Health inspection·September 30, 2022

F 0583 medical information about residents with employees or other providers from the clinical record. 5. The facility shall not release resident-identifiable information to the public . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 2 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure that each resident in a nursing facility was screened for a mental disorder prior to admission for 1 of 6 Residents (Resident # 40) reviewed for a PASRR. Residents Affected - Few The facility failed to provide an accurate PASRR Level I assessment for Resident #40 when he had a diagnosis of a bipolar disorder which would have triggered Resident #40 for a positive assessment for mental illness. This failure could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs. The Findings include: Review of Resident #40's face sheet dated 09/30/2022 revealed an original admission date of 03/24/2021, and readmission date of 11/11/2021, with diagnoses which included peripheral vascular disease (a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel), diabetes type 2 (a chronic (long-lasting) health condition that affects how your body turns food into energy), amputation of left leg above the knee (removing the leg from the body by cutting through both the thigh tissue and femoral bone), osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), hypertension (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease, major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar disorder ( a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #40's last PASRR Level 1 Screening dated 08/25/2022, under Section C0100 revealed documentation indicating Resident #40 does not have a mental illness. The PASRR Level I Screening was also certified by the Assessor on 08/25/2022 indicating the information was true and accurate. Resident #40 has had the diagnosis of bipolar disorder since 02/28/2020. Review of Resident #40's consolidated physician's orders for September 2022 revealed the Resident was receiving Lexapro for depression. Review of Resident #40's original admission MDS assessment, dated 03/31/2021, revealed in section A Identification Information, A0050- New Record, A1500 (1510 A-C), Preadmission Screening Resident Review (PASRR) The resident currently is not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Review of Resident #40's admission MDS assessment, dated 11/29/2021, under section A1500 indicated the same as MDS 03/31/21 and, also Resident #40 had a BIMS score of 15, which indicated Resident #40's cognitive response was intact. Record review of the Resident #40's care plan, dated 03/31/2021, revealed Resident #40 did not have a care plan addressing his bipolar disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 3 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 09/30/2022 at 09:31 a.m. with LVN D revealed the last social worker handled the PASRR information. LVN D stated yes Resident #40 should have had an accurate PASRR Screening and a PASRR Level 2 should have been completed and the local authorities could have provided extra therapy services, durable medical equipment (DME), psychological services and day programs. LVN D stated if the mental illness was not recognized the resident could miss out on services. LVN D further stated once a person was determined to be PASRR positive a quarterly PASRR Care Plan Meeting needs to be done. Review of the facility's PASRR Screening Guidelines, dated 04/26/2016, with the last revision on 05/29/2019 stated in part If the resident has a qualifying mental illness (MI) diagnosis. The Local Mental Health Authority (LMHA) is notified to conduct a physical exam (PE) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 4 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to review and revise the person-centered comprehensive care plan after each assessment for 4 (Residents #23, #78, #35 and #144) of 16 residents reviewed for care plan revisions in that: 1. Resident #23's comprehensive person-centered care plan was not revised to address an order for oxygen or the admission to hospice. 2. Resident #78's comprehensive person-centered care plan contained a goal and intervention for tube feeding when resident did not have a feeding tube. 3. Resident #35's comprehensive care plan was initiated on 08/01/22 and was not closed out when the resident was discharged with return not anticipated on 08/22/22 and readmitted on [DATE]. and the previous care plan was used. 4. Resident #144's comprehensive care plan was initiated on 08/01/18 and was not closed out when Resident #144 was discharged with return not anticipated on 08/28/19. Resident #144 was readmitted on [DATE] and the previous care plan was used. These failures could place residents at risk of their needs being missed and not receiving appropriate care and treatment. The findings included: 1. Record review of Resident #23's electronic admission record dated 09/28/22 documented a [AGE] year-old male originally admitted to facility 07/12/22 and most recently admitted on [DATE] following a hospital stay. Resident #23's diagnoses included lobar pneumonia, unspecified dementia with behavioral disturbance, dysphagia, oropharyngeal phase (difficulty swallowing), cognitive communication deficit and acute and chronic systolic (congestive) heart failure (the heart does not pump blood as it should). Record review of Resident #23's Care Plan last revised on 09/27/22, did not have a plan of care for hospice or use of oxygen. Record review of Resident #23's physician orders as of 09/28/22 revealed he was admitted to hospice services on 07/18/22. There were no orders for oxygen listed. Record review of hospice orders in a separate hospice binder for Resident #23 contained an order dated 7/18/22 for Oxygen (O2) 2-3L Liter inhaled, PRN Shortness of Breath. Record review of Resident #23's Significant Change MDS assessment, dated 07/18/22, revealed the resident was marked as being on oxygen. The significant change payer was noted as Hospice Medicaid Forms Pending. During an observation of Resident #23 on 09/28/22 at 12:54 p.m., resident was noted to be in bed with his eyes closed and using oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 5 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0657 Level of Harm - Minimal harm or potential for actual harm During an interview on 09/30/22 at 11:38 p.m. with ADON E, oxygen orders were discussed. ADON E stated The oxygen orders should be on PCC (Electronic Medical Record). When hospice did the admission, they talked with the charge nurses and then the orders were supposed to be put in PCC. It was an oversight that the oxygen orders were not put in PCC. ADON E also stated the orders for oxygen and hospice should have been put in the care plan. Residents Affected - Some 2. Record review of Resident #78's electronic admission Record dated 09/28/22 documented a [AGE] year-old male admitted to facility 08/24/22. The diagnoses included chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), unspecified dementia, and Tourette's disorder (a nervous system disorder involving repetitive movements or unwanted sounds). Record review of Resident #78's care plan documented focus, goals and interventions initiated on 09/22/22 for a feeding tube. Record review of Resident #78's admission MDS assessment dated [DATE] documented in section K that he did not have any complaints or difficulty or pain when swallowing but Parenteral/IV feeding and Feeding tube - nasogastric or abdominal (PEG) sections were checked Yes indicating he had a feeding tube. Record review of Resident #78's physician order summary as of 09/28/22 documented a dietary order for double portions diet mechanical soft texture, thin liquids consistency. During an interview with Resident #78 on 09/28/22 at 12:12 p.m., resident stated he was able to feed himself and was waiting for lunch to be served in his room. Resident #78 stated he did not have a feeding tube. During an interview with charge nurse, LVN F, on 09/28/22 at 12:20 p.m., LVN F was asked if Resident #78 had ever had a feeding tube. LVN F stated he was not aware he had ever had one and went to check Resident #78 to see if he had any type of scar. LVN F stated there was no scar on Resident #78 that would indicate he had a feeding tube previously. During an interview on 09/30/22 at 9:56 a.m. with LVN D, MDS Coordinator, stated she did not know why Resident #78 had a feeding tube on his care plan as well as on his MDS. LVN D stated she would modify the MDS as well as the Care Plan to ensure they were accurate. LVN D stated she did not attend the care plan meetings but the staff who attend placed a note in the electronic medical record and then changes are discussed in morning meetings. 3. Record review of Resident #35's Face Sheet dated 09/30/2022 revealed the resident was originally admitted to the facility on [DATE] and was discharge with return not anticipated on 08/22/2022 and then readmitted on [DATE] with diagnoses which included peripheral vascular disease (a slow and progressive circulation disorder. narrowing, blockage, or spasms in a blood vessel), diabetes Type 2(a chronic (long-lasting) health condition that affects how your body turns food into energy), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), pressure ulcer (localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time). Record review of Resident #35's comprehensive care plan on 09/30/2022 revealed the initiated date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 6 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0657 was 08/01/2022 with the next review date on 09/29/2022. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #35's Minimum Data Sets (MDS) assessment history from 07/29/2022 to 09/19/2022 revealed an MDS dated [DATE], Discharge Return Not Anticipated an MDS dated [DATE], Entry and an MDS dated [DATE], Admission. Residents Affected - Some Record review of Resident #144's Face Sheet dated 09/30/2022 revealed the resident was originally admitted to the facility on [DATE] and discharged on with return not anticipated on 08/28/2019, then readmitted on [DATE] with diagnoses which included cognitive communication deficit (difficulty with thinking and how someone uses language), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Psychotic Disturbance (are severe mental disorders that cause abnormal thinking and perceptions), Mood Disturbance (can be feelings of distress, sadness or symptoms of depression, and anxiety), Anxiety (a normal reaction to stress an intense, excessive, and persistent worry and fear about everyday situations) and Benign Prostatic Hyperplasia (Age-associated prostate gland enlargement that can cause urination difficulty). Record review of Resident #144's comprehensive care plan on 09/30/22 revealed the initiated date was 08/01/2018 with the next review date on 09/27/2022. Record review of Resident #144's Minimum Data Sets (MDS) assessment history from 07/29/2019 to 09/19/2022 revealed an MDS dated [DATE] Discharge Return Not Anticipated an MDS dated [DATE], Entry and an MDS dated [DATE], Admission. During an interview on 09/30/2022 at 10:11a.m. with LVN D revealed if an old care plan might not have been closed out and deactivated it would go into the new care plan. LVN D stated the old care plan could be used against us and may no longer apply to the resident. LVN D confirmed the old care plans for Resident #35 and Resident #144 should have been deactivated. Record review of the Facility Care Plan Guidelines dated 01/21/2015 and revised on 05/06/2016 revealed in part and states The purpose of this is to ensure that interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers (CAT) that were generated by the completion of the Minimum Data Set (MDS) in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident Care Plan Updates The IDT will review the care plans Annually, Quarterly and as needed to ensure all goals and approaches are appropriate Acute Care Plans As acute problems or changes to intervention or goals are identified, as appropriate care plan will be developed or modified Procedure All comprehensive care plans will be completed utilizing the Point Click Care electronic system . Record review of the Facility Comprehensive Care Plans Policy and Procedure dated 02/10/2021 states in part 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but, are not provided due to the resident's exercise of his or her right to refuse treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 7 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0657 c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. Level of Harm - Minimal harm or potential for actual harm d. The resident's goals for admission, desired outcomes, and preferences for future discharge. Residents Affected - Some e. Discharge plans as appropriate . Review of the Center for Medicare Services (CMS), Resident Assessment Instrument (RAI), Version 3.0 manual, dated 10/2019 page 2-42, states in part Care Plan Completion- The care plan completion date, must be either later than or the same date as the CAA completion date but, no later than 7 calendar days after the CAA completion date. The MDS completion date must be earlier than or the same date as the care plan completion date Resident's preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident's representative, so changes can be reflected in the comprehensive care plan . Review of the facility's electronic system Point Click Care, modified 04/07/21, page 1/11 and page 6/11, the area for care plans states in part Care Plans: Navigating the Care Plan Tab . 2. Date Initiated and Review Date a. Date Initiated- Date the Care Plan was started. b. Next Review Date-Date for next Care Plan review Closing the Care Plan: Residents that are discharged without anticipated return will have their care plans closed automatically by the completion of the MDS Discharge Return not anticipated . (https://cfc.freshdesk.com/support/solutions/articles/4000171354-pcc-care-plans-and tasks) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 8 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (Resident #32) of 3 reviewed for quality of care. Residents Affected - Few LVN P failed to provide intervention to Resident #32 once she identified the Resident was experiencing a hypoglycemic (when a person's blood sugar is low) episode. This deficient practice could affect residents requiring assistance from staff for diabetic management and could place them at risk for harm and not attaining the highest practicable well-being. The findings included: Record review of Resident #32's admission record, dated 09/29/22, revealed an admission date of 01/19/2019 and a readmission date of 05/07/2021. Resident #32 had diagnoses of type 2 diabetes mellitus, high blood pressure, muscle weakness, morbid obesity, and a history of falling. Record review of Resident #32's physician orders, dated 09/29/2022, revealed an order for Novolog Flexpen solution Pen-injector 100 UNIT/ML, inject as per sliding scale: if 201-250=5; 251-300=7; 301-350=9; 351-400=11, subcutaneously before meals for DM start date 09/21/2022 and no end date. Another order stated Glucagon (rDNA) Kit 1 MG, inject 1 syringe intramuscularly every 24 hours as needed for low blood sugar start date 04/06/2022 and no end date. Record review of Resident #32's careplan, with revision date of 06/14/2022, revealed Diabetes: Resident has a diagnosis of diabetes and is at risk for unstable blood sugars and abnormal lab results .Interventions: .Monitor blood sugar .HYPOGLYCEMIA: Monitor for signs and symptoms of hypoglycemia such as: diaphoresis (Sweating that does not occur due to heat), dizziness, headache, confusion, hunger, irritability, pallor (Unusual loss of brightness in complexion visible in skin), tachycardia (fast hear rate), slurred speech, tremor (shaking), lack of coordination, and staggering gait. Document and report to physician as needed. During an observation on 09/28/2022 at 12:23 p.m. LVN P entered Resident #32's room. The resident was sitting up in the bed with her head pointed down, touching her chest, and her eyes were closed. LVN P loudly called the resident's name several times before she opened her eye and picked her head up slightly. LVN P checked Resident #32's blood glucose. It was 67. LVN P asked Resident #32 if she had eaten her breakfast. Resident #32 stated no. LVN P told Resident #32 to make sure she ate her lunch. No lunch tray was in the room for the resident at this time. Two pieces of bread in bags were observed on the bed side table. LVN P turned to walk out of the residents room and stated to this surveyor, she knew the resident's sugar was low because she was never that tired. LVN P did not return to the resident's room and continued passing medications to other residents on the hallway. During an interview on 09/29/22 at 11:13 a.m. LVN P stated a glucose reading below 60 or above 600 would be out of parameters. She stated symptoms of hypoglycemia could be lethargic (A feeling of fatigue, tiredness, and exhaustion), talking gibberish, not responsive, sweating, and chest pain. She stated they only give Resident #32 insulin if her blood sugar was above 201 now. She stated anything below 60 for a blood glucose reading she would provide interventions such as administering orange juice, or glucagon, notify the provider, or send the resident to the hospital if needed. When asked if she provided the appropriate interventions, she stated she knew the Resident had muffins close to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 9 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her yesterday. She stated they had a verbal policy of waiting until blood glucose was below 60 before they need to provide interventions. During an interview on 09/29/22 the DON stated parameters for resident's blood glucose and insulin were in the orders and was on a per resident basis. She stated nurses needed to use nursing judgement to assess if a Resident was experiencing hypoglycemia. She stated the resident could show symptoms such as cold, clammy (wet or sweaty skin), and decreased mentation. She stated a normal blood sugar was between 80-120 and anything below 80 or per the PRN order needed to be assessed. She stated if the resident was responsive the nurse should have checked the PRN order. The DON stated the nurse should get them a snack, provide it to them at that time, get a drink of orange juice or depending on what the order states, open the snack, encourage them to eat it, watch and observe, read the orders again, and recheck the blood glucose to make sure it has come up. The DON stated they provided training and education on diabetic management along with a skill check off upon entry to the company. Record review of the Facility's Policy titled Diabetic Management, dated 09/09/22, stated It is the policy of the facility to provide effective management for diabetic residents .10. Hypoglycemia Response: Hypoglycemia is typically defined as a blood glucose level below 70mg.dL .b. If the resident can eat regular food/fluid consistency administer a protein along with a carbohydrate. For example, 8oz milk and 2 graham crackers . 11. A bedside blood glucose test should be administered initially and 15-20 min post treatment for any resident reporting or experiencing symptoms of hypoglycemia such as .f. confusion .k. feeling sleepy .l. weakness or having no energy .p. coordination problems .12. Notify the practitioner of hypoglycemic episode and resident response to treatment. 13. Nursing will continue to follow up and observe for any further hypoglycemic episodes post treatment and notify the practitioner of any changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 10 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 1 of 1 resident (Residents #37) reviewed for pressure ulcers. Residents Affected - Few 1. Registered Nurse (RN) R failed to provide Resident #37's pressure ulcer treatments as prescribed by the physician. 2. RN R failed to perform hand hygiene practices per the facility's policy and procedure, prior to initiating Resident #37's wound care on her pressure ulcers and during wound care. 3. RN R contaminated clean gloves she used while providing Resident #37's wound care on her pressure ulcers. These failures could place residents with pressure ulcers at risk of worsening in size and staging, and result in pain and infection. The findings included: Record review of Resident #37's admission record, dated 09/29/22, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that cellulitis of unspecified part of limb (A serious bacterial infection of the skin.), peripheral vascular disease (affects the blood vessels), and pressure ulcer of the left heel stage 4. Record review of Resident #37's wound care orders, dated 09/29/2022, revealed Site 3 (non pressure wound to left medial ankle) Continue Hypochlorite Gel (Anasept) Once Daily 9, Collagen Powder Once Daily for 9 (days), Discontinue Alginate Calcium w/silver. Continue Gauze Roll (Kerlix) 3.4 Once Daily for 9 (days), ACE Bandage 6 Once Weekly for 9 (days). Site 10 (Venous wound to left proximal dorsal foot) Continue Hypochlorite Gel (Anasept) Once Daily for 9 (days), Collagen Powder Once Daily for 9 (days), Discontinue Alginate Calcium w/silver, Continue Gauze Island w/ bdr Once Daily for 9 (days), Gauze Roll (Kerlix) 3.4 Once Daily 9 (days), ACE Bandage 6 Once Weekly 9 Site 12 (non pressure wound to left posterior lateral leg) Continue Hypochlorite Gel (Anasept) Once Daily for 9 (days), Collagen Powder Once Daily for 9 (days), Discontinue Alginate Calcium w/silver Continue Gauze Roll (Kerlix) 4.5 Once Daily for 9 (days), Gauze Island w/ bdr Once Daily for 16 (days). Site 13 (Stage 4 pressure wound of left heel) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 11 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0686 Level of Harm - Minimal harm or potential for actual harm add Sodium Hypochlorite Solution (Dakins), Once Daily, for 30 (days) Cleanse wound prior to tx (treatment) application and as needed, pack with lightly soaked gauze. Continue Alginate Calcium w/silver Once Daily for 16 (days) and continue Santyl Once Daily for 16 (days). Discontinue Betadine. Continue Gauze Roll (Kerlix) 4.5 Once Daily for 16 (days). Residents Affected - Few No orders were provided or found for wound care performed on the right leg. Record review of Resident 37's Order Summary, dated 09/29/22, start date 09/22/22 and end date 10/22/22. The order did not match the physicians' last orders. It stated stage 4 wound left posterior heel, cleanse with NS, wound cleanser pat dry apply betadine, Santyl, calcium alginate with silver, and wrap with gauze roll daily. Every day shift for wound healing for 30 Days. An Observation on 09/30/22 at 9:12 a.m. revealed Preparation: Resident #37 was sitting in a wheelchair near his bed. RN R placed wax paper on the floor in front of Resident #37's wheelchair and on a bedside table near the foot of the bed. RN R went to the nurse's cart and pulled out 3 plastic medicine cups. RN R placed Santyl ointment in one cup, placed her bare hand over the next cup, positioned a spray bottle sodium hypochlorite solution under her hand, and began to spray the sodium hypochlorite solution into the medicine cup. RN R sprayed derm cleanse, containing Benzethonium chloride, into a 3rd medicine cup (no order for this). No hand hygiene was performed, and no gloves were worn. RN R gathered various supplies in her arms, held them against her body, and brought them to the bedside table in Resident 37's room. RN R performed hand hygiene, then touched a light cord to turn on a light, and moved and locked the Resident's wheelchair. RN R went back to the nurse's cart, and poured Hibiclens, containing chlorhexidine gluconate, into a medicine cup (no order for this). RN R went to the sink, turned on the water, returned to wax paper on the floor, and placed a towel and clean gloves on the wax paper. RN N went back to the nurse cart, grabbed scissors, and placed them on the wax paper on the floor. RN R took a towel to the sink and placed in in the sink. RN R donned gloves. RN R brought the towel to Resident 37 and asked him to feel it. Resident 37 touched the wet towel. RN R opened a trash bag and placed it under Resident 37's right foot. Site Right leg: LVN T performed hand hygiene, donned clean gloves, knelt on the ground, and held the Resident's right leg. RN R cut bandage dated 9/29/22 off the right foot with non-sanitized scissors. RN R removed her gloves, sanitized her hands, and donned clean gloves from a box on the floor. RN R dampened a gauze with chlorhexidine gluconate solution, wiped the Resident's right leg, and used the contaminated washcloth from the sink to wipe the Resident's right leg and foot. RN R moved quickly while cleaning Resident #37's leg, with a gauze with unknown solution, stating she cleaned from inside out, and then wiped the leg with a dry washcloth. RN R rolled up the wax paper on the floor with discarded trash and threw it away. RN R slid over another piece of wax paper on the floor from behind her, to in front of the Resident's wheelchair. RN R removed gloves, sanitized her hands, touched her jeans, and donned clean gloves. RN R picked up collagen gauze and places on the wax paper on the floor. RN R stated she could not use an island dressing for wounds on the Resident's right leg because the coban wrap she planned to use, instead of the ACE wrap, will trap moisture. RN R then stepped on the wax paper on the floor. RN R grabbed gauze, from the contaminated wax paper, applied skin prep around wounds on the right leg, and placed dry gauze on them. RN R wrapped the Resident's right leg up to his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 12 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few knee with a medicated gauze wrap, containing zinc and calamine dermerite, then applied a dry gauze wrap, and coban instead of an ACE wrap (no order for this). Site 3, 10, 12, and 13: RN R then removed her gloves, went to the bathroom sink, washed her hands, and touched the handle with her bare hand to turn off the water. RN R grabbed a trash bag off her cart, brought in another package of coban, placed boxes of gloves on the floor, kicked the box out of the way. RN R adjusted the Resident's wheelchair. RN R put wax paper from the Resident's bed onto the floor, placed a sheet or pillowcase on the floor, used alcohol wipes to clean scissors. LVN T and RN R both lifted the Resident's left leg and placed a trash bag under it, removed the ace bandage, and cut coban off the left leg. RN R stepped on wax paper, removed gauze from wounds on the Resident's left leg, used trash bag to pick gauze off Resident's foot, removed and threw gloves into trash bag under Resident's foot, sanitized her hands, applied new gloves, dipped gauze into chlorhexidine gluconate solution (no order), placed cup of liquid on the floor on top of contaminated wax paper, poured liquid onto leg, removed bandages, removed bandage from left heel, wiped with chlorhexidine gluconate gauze (no order), touched wound areas with gloved hand and poured saline onto left bottom of Resident's foot while moving hand to splash solution on to the bottom of the foot. RN R removed gloves, sanitized hands, and donned new gloves. LVN T continued to hold Resident's leg up. RN R stated the bottom heel of the left foot got the dikins solution applied. RN R placed gauze on it and held it on the left foot. RN R has a pair of new clean gloves in her hand and was touching them directly on the floor. RN R stood up and placed contaminated gloves under her arm in her arm pit, sanitized her hands, touched gauze on table, opened a skin prep, sanitized hands, put contaminated gloves from under arm pits on. RN R returned to wax paper on the floor, opened calcium alginate and collagen pads, and placed them on contaminated wax paper. RN R removed gauze with dikins on it, used a piece of a package from the trash pile on the floor to apply ointment to the Resident's left foot wound, put a dry gauze pad on the left foot, then a stained gauze back on the foot, and dropped alginate gauze. LVN T removed gloves, sanitized hands, and grabbed a new alginate gauze. LVN T donned clean gloves. RN R pressed alginate gauze pad into left heel, placed towel from residents lap under left foot, removed gloves, sanitized hands, put wax paper on the floor, put betadine into cup on the floor (no order), grabbed gloves from box on the floor, sanitized hands, donned clean gloves, opened dry gauze roll, opened gauze wrap with zinc and calamine dermerite (no order), wrapped up all stuff on the floor into wax paper including a cup of betadine (never used the betadine), spilled betadine all over floor, used pillow case to clean up floor, put wax paper on the floor, washed hands, touched sink handle with bare hands to turn off the water, went to get cups off cart, sprayed saline into cups, held gauze packages under arm, brought in cup of saline, sanitized hands, donned clean gloves, bunched up a trash bag in her hands, opened gauze placed in it in cup with spray/liquid/clear, moved wax paper across the floor with supplies on it, put another trash bag under residents left leg, removed gloves, sanitized hands, donned gloves, placed cups of gauze and liquid inside each other, moved down to floor separated the cups, removed dressing from left anterior ankle area, removed gloves, sanitized hands, donned gloves, cleansed left posterior ankle area wound with saline, removed gloves, no hand hygiene, donned clean gloves, threw dirty gloves onto floor next to clean supplies. RN R removed the trash bag from under the Resident's foot, picked up wax paper off the floor, and placed it under the Resident's foot. Sanitized hands, donned gloves, moved wax paper from floor behind her with supplies on it to in front of her by resident. RN R opened the calcium alginate gauze package, and stated she will put calcium alginate first, then the collagen pad, tore the medicated pads in half. LVN T continued holding Resident 37's left leg. RN R threw some supplies into trash can behind her, removed a skin prep from package, rubbed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 13 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it around wound on left anterior ankle area, placed calcium alginate gauze in wound, then collagen gauze, covered with dry gauze, applied alginate to left posterior ankle area, then collagen was packed into wound covered with dry gauze. RN R removed gloves, sanitized hands, donned gloves, placed alginate and collagen to wound on left posterior side of foot, covered with dry gauze, wrapped foot with zinc calamine dermerite gauze wrap (no order), then wrapped left leg up to knee with dry gauze roll, and the wrapped left leg up to knee in coban (no order). RN N did not date any bandages. During an interview on, 09/30/22, 10:21 a.m., RN R stated normally Resident #37 would be in bed the hours between 3:30 a.m. and 6:00 a.m. and she tried to do wound care at that time. She stated she also performed wound care while the resident was in the shower. RN R stated if it had a barrier, the stuff on the ground was clean. RN R stated if she stepped on the wax paper it was dirty. RN R denied using the towel from the sink on the Resident's legs during wound care. When asked why she used the wrap containing zinc calamine dermerite she stated she would call the doctor and have him add it to the order. She stated she could not use an island dressing under the wrap and she will have the doctor modify the orders. She stated she liked to alternate between the ACE wrap and coban because it was a better barrier. When asked about using contaminated gloves during wound care she stated they are dirty wounds. If she dropped it or held it under her arm she was still in a dirty area. She stated she did catch that she stepped on one of the wax papers. She stated it was best practice to do wound care on the Resident in the bed and not on the floor. She stated normally she used a wooden spoon or a sterile 4x4 to apply ointment to a wound, but she used a 2x2 package to measure how much ointment she would apply. During an interview on, 09/29/22, at 10:48 a.m., the DON stated typically the bedside table was disinfected and used for wound care. She stated there would never be a time they would set up wound care on the floor because the floor was not a clean area. The DON stated there was risk for infection when doing wound care on the floor. The DON stated they should always follow physician's orders and if they have a question, they should contact the physician and clarify it. The DON stated not following proper wound care techniques and orders could place the Resident at risk of a multitude of things including worsening wounds and infections. Record review of facility policy titled Wound Management dated 02/07/2019, stated To promote wound healing of various types of wounds .1. Wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change .6. Guidelines for dressing selection may be utilized in obtaining physician orders .c. The facility will follow specific physician orders for providing wound care. Record review of facility policy titled Infection Control Guidelines, dated 09/22/2017, stated The purpose for this policy is to reduce and prevent the spread of infections by the use of evidenced based techniques established infection control policies and procedures .3 .c. Direct care staff use infection control practices in patient care procedures established to prevent spread of microorganisms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 14 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 (#62, #41, and #13) of 3 residents reviewed for accidents, hazards, and supervision. 1. Resident #13 had a package of razors in his room. 2. Resident # 62 had a cup of razors in his room. 3. Resident #41 was unsupervised during meals. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: 1. Record review of Resident #13's MDS assessment, dated 06/24/22, revealed an admission date of 09/12/20 and a readmission date of 06/28/21. Resident #13 had a diagnoses of alzheimer's disease, stroke, dementia, schizophrenia, and hip fracture. Resident #13 had a BIMS of 5 (severely impaired cognition). Under section G functional status resident was an extensive, one-person assist with personal hygiene. Observation on 09/27/22 at 10:00 a.m. revealed Resident #13's bottom dresser drawer was opened, and a package of disposable razors was observed. During an interview on 09/27/22 with Nurse Aide N and Nurse Aide O stated the razors were in the room because hospice left them there. They stated normally they kept them in a locked closet. 2. Record review of Resident #62's admission Record dated 09/29/22, revealed an admission date of 07/28/20. Resident #62 has diagnoses including mild intellectual disabilities, muscle wasting and atrophy, schizoaffective disorder, and anxiety. Record review of Residents #62's MDS assessment, dated 08/24/2022, revealed a BIMS of 8 (moderately impaired cognition). Under section G functional status, resident required supervision- oversight, encouragement, or cueing and setup help for personal hygiene. Observation on 09/27/22 at 10:46 a.m. revealed Resident #62 had a cup of disposable razors on the top of his dresser. In an interview on 09/29/22 at 11:13 a.m. with LVN P revealed, residents were not supposed to have sharp objects such as scissors, knives, or razors in their possession or in their rooms. LVN P stated Resident #62 has an electric razor but not a manual one. LVN P stated this was because they could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 15 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - Some hurt themselves or someone else by using it as a weapon. LVN P stated if they have dementia, they could forget what it was used for or try to eat it. This surveyor informed LVN P a cup of razors was observed in the resident's room on 09/27/22. LVN P entered Resident #62's room and lifted some items on the resident's dresser. Under the items was one disposable razor. In an interview on 09/29/22 at 3:57 p.m., the DON stated residents were not allowed to have items such as knives, razors, disposable razors, lighters, cigarettes, vapes, guns, and medications in their possession with out supervision. The DON stated to her knowledge she does not know of any residents who were allowed to have these items unsupervised. 3. Record review of Resident #41's admission record dated 09/28/22, revealed an admission date of 12/01/1985 and a readmission date of 09/12/2020. Resident #41 has diagnoses of cerebral palsy (A group of disorders that affect movement, muscle tone, balance, and posture.), apraxia (A neurological syndrome characterized by difficulty in performing daily tasks even if the instructions are understood. The person affected finds it difficult to tie shoelace, button the shirt, difficulty in making certain facial expressions etc.), lack of coordination, dysarthria (Difficulty in speech due to weakness of speech muscles.) and anarthria (inability to articulate remembered words as a result of a brain lesion), abnormal posture, muscle weakness, unspecified convulsions (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness.), and dysphagia oropharyngeal phase (A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing). Record review of Resident #41's MDS assessment, dated 08/05/22, revealed under section C Cognitive Patterns the resident was severely impaired-never/rarely made decisions. Under section G Functional Status eating- limited assistance-resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance and One-person physical assist. Record review of Resident #41's care plan last revised on 05/16/22, stated The resident has, a swallowing problem r/t loss of food/liquids from mouth while eating, Coughing or choking during meals or swallowing med, Swallowing assessment results, Dysphagia. Resident failed swallow study and refused G-Tube. puree diet with fortified foods, divided plate .Resident to eat only with supervision. Record review of Resident #41's document labeled Restorative Care Program ST dated 06/17/2017, stated Precautions: Choke and aspiration precautions. Should be supervised for all intake .RNA training provided to all shifts as indicted. The document is signed by Speech Therapist S. An observation on 09/27/22 at 12:10 PM, revealed Resident #41 sitting in the dinning room at a table alone. The Resident had two cups in front of her with straws in them. Later RN Q served this Resident a meal tray. RN Q left the table and served approximately 4 other Residents in the dining room their lunch trays. RN Q left the area several times for various times during the meal service. No other staff were assisting with meal service in the dinning room. Resident #42 used a weighted spoon to serve herself. Resident #41's food appeared pureed (soft, moist, and smooth). Resident #41 moves the spoon slowly to her mouth while shaking and dropping food from the spoon. The Resident #41's tongue rest outside her mouth at all times and while eating. RN Q was observed standing at the Resident 41's table assisting her to place condiments on her food and overheard telling Resident #41 that she will be back later to help her finish her food. RN Q left the dining room area again. In an interview with Resident #41's Representative on 9/28/2022 at 9:46 a.m. stated Resident #41 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 16 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - Some liked her snack at night. She stated Resident #65 came in and gives it to her at night. Resident #41's Representative stated the staff could not be relied on to help her with her nightly snack, she gave a key to Resident #65 to feed Resident #41 her snack at night in her room. In an interview on 09/29/22 at 3:39 p.m. the DON stated Resident #41 was on a puree diet. She stated staff helped her set up her meal and supervised her during meals. She stated Resident #41 slept in till noon and sometimes did not get up for breakfast. Resident #41 liked a nightly snack. The kitchen staff ensured the item required for her snack follows her diet. She stated she had heard Resident #65 did assist with Resident #41's nightly snacks. She stated Resident #41 had Vienna sausages for a snack and Resident #65 prepared them for Resident #41. She stated it was not acceptable for Resident #65 to prepare the snack and assist Resident #41 with eating because she could choke or have other issues. Record review of facilities policy document titled Investigation of Incidents and Accidents dated 12/3/20, states The residents environment will remain as free of accidents hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: .3. Implementing interventions to reduce hazard(s) and risk(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 17 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on interview and record review the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 4 (09/15/2020 and 09/16/2020) of 7 days reviewed for staffing in that: Residents Affected - Many The daily posted nurse staffing data was not posted in the facility from 9/24/2022 to 9/27/2022. This deficient practice could place residents and visitors at risk of not being unaware of staffing levels in the facility. Findings include: Record review on 9/27/2022 at 8:43 AM of the Facility Staffing Disclosure posting on a bulletin board near the front entry revealed a date of 9/23/2022. The census was blank and actual staff count for the evening and night shift were blank. It had not been updated for 4 days upon entry. In an interview on 9/30/2022 at 11:30 AM, the ADON E confirmed the Daily Nurse Staffing posting was dated 9/23/2022, was not updated for 4 days. When asked who filled out the Daily Nursing Staff posting she stated she handled staffing. She stated when she came in, she got bombarded, and it was hard to get to it. She stated if she did not have it updated daily this could cause inaccurate reporting, or not enough staffing for how many people they have in the building. In an interview on 9/29/2022 at 4:05 PM, the DON stated the posting should have been updated daily and reflect a live time scheduling. She stated ADON E was responsible for updating this posting daily. No facility policy was provided for the nurse staffing data posting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 18 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - 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 observation, interview, and record review, the facility failed to provide pharmaceutical services, including a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled drugs for 3 of 10 (#3, #37, #74) residents reviewed for medication administration in that: The medication cart for rooms 137-154, contained an inaccurate narcotic log for Residents #3, #37, and #74. This deficient practice could place residents at risk of inaccurate care due to improper procedures. The findings were: Record review of Resident #3's admission Record, dated 09/29/2022, revealed an admission date of 04/11/2017, and a readmission date of 07/25/2013, with diagnoses that included stroke affecting the right side, speech and language deficits, pain, heart failure, high blood pressure, and muscle weakness. Record review of Resident #3's physician orders for September 2022 revealed an order for Acetaminophen-Codeine #4 Tablet 300-60MG (a narcotic used to treat moderate to severe pain) Give 1 tablet by mouth four times a day for pain, with an order date 10/29/21 and no end date. Record review of Resident #37's admission record, dated 09/29/22, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that cellulitis of unspecified part of limb (A serious bacterial infection of the skin.), peripheral vascular disease (affects the blood vessels), chronic pain, and pressure ulcer of the left heel stage 4. Record review of Resident #37's physician orders for September 2022 revealed an order for Oxycodone HCl Tablet 20 MG (a narcotic used to treat severe pain) Give 1 tablet by mouth five times a day for chronic pain, with an order date 09/13/22 and no end date. Record review of Resident #74's admission Record, dated 09/29/2022, revealed an admission date of 11/12/2021, with diagnoses that included chronic pain syndrome, glaucoma, muscle weakness, and stroke. Record review of Resident #74's physician orders for September 2022 revealed an order for Morphine Sulfate Tablet 15 MG (a narcotic used to treat severe pain) Give 1 tablet via G-Tube every 4 hours for pain, with an order date 06/30/22 and no end date. During an observation on 09/28/22 at 12:19 p.m., LVN P administered Resident #37 20 MG of Oxycodone from a blister pack that contained 17 remaining pills after administration. LVN P did not document in the MAR or narcotic logbook at this time and continued down the hallway to administer medications to a different resident. During an observation on 09/28/22 at 12:36 p.m., LVN P administered Resident #3 1 tablet of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 19 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - Some 300-60MG of Acetaminophen-Codeine from a blister pack that contained 28 remaining pills after administration. LVN P did not document in the MAR or narcotic logbook at this time and continued down the hallway to administer medications to a different resident. During an observation on 09/28/22 at 12:40 p.m., LVN P administered Resident #74 15 MG of Morphine Sulfate tablet from a blister pack that contained 15 remaining pills after administration. LVN P did not document in the MAR or narcotic logbook at this time and stated she was done with medication administration at that time. Record review on 09/28/22 at 12:56 p.m. of the narcotic count logbook located on nurse cart for rooms 137-154 showed Resident #37's count sheet for 20 mg of Oxycodone documented 2 blister packs of 30 and one with 18 remaining pills. The blister pack had 17 remaining. 1 pill was not signed out on the count sheet. Record review on 09/28/22 at 12:57 p.m. of the narcotic count logbook located on nurse cart for rooms 137-154 showed Resident #3's count sheet for 300-60MG of Acetaminophen-Codeine documented 3 blister packs of 30. 1 Blister pack had 29 remaining. 1 pill was not signed out on the count sheet. Observation on 09/28/22 from 12:08 p.m. to 12:46 p.m. revealed LVN P did not document any medications administered to residents between these times. During an interview on 09/28/22 at 12:56 p.m., LVN P stated she was supposed to document medications in the narcotic count logbook and medication administration record as she gave them. She stated if she did not document at the time she gave the medication, she could forget to sign them out, she could be pulled away, forget she gave something, and it would not be signed out. She stated she did not have a pen on her, it was at her desk, to document in the paper medication records located on the nursing cart. During an interview on 09/29/22 at 4:03 p.m. the DON stated staff should follow the medication administration, administer the medications, and then sign them out. The DON stated it would not be acceptable for a nurse to administer medication to the whole hallway then document after. The DON stated if they did not have a pen, then they needed to get one. The DON stated the process for narcotics was to sign it out whenever was it popped out of the blister pack. Record review of the Facilities Policy titled Medication- Treatment Administration and Documentation Guidelines, dated 2/2/2014, stated Anticipated Outcome, to provide a process for accurate, timely administration and documentation of medication and treatments .5. Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. 6. When controlled medication is administered the licensed nurse obtains the medication from the locked area. The licensed nurse administering the medication immediately enters the following information on the accountability record when removing the dose from controlled storage; date and time of administration, amount administered, signature of the nurse administering the dose. (Also document controlled medication dose administered on the MAR). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 20 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. 3 of 4 food racks in the dry storage area were rusted. 2. Ice machine had dust buildup on the left vent and a heavy buildup of a gray substance running down the right side of the ice machine. 3. Refrigerator #4 had 3 of 3 doors with a brown color midway up each door and the rubber gasket inside the right door was broken. 4. Freezer #2 did not have a thermometer. 5. Floor drain in front of the walk-in Refrigerator #5 had pooled water beside the floor drain. 6. The drain from the vegetable preparation sink had the ice machine drain connected to the side of the sink drain and was connected directly to the floor drain. The drain pipe was covered with a black substance. 7. Air conditioner vent on the left side of the steam table was covered with a black substance. This failure could place residents who ate from the kitchen at risk for cross-contamination and food-borne illnesses. The Findings included: Observations on 09/28/2022 from 08:39 a.m. to 09:07 a.m. revealed the following: 1. Dry food storage area- 3 of 4 racks use to store food were rusted. 2. The ice machine had a buildup of dust on the left vent and a heavy buildup of a gray substance running down the right side. 3. Refrigerator #4 had 3 of 3 doors with a brown color midway up each door and the rubber gasket was broken on the inside right door causing ice buildup along the door edge and condensation. 4. Freezer #2 did not have a thermometer. 5. Floor drain in front of walk-in Refrigerator#5 had pooled water beside the floor drain. 6. The drainpipe from the ice machine was attached to the vegetable preparation sink drainpipe and draining directly into a floor drain and was also covered with a black substance. 7. The air conditioner vent on the left side of the stem table was covered with a black substance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 21 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - Some Observations on 09/28/2022 at 08:50 a.m. at the vegetable preparation sink and the ice machine revealed the drainpipe from the ice machine was connected to the drainpipe from the vegetable preparation sink straight into the drainpipe into the floor. The drainpipe from the ice machine to the other drainpipe was covered in a black substance. Observation on 09/28/2022 at 9:07 a.m. revealed the air conditioner vent on the left side of the steam table was heavily covered with a black substance. During an interview on 09/08/2022 at 8:48 a.m. with the Food Service Supervisor (FSS), she confirmed there were 3 of 4 racks used for dry food storage was rusted, the ice machine had a buildup of dust on the left vent and a heavy buildup of a gray substance running down the right side and no thermometer in freezer#2. The FSS stated further the rubber gasket for the right door on freezer#2 was broken and was ordered yesterday, 10/27/2022 and had been like that since she came to work on 10/2020. The FSS stated she knows the rusted racks in the dry storage area can cause rust to get into food and the seal on the door not being fixed can cause food to ruin. The FSS stated the water pooled by the floor drain by the walk-in refrigerator #5 has been that way for years and it is coming from the sewer. She stated it does that every time it rains or if you use the vegetable prep sink. During an interview on 09/28/2022 at 8:55 a.m. with the FSS revealed the drain had been connected directly to the vegetable preparation sink and the black substance on the pipes since she had been working at the facility. The FSS further stated when the vegetable preparation sink was used, the drain in the floor by the walk-in freezer will also have water coming up. During an interview on 09/28/2022 at 9:00 a.m. with the cook/dietary aide revealed she had worked at the facility for 3 years, the drainpipe from the vegetable preparation sink and the ice machine drainpipe have been connected straight into the drainpipe. During an interview on 09/28/2022 at 09:10 a.m. with the FSS confirmed the air conditioner vent was covered with a black substance and was the only vent operating in the kitchen. The FSS stated maintenance was in charge of cleaning the air conditioner vent and did not know when it was to be cleaned. Further the FSS stated the black substance could possibly blow down into the food on the steam table. During an interview on 09/30/2022 at 8:15 a.m. with the Administrator stated the air conditioner vent was not taken care of on 09/29/2022 because the vent was going to have to be cut out and replaced and did not want to remove it while cooking was going on. Review of the Facility Policy for Food Service Safety and Sanitation Plan dated 09/2005 and revised on 11/20/2017, pages 1 of 8, 2 of 8, 7 of 8 and 8 of 8, stated in part: It is the policy of the facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur Food contaminations means the unintended presence of potentially harmful substance including but not limited to microorganisms, chemicals or physical objects in food Ice- Appropriate ice and water handling practices prevent contamination and the potential for waterborne illness. Keeping the ice machine clean and sanitary will help prevent contamination of the ice. Contamination risks associated with ice and water handling practices may include but, are not limited to: Unclean equipment, to include internal components of ice machines that are not drained and sanitized as needed according to manufacturer's specifications . Review of the Easyice Ice Machine Safety requirements dated 05/16/2018, states in part: What is an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 22 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - Some Air Gap? An air gap is the amount of space that separates a water line from an ice machine drain to a sewer. Proper air gap installation makes sure dirty water does not contaminate the municipal water supply According to health codes, any piece of equipment where food, drinkable liquids or eating utensils are placed cannot have a direct line into the sewage system. Since the Food and Drug Administration classifies ice as a food, ice machines must follow these guidelines as well. Health codes require two air gap instillations for each ice machine. The first air gap must exist between an ice machine's drain lines and the water supply line that directly connects to the city water supply. The other air gap, or backflow prevention, must be between an ice machine drain and the sewer drain. This makes sure the sewer lines can't create a vacuum which allows water to flow back up into the machine contaminating ice that could end up in someone's drink . (https://Easyice.com/air-gap-tips-health inspector) Review of the Texas Commission on Environmental Quality Chapter 290- Public Water System Effective 01/03/2019, 290.38 Definitions states in part: 2. Air gap- The unobstructed vertical distance through the free atmosphere between the lowest opening from any pipe The vertical, physical separation must be at least twice the diameter of the pipe . (www.aitceq.texas.gov) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 23 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters and the grounds along the side and around the dumpsters reviewed in that: Residents Affected - Some 1. The two dumpsters had the doors open and 1 had a large bag of soiled items hanging out the side door. 2. There was broken, discarded furniture alongside and behind the dumpster (couch, recliner, beds, mattresses, oxygen concentrators and a torn up disposable blue pad with a soiled brief and numerous pairs of used disposable gloves strung around on the ground). These failures could place residents at risk of infection and vermin from improperly disposed garbage and furniture. Findings include: An observation on 09/30/2022 at 07:45 a.m., behind the facility, revealed 2 dumpsters with the doors open on both sides and one of the dumpsters had a large bag of soiled items hanging out one of the doors. Alongside and behind the dumpsters, there was a wooden pallet, wall panel, couch, a portion of a recliner, a torn up disposable blue pad, and a soiled disposable brief. There were also 3 beds, 3 mattresses, an over the bed table, 2 wooden shelves, 3 oxygen concentrators, and numerous soiled disposable gloves left on the ground. An interview on 09/30/2022 at 8:07 a.m. with the Administrator revealed the city picked up trash every Monday, Wednesday and Friday. The Administrator stated he was in the facility that morning when they came to empty the dumpsters . He stated because the dumpster doors were open and the items around the dumpsters could fly around and attract bugs and flies. Review of a statement, dated 09/30/2022 at 10:25 a.m., by the Administrator revealed trash was to be picked up every Monday, Wednesday and Friday of each week. Housekeeping and Maintenance went out afterwards to ensure trash that was dropped was picked up and lids are closed on the dumpsters. Failure to ensure lids are closed could result in trash being blown around, attracting insects or rodents. Review of an invoice statement, dated 08/01/2022 from the facility, revealed 8 yards 3 X week by the city was being picked up. Review of the facility Dietary Policy and Procedure - Garbage and Refuse Disposal dated 11/2006 and revised on 03/2012 stated in part: The dietary department will hold, transfer and dispose of garbage and refuse in a manner that does not create a nuisance or a breeding place for insect and rodents or otherwise permit transmission of disease Proper disposal of garbage and refuse are required to protect food and equipment from contamination. Insects and rodents and other pets are less likely to be attracted when garbage and refuse are properly managed Dumpster lids and doors must be kept closed when not in use. Garbage pick-up should prevent odors and conditions that would promote the harboring of insects and rodents frequent enough to prevent objectionable odors that would promote the harboring of insects and rodents . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 24 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0814 A record review of the August 2021 version of the TFER reflected the following: Level of Harm - Minimal harm or potential for actual harm (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. Residents Affected - Some Record review of the Food Code, U.S. Public Health Services, U.S. FDA, 2017, U.S. Department of H&HS, 5-501.110 Storing Refuse, Recyclables, and Returnables, revealed Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 25 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 observation, interview, 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 19 residents (Resident #37) reviewed for infection control in that: Residents Affected - Some The facility failed to ensure RN R used proper infection control protocol as evidenced by the following failures: 1. Completed wound care on the floor. 2. Stepped on the wax paper several times that she had on the floor with wound care supplies on it. 3. Contaminated clean gloves. 4. Used a towel from the sink during wound care. 5. Threw trash onto the floor on top of the wax paper mixing clean and dirty supplies. 6. Used a piece of discarded wrapper to apply ointment to a wound. 7. Touched a sink handle with her bare hands after washing them. These deficient practices could place residents who received wound care at risk for infection. The findings were: Record review of Resident #37's admission record, dated 09/29/22, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that cellulitis of unspecified part of limb (A serious bacterial infection of the skin.), peripheral vascular disease (affects the blood vessels), and pressure ulcer of the left heel stage 4. Record review of Resident #37's wound care orders, dated 09/29/2022, revealed Site 3 (non pressure wound to left medial ankle) Continue Hypochlorite Gel (Anasept) Once Daily 9, Collagen Powder Once Daily for 9 (days), Discontinue Alginate Calcium w/silver. Continue Gauze Roll (Kerlix) 3.4 Once Daily for 9 (days), ACE Bandage 6 Once Weekly for 9 (days). Site 10 (Venous wound to left proximal dorsal foot) Continue Hypochlorite Gel (Anasept) Once Daily for 9 (days), Collagen Powder Once Daily for 9 (days), Discontinue Alginate Calcium w/silver, Continue Gauze Island w/ bdr Once Daily for 9 (days), Gauze Roll (Kerlix) 3.4 Once Daily 9 (days), ACE Bandage 6 Once Weekly 9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 26 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 Site 12 (non pressure wound to left posterior lateral leg) Level of Harm - Minimal harm or potential for actual harm Continue Hypochlorite Gel (Anasept) Once Daily for 9 (days), Collagen Powder Once Daily for 9 (days), Discontinue Alginate Calcium w/silver Continue Gauze Roll (Kerlix) 4.5 Once Daily for 9 (days), Gauze Island w/ bdr Once Daily for 16 (days). Residents Affected - Some Site 13 (Stage 4 pressure wound of left heel) add Sodium Hypochlorite Solution (Dakins), Once Daily, for 30 (days) Cleanse wound prior to tx (treatment) application and as needed, pack with lightly soaked gauze. Continue Alginate Calcium w/silver Once Daily for 16 (days) and continue Santyl Once Daily for 16 (days). Discontinue Betadine. Continue Gauze Roll (Kerlix) 4.5 Once Daily for 16 (days). No orders were provided or found for wound care performed on the right leg. Record review of Resident 37's Order Summary, dated 09/29/22, start date 09/22/22 and end date 10/22/22. The order did not match the physicians' last orders. It stated stage 4 wound left posterior heel, cleanse with NS, wound cleanser pat dry apply betadine, Santyl, calcium alginate with silver, and wrap with gauze roll daily. Every day shift for wound healing for 30 Days. An Observation on 09/30/22 at 9:12 a.m. revealed Preparation: Resident #37 was sitting in a wheelchair near his bed. RN R placed wax paper on the floor in front of Resident #37's wheelchair and on a bedside table near the foot of the bed. RN R went to the nurse's cart and pulled out 3 plastic medicine cups. RN R placed Santyl ointment in one cup, placed her bare hand over the next cup, positioned a spray bottle sodium hypochlorite solution under her hand, and began to spray the sodium hypochlorite solution into the medicine cup. RN R sprayed derm cleanse, containing Benzethonium chloride, into a 3rd medicine cup (no order for this). No hand hygiene was performed, and no gloves were worn. RN R gathered various supplies in her arms, held them against her body, and brought them to the bedside table in Resident 37's room. RN R performed hand hygiene, then touched a light cord to turn on a light, and moved and locked the Resident's wheelchair. RN R went back to the nurse's cart, and poured Hibiclens, containing chlorhexidine gluconate, into a medicine cup (no order for this). RN R went to the sink, turned on the water, returned to wax paper on the floor, and placed a towel and clean gloves on the wax paper. RN N went back to the nurse cart, grabbed scissors, and placed them on the wax paper on the floor. RN R took a towel to the sink and placed in in the sink. RN R donned gloves. RN R brought the towel to Resident 37 and asked him to feel it. Resident 37 touched the wet towel. RN R opened a trash bag and placed it under Resident 37's right foot. Site Right leg: LVN T performed hand hygiene, donned clean gloves, knelt on the ground, and held the Resident's right leg. RN R cut bandage dated 9/29/22 off the right foot with non-sanitized scissors. RN R removed her gloves, sanitized her hands, and donned clean gloves from a box on the floor. RN R dampened a gauze with chlorhexidine gluconate solution, wiped the Resident's right leg, and used the contaminated washcloth from the sink to wipe the Resident's right leg and foot. RN R moved quickly while cleaning Resident #37's leg, with a gauze with unknown solution, stating she cleaned from inside out, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 27 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - Some then wiped the leg with a dry washcloth. RN R rolled up the wax paper on the floor with discarded trash and threw it away. RN R slid over another piece of wax paper on the floor from behind her, to in front of the Resident's wheelchair. RN R removed gloves, sanitized her hands, touched her jeans, and donned clean gloves. RN R picked up collagen gauze and places on the wax paper on the floor. RN R stated she could not use an island dressing for wounds on the Resident's right leg because the coban wrap she planned to use, instead of the ACE wrap, will trap moisture. RN R then stepped on the wax paper on the floor. RN R grabbed gauze, from the contaminated wax paper, applied skin prep around wounds on the right leg, and placed dry gauze on them. RN R wrapped the Resident's right leg up to his knee with a medicated gauze wrap, containing zinc and calamine dermerite, then applied a dry gauze wrap, and coban instead of an ACE wrap (no order for this). Site 3, 10, 12, and 13: RN R then removed her gloves, went to the bathroom sink, washed her hands, and touched the handle with her bare hand to turn off the water. RN R grabbed a trash bag off her cart, brought in another package of coban, placed boxes of gloves on the floor, kicked the box out of the way. RN R adjusted the Resident's wheelchair. RN R put wax paper from the Resident's bed onto the floor, placed a sheet or pillowcase on the floor, used alcohol wipes to clean scissors. LVN T and RN R both lifted the Resident's left leg and placed a trash bag under it, removed the ace bandage, and cut coban off the left leg. RN R stepped on wax paper, removed gauze from wounds on the Resident's left leg, used trash bag to pick gauze off Resident's foot, removed and threw gloves into trash bag under Resident's foot, sanitized her hands, applied new gloves, dipped gauze into chlorhexidine gluconate solution (no order), placed cup of liquid on the floor on top of contaminated wax paper, poured liquid onto leg, removed bandages, removed bandage from left heel, wiped with chlorhexidine gluconate gauze (no order), touched wound areas with gloved hand and poured saline onto left bottom of Resident's foot while moving hand to splash solution on to the bottom of the foot. RN R removed gloves, sanitized hands, and donned new gloves. LVN T continued to hold Resident's leg up. RN R stated the bottom heel of the left foot got the dikins solution applied. RN R placed gauze on it and held it on the left foot. RN R has a pair of new clean gloves in her hand and was touching them directly on the floor. RN R stood up and placed contaminated gloves under her arm in her arm pit, sanitized her hands, touched gauze on table, opened a skin prep, sanitized hands, put contaminated gloves from under arm pits on. RN R returned to wax paper on the floor, opened calcium alginate and collagen pads, and placed them on contaminated wax paper. RN R removed gauze with dikins on it, used a piece of a package from the trash pile on the floor to apply ointment to the Resident's left foot wound, put a dry gauze pad on the left foot, then a stained gauze back on the foot, and dropped alginate gauze. LVN T removed gloves, sanitized hands, and grabbed a new alginate gauze. LVN T donned clean gloves. RN R pressed alginate gauze pad into left heel, placed towel from residents lap under left foot, removed gloves, sanitized hands, put wax paper on the floor, put betadine into cup on the floor (no order), grabbed gloves from box on the floor, sanitized hands, donned clean gloves, opened dry gauze roll, opened gauze wrap with zinc and calamine dermerite (no order), wrapped up all stuff on the floor into wax paper including a cup of betadine (never used the betadine), spilled betadine all over floor, used pillow case to clean up floor, put wax paper on the floor, washed hands, touched sink handle with bare hands to turn off the water, went to get cups off cart, sprayed saline into cups, held gauze packages under arm, brought in cup of saline, sanitized hands, donned clean gloves, bunched up a trash bag in her hands, opened gauze placed in it in cup with spray/liquid/clear, moved wax paper across the floor with supplies on it, put another trash bag under residents left leg, removed gloves, sanitized hands, donned gloves, placed cups of gauze and liquid inside each other, moved down to floor separated the cups, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 28 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 - Some removed dressing from left anterior ankle area, removed gloves, sanitized hands, donned gloves, cleansed left posterior ankle area wound with saline, removed gloves, no hand hygiene, donned clean gloves, threw dirty gloves onto floor next to clean supplies. RN R removed the trash bag from under the Resident's foot, picked up wax paper off the floor, and placed it under the Resident's foot. Sanitized hands, donned gloves, moved wax paper from floor behind her with supplies on it to in front of her by resident. RN R opened the calcium alginate gauze package, and stated she will put calcium alginate first, then the collagen pad, tore the medicated pads in half. LVN T continued holding Resident 37's left leg. RN R threw some supplies into trash can behind her, removed a skin prep from package, rubbed it around wound on left anterior ankle area, placed calcium alginate gauze in wound, then collagen gauze, covered with dry gauze, applied alginate to left posterior ankle area, then collagen was packed into wound covered with dry gauze. RN R removed gloves, sanitized hands, donned gloves, placed alginate and collagen to wound on left posterior side of foot, covered with dry gauze, wrapped foot with zinc calamine dermerite gauze wrap (no order), then wrapped left leg up to knee with dry gauze roll, and the wrapped left leg up to knee in coban (no order). RN N did not date any bandages. During an interview on, 09/30/22, 10:21 a.m., RN R stated normally Resident #37 would be in bed the hours between 3:30 a.m. and 6:00 a.m. and she tried to do wound care at that time. She stated she also performed wound care while the resident was in the shower. RN R stated if it had a barrier, the stuff on the ground was clean. RN R stated if she stepped on the wax paper it was dirty. RN R denied using the towel from the sink on the Resident's legs during wound care. When asked why she used the wrap containing zinc calamine dermerite she stated she would call the doctor and have him add it to the order. She stated she could not use an island dressing under the wrap and she will have the doctor modify the orders. She stated she liked to alternate between the ACE wrap and coban because it was a better barrier. When asked about using contaminated gloves during wound care she stated they are dirty wounds. If she dropped it or held it under her arm she was still in a dirty area. She stated she did catch that she stepped on one of the wax papers. She stated it was best practice to do wound care on the Resident in the bed and not on the floor. She stated normally she used a wooden spoon or a sterile 4x4 to apply ointment to a wound, but she used a 2x2 package to measure how much ointment she would apply. During an interview on, 09/29/22, at 10:48 a.m., the DON stated typically the bedside table was disinfected and used for wound care. She stated there would never be a time they would set up wound care on the floor because the floor was not a clean area. The DON stated there was risk for infection when doing wound care on the floor. The DON stated they should always follow physician's orders and if they have a question, they should contact the physician and clarify it. The DON stated not following proper wound care techniques and orders could place the Resident at risk of a multitude of things including worsening wounds and infections. Record review of facility policy titled Wound Management dated 02/07/2019, stated To promote wound healing of various types of wounds .1. Wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change .6. Guidelines for dressing selection may be utilized in obtaining physician orders .c. The facility will follow specific physician orders for providing wound care. Record review of facility policy titled Infection Control Guidelines, dated 09/22/2017, stated The purpose for this policy is to reduce and prevent the spread of infections by the use of evidenced based techniques established infection control policies and procedures .3 .c. Direct care staff use infection control practices in patient care procedures established to prevent spread of microorganisms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 29 of 30 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 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 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 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to maintain the required minimum of 12 hours annual in-service records for 7 of 7 CNAs (CNAs G, H, I, J, K, L, and M) records reviewed for staff training. Residents Affected - Some The facility failed to provide CNAs G, H, I, J, K, L, and M with 12 hours of in-service training per year. This failure could place residents at risk of being cared for by untrained staff. Findings included: Record review of training hours for CNAs G, H, I, J, K, L, and M, on 09/30/22 revealed: CMA G had a hire date of 09/15/17 and had 9.25 hours of training in the past year. The training transcript did not include evidence of training in abuse, dementia, QAPI, Ethics, Behavioral Health or Emergency Preparedness. CNA H had a hire date of 01/07/21 and had 1 hour of training in the past year. The training transcript did not include evidence of training in communication, resident rights, abuse, dementia, QAPI, ethics, behavioral health, falls, restraints or emergency preparedness. CNA I had a hire date of 09/30/15 and had 8.25 hours of training in the past year. The training transcript did not include evidence of training in abuse, dementia, QAPI, ethics, behavioral health, falls or emergency preparedness. CNA J had a hire date of 08/16/11 and had 10.75 hours of training in the past year. The training transcript did not include evidence of training in communication, dementia, QAPI, ethics or emergency preparedness. CNA K had a hire date of 04/14/20 and had 10.50 hours of training in the past year. The training transcript did not include evidence of training in abuse, dementia, QAPI, ethics, behavioral health, falls, restraints or emergency preparedness. CNA L had a hire date of 09/24/19 and had 4.25 hours of training in the past year. The training transcript did not include evidence of training in resident rights, abuse, dementia QAPI, infection control, ethics, behavioral health, falls, restraints or emergency preparedness. CNA M had a hire date of 01/03/19 and had 4.25 hours of training in the past year. The training transcript did not include evidence of training in resident rights, abuse, dementia, QAPI, infection control, ethics, behavioral health, falls, restraints or emergency preparedness. An interview with the ADM on 09/30/22 at 5:00 PM revealed that the corporation chose to use an online training program whereby staff could do the training either at work or at home. The ADM, who was hired in March 2022, stated he did not realize that staff had not met the required training hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 30 of 30