) and schizoaffective disorder bipolar type (mood disorder that can include depression, delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #4's Comprehensive MDS assessment dated [DATE] indicated Resident #4 was understood by others and understood others. Resident #4 had a BIMS score of 15, which indicated her cognition was intact. Resident #4 required substantial/maximal assistance with showering/bathing herself. Record review of Resident #4's care plan dated 08/28/2024, indicated she had an ADL self-care performance deficit related to impaired balance. Resident #4's care plan indicated she was able to wash the upper front and lower front of her body and staff was to wash her back areas. Record review of Resident #4's Shower/Bathe Task Record for October 2025 indicated she received showers on Tuesday, Thursday, and Saturday on the 2 PM-10 PM shift. Resident #4's Shower/Bathe Task Record did not indicate she missed any showers. During an interview on 10/21/2025 at 4:04 PM, Resident #4 said she was not getting showers sometimes on Saturdays. Resident #4 said the staff told her they were short-handed, so they could not give her a shower. During an interview on 10/22/2025 at 12:33 PM, the Executive Director said the facility assessment direct care staff hours per resident day indicated the number of staff required per shift, which indicated 4 CNAs for days (6 AM-2 PM) and evenings (2 PM-10 PM), 3 CNAs for nights (10 PM-6 AM), and 1 MA for days and evenings. During an interview on 10/22/2025 at 1:42 PM, LVN F said she worked the weekends (6 AM10PM) and a lot of times they were short staffed. LVN F said usually they had 1 CNA on each side of the building and 2 nurses. LVN F said the past weekend the ADON worked because they were short staffed. LVN F said when they were short staffed it was not possible to provide the required care, and if they were not able to provide the required care due to being short staffed, this could be considered neglect. During an attempted phone interview on 10/22/2025 at 1:51 PM, LVN D did not answer the phone. During an interview on 10/23/2025 at 10:38 AM, MA H said she worked Saturday, 10/18/2025. MA H said they were 675471 Page 4 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many short, and she worked all over the building, and she did not know if the residents' received showers. MA H said they were short staffed frequently, and sometimes they missed the showers. MA H said Saturdays were awful. MA H said she did not give any showers on 10/18/2025. MA H said not having sufficient staff to care for the residents could affect them emotionally and physically because the residents deserved the care they required while in the facility. During an interview on 10/23/2025 at 11:39 AM, the ADON said the DON and herself were responsible for scheduling the staff. The ADON said she was not aware the facility required a set number of CNAs for each shift. The ADON said they would like to have 4 CNAs for the 6 AM-2 PM shift and 2 PM-10 PM shift and 3 CNAs for the night shift. The ADON said MA H and herself covered the call-ins. The ADON said Saturday, 10/18/2025, she worked and gave medications to the residents for 12 hours and then worked as a CNA the last 4 hours of her shift, due to being short staffed. The ADON said the staff had not told her they were unable to complete their tasks due to insufficient staff. The ADON said if there were not enough CNAs the nurses should be helping the CNAs. The ADON said she did not see there could be a potential negative outcome for being short staffed.3. Record review of Resident #5's face sheet, dated 10/23/25, indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation (an irregular heartbeat, or arrhythmia), muscle weakness, unsteadiness on her feet, and cognitive communication deficit. Record review of Resident #5's OBRA (Omnibus Budget Reconciliation Act) MDS dated [DATE] indicated a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated she required total assistance with toileting, transfers, bathing, and bed mobility, and required setup assistance for eating. Record review of Resident #5's care plan dated 02/25/25 indicated she had an ADL self-care performance deficit related to impaired mobility, cellulitis, and a history of a fracture. The interventions were for staff to help with toileting, transfers, bed mobility, bathing, and personal hygiene. During an observation and interview on 10/21/25 at 10:35 a.m., Resident #5 was observed to be lying in bed. The resident said she had a problem with staff getting her up over the weekend, some months back. She said at times it still occurs if she does not remind them, but it has been much better. She said the staff would tell her they were short-handed; therefore, they could not get her up. She said she wanted to be up for lunch and supper meals. During an interview on 10/21/25 at 10:50 p.m., CNA I said she worked a 10 pm - 6 am shift and most times it was 2 aides, but sometimes it was only 1 aide for the entire building. She said she was working double weekends (6 am-10 pm), but she came tonight because most of the time they only had 3 aides and sometimes 2 aides until they could get someone to come in to work the shift. She said it was very hard to complete the task that needed to be done, but they worked together as much as they could to get things done. She said not having enough staff placed the residents at risk of not receiving the care they needed. She said management was aware that they were short over the weekend and at night, and it was difficult to provide timely care to the residents. During an interview on 10/23/25 at 11:55 a.m., the ADON said she knew Resident #5 had mentioned she was not getting up, but she had asked the staff, and they said they were getting her up. She said staff should never tell a resident that they were shorthanded, but they might have. She said she agreed they were short-handed during the period Resident #5 said she was not getting up, according to the facility assessment. She said she was not aware of the requirements of how many staff they should have. She said she would like them to have 4 aides on days (6 am -2 pm) and evenings (2 pm-10 pm), and 2 aides on nights (10 pm- 6 am), but they mostly had 3 aides on the day and evening shifts. During an interview on 10/23/2025 at 12:28 PM, the Medical Director said he was not aware of staffing shortages at the facility. The Medical Director said he had been notified occasionally of medications being administered late, but it had not been 675471 Page 5 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many frequently. The Medical Director said staffing shortages could affect the residents' care and the care they received. During an interview on 10/23/2025 at 1:29 PM, the DON said nobody had reported to her not being able to complete their tasks due to not having enough staff. The DON said the ADON was responsible for scheduling the staff, and she was not aware of the facilities staffing requirements. The DON said she had requested the facility assessment from the previous administrator, and he never provided it. Therefore, she had not seen it. The DON said insufficient staffing could result in delays in the care the residents received. During an interview on 10/23/2025 at 2:21 PM, the Interim Administrator said she was not aware of there being staff shortages in the facility. The Interim Administrator said based on their facility assessment they were adequately staffed. The Interim Administrator said not having enough staff could result in a delay in care. Record review of the Facility Assessment updated, 04/22/2025, indicated Direct Care Staff Hours Per Resident Day: Days: 1 RN, 1 LVN, 4 CNAs/Hospitality, and 1 Med Aide. Evenings: 2 LVNs, 4 CNAs/Hospitality, and 1 Med Aide. Nights: 2 LVNs, 3 CNAs/Hospitality. Record review of the Punch Detail for 05/03/2025 indicated 2 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 05/04/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 05/10/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 05/11/2025 indicated 2 CNAs worked on the 2 PM-10 PM shift. Record review of the Punch Detail for 06/20/2025 indicated 2 CNAs worked on the 2 PM-10 PM shift and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 06/21/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift and 1 CNA worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 06/28/2025 indicated 2 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 07/01/2025 indicated 2 CNAs worked on the 2 PM-10 PM shift and 1 CNA worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 07/05/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 07/06/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 07/12/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 08/02/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift and 1 CNA worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 08/03/2025 indicated 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 09/01/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift. Record review of the Punch Detail for 09/20/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift. The punch detail did not indicate an MA for the 6 AM-2 PM or 2 PM-10 PM shift. Record review of the Punch Detail for 09/21/2025 indicated 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 10/5/2025 indicated 1 CNA worked on the 10 PM-6 AM shift. The punch detail did not indicate an MA for the 6 AM-2 PM shift. Record review of the Punch Detail for 10/12/2025 indicated 2 CNAs worked on the 6 AM-2 PM shift, 2 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. The punch detail did not indicate an MA for the 6 AM-2 PM shift. Record review of the Punch Detail for 10/18/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift and 2 CNAs worked on the 10 PM-6 AM shift. During an interview on 10/23/2025 at 2:33 PM, the Interim Administrator said the facility did not have a policy for staffing. Record review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, indicated, Residents will be provided with 675471 Page 6 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing .). Record review of the facility's policy titled, Medication Administration, revised June 2025 reflected, . Medications are administered in a safe and timely manner, and as prescribed.3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 675471 Page 7 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2 medications were administered during the scheduled time. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.Findings included: 1. Record review of Resident #2's face sheet, dated 10/23/25, reflected Resident #2 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Parkinson's (a disorder that affects movement, balance, and coordination) with dyskinesia (involuntary, uncontrolled, and abnormal muscle movements). Record review of the order summary report dated 10/23/25 indicated Resident #2 was ordered:Carbidopa-Levodopa 25-100mg 1 tablet by mouth three times a day. Buspirone 5 mg 1 tablet by mouth three times a day. Record review of the Medication Administration Audit Report dated 10/23/25 reflected Resident #2 received her medications on 10/05/25 by MA B as listed: Carbidopa-Levodopa 25-100mg 1 tablet given at 11:06 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Buspirone 5 mg 1 tablet given at 11:06 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:46 a.m. of the scheduled medication pass 12:00 p.m.Buspirone 5 mg 1 tablet given at 11:46 a.m. of the scheduled medication pass 12:00 p.m. During an interview on 10/23/25 at 10:39 a.m., MA B stated medications should be administered one hour before or one hour after the scheduled time. MA B stated medications were given late due to short staff and her being the only MA that worked that day. MA B stated she did not remember given Resident #2 the second dose of Buspirone and Carbidopa-Levodopa that was scheduled at 12:00 p.m. MA B stated she probably just clicked it off on the MAR as given to show the task was completed. MA B stated she did not notify the physician or the DON about the second dose not given, or medications given late. MA B stated it was important medications were given on time to ensure the dose was effective and prevent an overdose. Record review of the Medication Administration Audit Report dated 10/23/25 reflected Resident #2 received her medications on 10/18/25 by the ADON as listed: Buspirone 5 mg 1 tablet given at 11:25 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m.Carbidopa-Levodopa 25-100mg 1 tablet given at 11:25 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:26 a.m. of the scheduled medication pass 12:00 p.m.Buspirone 5 mg 1 tablet given at 11:26 a.m. of the scheduled medication pass 12:00 p.m. During an interview on 10/23/25 at 11:27 a.m., the ADON stated medications should be given within the scheduled time. The ADON stated she rarely passed medications, and she did not know the medications like the staff that normally administered the medications. The ADON stated she did not notify the MD that the medications were given late nor the 12:00 p.m. dose of Buspirone or Carbidopa-Levodopa were not given. The ADON stated she guessed when she was clicking off the medications on the MAR, she did not realize it was duplicate. The ADON stated it was important medications were given as scheduled to prevent overmedication and a medication error. During a telephone interview on 10/23/25 at 12:24 p.m., the MD stated staff should have notified him if the medications were given late or if the second dose was close to the first dose that was administered. The MD stated he had received text messages about medications been administered late but not frequently. The MD stated he did not know anything about culture time window just the one hour before and one hour after. The MD stated the risk of not administering medications on time was if the resident received a blood pressure medication it could 675471 Page 8 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some affect their blood pressure. During an interview on 10/23/25 at 12:54 p.m., the DON stated medications can be given one hour before or one hour after. The DON stated the facility did have a culture time which means a window for medication administration. The DON stated if the first dose was given close to when the second dose should be given, the second dose should be held and the MD notified. The DON stated she was responsible for monitoring and overseeing by pulling the medication administration audit report in PCC randomly. The DON stated there have been issues in the past and when she investigated it the staff stated it was given on time just documented late. The DON stated it was important medications were given on time to ensure the residents received the accurate dose and decrease their risk of complications. During an interview on 10/23/25 at 2:08 p.m., the Administrator stated she expected the medications to be administered according to the schedule to ensure effectiveness. The Administrator stated the DON and the ADON were responsible for monitoring and overseeing medication administration. The Administrator stated it was important to ensure medications were given on time to prevent an adverse reaction. Record review of the facility's policy titled, Medication Administration, revised June 2025 reflected, . Medications are administered in a safe and timely manner, and as prescribed.3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 675471 Page 9 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interview and record review the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition service for 1 of 4 dietary staff (Dietary Aide G). The facility failed to ensure that dietary staff (Dietary Aide G) serving in the kitchen maintained a current Food Handler Certificate. This failure could place residents at risk of the facility not having staff to provide dietary services requirements. Findings included: During an interview on 10/21/2025 at 2:28 PM, the Dietary Manager said Dietary Aide G's food handler certificate was expired. Record review of Dietary Aide G's employee file indicated her date of hire was 07/17/2025, and her Texas Food Handler Certificate was issued 10/06/2022 and expired 10/05/2024. During an interview on 10/21/2025 at 4:21 PM, the Dietary Manager said the food handler certificate should be obtained within 30 days of hire. The Dietary Manager said she did not pay attention to when Dietary Aide G's food handler certificate expired. The Dietary Manager said she and the human resources department were responsible for ensuring the dietary staff had their food handler certificates. The Dietary Manager said it was important for the kitchen staff to have food handler certificates, so they knew the importance of food temperatures and cleaning. During an interview on 10/21/2025 at 4:29 PM, Dietary Aide G said she realized her food handler certificate expired 3-4 days ago. Dietary Aide G said she did not renew it because she did not have the money to pay for the renewal. Dietary Aide G said it was important to have a food handler certificate to know how to handle food and prevent cross contamination. During an interview on 10/23/2025 at 2:30 PM, the Interim Administrator said she was not aware Dietary Aide G's food handler certificate had expired. The Interim Administrator said the Dietary Manager was responsible for ensuring the food handler certificates were maintained up to date. The Interim Administrator said she did not know the risks associated with dietary staff having an expired food handler certificate. During an interview on 10/23/2025 at 2:33 PM, the Interim Administrator said the facility did not have a policy regarding food handler certificates. 675471 Page 10 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to provide rehabilitative services as the physician ordered, for 1 (Resident #5) of 12 residents reviewed for rehabilitative services. The facility failed to ensure that Resident #5 received physical therapy (PT) or occupational therapy (OT) treatments as ordered by the physician from 06/16/25 through 06/20/25 and again from 06/23/25 through 06/24/25. This deficient practice could place residents who require rehabilitative services at risk of a decline or decrease in their physical capabilities.The findings included: Record review of Resident #5's face sheet, dated 10/23/25, indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation (an irregular heartbeat, or arrhythmia), muscle weakness, unsteadiness on her feet, and cognitive communication deficit. Record review of Resident #5's OBRA (Omnibus Budget Reconciliation Act) MDS dated [DATE] indicated a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated she required total assistance with toileting, transfers, bathing, and bed mobility, and required setup assistance for eating. The MDS indicated she received at least 663 minutes of OT and 649 minutes of PT during the 7-day look-back period. Record review of Resident #5's care plan dated 02/25/25 indicated she had an ADL self-care performance deficit related to impaired mobility, cellulitis ( bacterial infection of the skin), and a history of a fracture. The interventions were for staff to help with toileting, transfers, bed mobility, bathing, and personal hygiene. The care plan also indicated she was at risk for falls due to an unsteady gait and a history of falls. The intervention was for therapy screening. Record review of Resident #5's order summary report of active orders dated 06/01/25 indicated an order for OT to evaluate and treat. Patients receive OT services 5 times a week for 30 days for therapeutic exercise, therapeutic acts, neuro re-education, coordination, activities of daily living re-education, safety training, and modalities as indicated. Record review of Resident #5's order summary report of active orders dated 06/01/25 indicated an order for PT to evaluate for plan of care (POC). PT Clarification: Skilled PT to treat 5 times a week for 60 days per POC with modalities as indicated. Record review of a NOMNC dated 6/13/25 with service ended on 6/15/25 for OT and PT. Record review of a NOMNC dated 6/26/25 with service ended on 6/28/25 for OT and PT. Record review of OT progress notes dated 06/12/25 through 6/26/25 indicated she did not have a change in function. Record review of PT progress notes dated 06/12/25 through 6/26/25 indicated she did not have a change in function. Record review of Resident #5's service log matrix dated 06/01/25 through 6/31/25 indicated she did not receive any therapy from 06/14/25 through 06/25/25. She did receive therapy on 06/26/25, 06/27/25, and 06/28/25 for 3 days of therapy during the week of 06/23/25 through 06/27/25. Resident #5 missed a total of 7 days in June 2025. During an observation and interview on 10/21/25 at 10:35 a.m., Resident #5 was observed to be lying in bed. The resident said she had a problem receiving her therapy a few months ago. She said she was upset that she did not receive the therapy as she should have because her goal was to go home. She said that since then, she had received her therapy. During a phone interview on 10/21/25 at 12:10 p.m., the RP said Resident #5 did not receive her therapy from approximately 1 week in June of 2025. She said she had told the therapist that her appeal was won, but they did not start Resident #5's therapy back for about a week. She said Resident #5 just laid in bed and did not receive her therapy. She said Resident #5's goal was to receive therapy and go home. During an interview on 10/22/25 at 4:00 p.m., the DOR said when a resident was given an NOMNC, they had 24 hours to file an appeal. She said once the resident/family let them know they would be filing an appeal, they would send in the paperwork to the insurance company to review. She said they would continue therapy until they heard back Residents Affected - Few 675471 Page 11 of 12 675471 12/01/2025 North Star Ranch Rehabilitation and Health Care Ce 709 W Fifth St Bonham, TX 75418

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from the insurance company. She said if the resident did not win the appeal, then the resident/family was aware that they might incur charges. She said they had some confusion with Resident #5 and her appeal process. She said they had problems reaching the RP, and they only became aware that Resident #5 had won the appeal through the RP in June 2025. She said once she was aware Resident #5 had won her appeal, during the period of June, when she missed therapy, she forgot to add her to the therapy schedule. She said it was an oversight. She said she was responsible for ensuring residents received their ordered therapy. She said failure to receive therapy could cause a decline in a resident's function. During an interview on 10/23/25 at 11:55 a.m., the ADON said she knew Resident #5 had mentioned she was not getting up, but she had asked the aides, and they said they were getting her up. She said the aides should never tell a resident that they were shorthanded, but they might have. She said she agreed they were short-handed during the period Resident #5 said she was not getting up, according to the facility assessment. She said she was not aware of the requirements of how many staff they should have. She said she would like them to have 4 aides on days (6 am -2 pm) and evenings (2 pm-10 pm), and 2 aides on nights (10 pm- 6 am), but they mostly had 3 aides on the day and evening shifts. She said she was not aware of any missed therapy visits for Resident #5 in June 2025. She said if a resident missed therapy, it could cause a setback or stall in their progress. During an interview on 10/23/25 at 1:35 p.m., the DON said she expected therapy to follow the order for any resident who had orders for therapy. She said she was not aware Resident #5 did not receive some of her therapy in June 2025. She said the DOR and the Administrator were responsible for ensuring therapy was received as ordered. She said if a resident was not receiving therapy as ordered, then they could have a functional decline. The DON said she did not have a policy on therapy. During an interview on 10/23/25 at 2:30 p.m., the interim Administrator said she expected residents to receive therapy if it was ordered. She said the DOR was responsible for ensuring the resident received therapy. She said if a resident did not receive therapy, it could be a potential decline in function. 675471 Page 12 of 12