Inspection·September 21, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some floor. [Resident #1] was assessed befpre rolling him on his back. Upon assesment, a skin tear was observed to left upper eye, which was cleaned and steristrips was placed. Skin tears were noted to left hand/wrist and bruising to bilateral hand/writs. [Resident #1] was assisted back to bed and is being monitired. [Resident #1] is AAOx1, and does not know wat happened . Nuero checks in progress. Review of Resident #1's neurological assessments, dated 08/15/2023, reflected completed assessments on 08/15/2023 at 1:30 PM, 1:45 PM and 2:00 PM, 08/16/2023 at 12:00 AM and 2:15 PM, and 08/17/2023 at 2:15 PM. There were incomplete assessments dated 08/15/2023 at 2:45 PM, 3:15 PM, 4:15 PM, 5:15 PM, 6:15 PM and 7:15 PM; they were missing Resident #1's current orientation, level of consciousness, pupil sizes, responses, pain level, and range of movement. Review of Resident #1's incident report, dated 08/29/2023 and completed by LVN B, reflected the following: [Resident #1] had an unwitnessed fall in which a CNA found him seated on the floor in another resident's room with his back and head laying against the wall and facing the lower side of the bed (facing dressers). She (CNA) immediately reported to the charge nurse (LVN B), who quickly moved into the room to assess [Resident #1] and ascertain any injuries he sustained. [Resident #1] told staff he wanted to get to bed. [Resident #1] was assessed by the charge nurse (LVN B), denied pain, and upon assessment, found to have two hematomas (abrasions) on the back of his head. Review of Resident #1's neurological assessments, dated 08/29/2023, reflected staff completed assessments on 08/29/2023 at 4:30 PM, 4:45 PM, 5:00 PM, 5:15 PM and 5:45 PM. There were incomplete assessments dated 08/29/2023 at 6:15 PM, 7:15 PM, 8:15 PM and 9:15 PM; they were missing Resident #1's current orientation, level of consciousness, pupil sizes, responses, pain level, and range of movement. Review of Resident #1's incident report, dated 09/14/2023 and completed by LVN B reflected the following: A nurse aide called the charge nurse (LVN B) and informed her that she found [Resident #1] on the hallway by the television area bleeding from his forehead. The charge nurse (LVN B) immediately ran to [Resident #1] and put pressure on his wound opening/injury to stop the bleeding and she called for help from the other staff. [Resident #1] told staff he fell and had a head injury. Staff called EMS and had [Resident #1] taken to the hospital for further diagnosis and evaluation. Review of Resident #1's neurological assessments, dated 09/14/2023, reflected staff completed assessments on 09/14/2023 at 9:45 PM, 10:45 PM and 11:45 PM, 09/15/2023 at 12:45 AM, 4:35 AM and 12:35 PM, 09/16/2023 at 1:00 AM, and 09/17/2023 2:08 AM. There were incomplete assessments dated 09/14/2023 at 5:00 PM, 5:15 PM, 5:30 PM, 5:45 PM, 6:15 PM, 6:45 PM, 7:45 PM and 8:45 PM; they were missing Resident #1's current orientation, level of consciousness, pupil sizes, responses, pain level, and range of movement. During an observation and interview on 09/21/2023 at 1:59 PM, Resident #1 was sitting in his wheelchair in the secure unit's living area. Resident #1 had a laceration on the right side of his forehead and bruises on the right side of his face. Resident #1 was unable to answer any questions. During an interview on 09/21/2023 at 2:02 PM, LVN A stated on 08/15/2023, Resident #1 tried to get out of bed by himself and fell. LVN A stated she was not working on the days Resident #1 had his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 2 of 4 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 09/21/2023 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 - Some subsequent falls. LVN A stated Resident #1 often tried to get up on his own. LVN A stated Resident #1's other falls were due to him trying to get up on his own. LVN A stated staff checked on Resident #1 every two hours or more. LVN A stated LVNs completed neurological assessments for 72 hours after a resident had an unwitnessed fall. LVN A stated she was trained and in-serviced on abuse, neglect, falls, neurological checks, and resident rights. LVN A stated if a resident was observed on the ground, she was trained to assess the resident, notify staff for assistance, assess the resident's head and pain levels, and notify all appropriate parties. During an interview on 09/21/2023 at 2:22 PM, CNA A stated on 09/14/2023, Resident #1 was taking off his shoes in the hallway. CNA A stated she took Resident #1's shoes and placed them on a nearby table. CNA A stated she had her back to Resident #1 when she placed his shoes on the table. CNA A stated as she turned back around, she observed Resident #1 on the ground. CNA A stated she notified an LVN and another CNA. CNA A stated the LVN put pressure on Resident #1's head and staff notified EMS. CNA A stated on 08/29/2023, Resident #1 attempted to get out of bed on his own, fell on his right side, and sustained bruises to the right side of his body. CNA A stated she often checked on Resident #1. CNA A stated LVNs conducted neurological checks on residents after they had a fall. During an interview on 09/21/2023 at 3:18 PM, DON stated Resident #1 often tried to get up from his bed and chair on his own. DON stated on 09/14/2023, Resident #1 was in the hallway near the dining area in the secure unit. DON stated a nurse aide was completing documentation when Resident #1 fell on the right side of his body. DON stated staff notified EMS, Resident #1 was transported to the hospital, obtained sutures to his laceration injury, and returned to the facility. DON stated she investigated the fall incident. DON stated Resident #1 could not recall his fall on 09/14/2023. DON stated she knew the neurological checks were incomplete. DON stated she did not know why the neurological checks were incomplete. DON stated she trained staff on how to complete neurological checks. During an interview on 09/21/2023 at 3:39 PM, ADM stated he was notified of Resident #1's falls on 08/15/2023, 08/29/2023, and 09/14/2023. ADM stated he was shocked the neurological checks were not completely documented. She stated a negative outcome could be a serious injury going unnoticed. Review of the facility in-services from August 2023 through September 2023 reflected staff were trained on call lights on 08/18/2023 and abuse, neglect, and resident rights on 09/08/2023. There were no in-services given to staff regarding neurological assessments. Review of the facility's neurological assessment policy and procedure, dated 04/29/2014, reflected the following: 1. Complete and document neurological assessments as indicated on Neurological Assessment Flow Sheet. Complete neurologic assessments for 72 hours and PRN with vital signs every 15 minutes for 1 hour, then every hour for 4 hours, then every eight hours for 72 hours. 2. Complete Neurological assessment with vital signs every 15 minutes times 4 equaling 1 hour, then every hour times 4 equaling 4 hours, then every 8 hours times 9 equaling a minimum of 72 hours. 3. More frequent or continued neurologic assessments may be indicated and conducted as assessment findings compared to prior assessments and evaluated. 4. Observe for any changes from baseline assessment such as refusal to eat, drink, restlessness, confusion, drowsiness or other progressive deterioration. Continue to compare assessment findings (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 3 of 4 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 09/21/2023 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 against prior assessments to determine if there has been a change. Compare current assessments to baseline assessments done prior to the incident/occurrence to determine if there is a neurological change. The elderly may experience neurologic changes later than younger people. Assessing for a minimum of 72 hours allows for possible changes to be documented and reported. Residents Affected - Some 8. Communicate episode and actions taken and to be taken using Center specific systems such as shiftto-shift verbal report, 24-hour report, and daily stand-up meetings, and alert charting. Suggested Documentation o Completion of assessment o Notification of Family/Legal representative, Physician notification, abnormal assessment findings, diagnostic studies ordered by Physician, and response to interventions. Review of the facility's fall management system policy and procedure, dated 02/19/2021, reflected the following: Procedure: D. Documentation requirements for residents sustaining a fall: 3. The licensed nurse will assess and document the condition of the resident at least once per shift for at least 72 hours post fall. 5. Un-witnessed falls are considered potential head injury and require completion of Neurochecks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 4 of 4