Inspection·December 23, 2023

F 0558 the resident's right side. The call light button was not in RES #18's reach. Level of Harm - Minimal harm or potential for actual harm Observations and interview on 11/29/2023 at 8:28 AM reflected RES #18's call light button was clipped to the pull string that controlled the wall light behind RES #18's bed. The call light button was 3-4 feet from resident and was unreachable. Resident stated the call light being placed so far away from him makes him feel terrible. Residents Affected - Some Observation on 11/29/23 at 9:38 AM reflected RES #18's call light button was clipped to the pull string that controlled the wall light behind RES #18's bed. Call device out of reach hanging on a light switch 3-4 feet from resident. Record review of RES #35's AR, dated 11/28/2023, reflected RES #35 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #35 was diagnosed with Chronic Obstructive Pulmonary Disease (which caused airflow blockage and breathing related problems), Cognitive Communication Deficit (which caused difficulty with thinking and how someone uses language) history of falling and acquired absence of right leg above knee. Record review of RES #35's Annual MDS, dated [DATE], reflected RES #35 was not assigned a BIMS Score; instead, RES #35 had a Staff Assessment for Mental Status, which indicated a score of 3. A Staff Assessment for Mental Status which resulted in a score of 3 indicated that RES #35 's cognitive skills regarding tasks of daily life were moderately impaired. Moderately impaired indicated decisions are poor / cures and supervision required. Record review of RES #35's CP indicated a focus area for ADL Self Care initiated on 2/4/2021. The goal for the Focus area, revised on 8/24/2023 with a target date of 10/6/2023, indicated RES #35 would maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date. The intervention for the CNA, initiated on 4/16/2021, was to encourage resident to use call light to call for assistance before attempting any activities of daily living that resident cannot do independently. RES #35's CP indicated a Focus area for impaired respiratory status initiated 6/14/2022. The goals for the Focus area, revised on 8/24/2023 with a target date of 10/6/2023 indicated (1) RES #35 would not have reports of unrelieved shortness of breath through the next review date; (2) RES #35 would not have reports of increase anxiety due to shortness of breath through the next review date; and (3) RES #35 would not have signs or symptoms of pneumonia through the next review date. The intervention for the CNA, initiated on 6/14/2022 was to encourage and remind RES #35 to use call light to call top report of shortness of breath immediately. RES #35's CP indicated a Focus area for Behavioral problems, initiated on 9/18/2023, evidence from resident removing his call white from reach and placing it on the floor. The goals for the Focus area, initiated on 9/18/2023 with a target date of 10/6/2023, indicated RES #35's behaviors would not interfere with the delivery of ADL care by staff through the next review date. The interventions for the CNA, initiated on 9/18/2023, was for staff to monitor the call light placement and place within reach as needed. RES #35's CP indicated a Focus area for Falls initiated on 2/4/2021. The goals for the Focus area, revised on 8/24/2023 with a target date of 10/6/2023, indicated RES #35's behaviors would not sustain a fall related injury by utilizing fall precautions through the next review date. The interventions for the CNA, initiated on 2/4/2021, was to keep call light within reach when in bed. Observations on 11/27/23 at 12:21 PM reflected RES #35's call light button was on the floor under the bed on the resident's right side. The call light button was not in Res #35's reach. Observations and interview on 11/27/23 at 02:15 PM reflected RES #35's call light button was on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 2 of 29 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 12/23/2023 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some floor under the bed on the resident's right side. RES #35 was observed pulling at his privacy curtain and communicated through tone (verbal sounds) and body language (motioning towards the cord protruding from the wall) that he was looking for his call light button. RES #35 was cued to the location of his call light button, and he attempted to it reach it, but it was too far from his reach. RES #35 's call light button was clipped to the bottom portion of his bed without enough slack between the clip and the actual button to reach the level of RES #35's bed. RES #35 did not appear to be happy, but seemed to appear more secure when he was able to secure the call light button in his hand. After he had his call light in his hand, he was observed back under the covers resting. Record review of RES #7's AR, dated 11/28/2023, reflected RES #7 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #7 was diagnosed with Unspecified Dementia (a description for when a person lost the ability to think, remember, learn, make decisions, and solve problems), Muscle wasting and muscle deterioration, Difficulty Walking; and history of falling. Record review of RES #7's Quarterly MDS, dated [DATE], reflected RES #7 had a BIMS Score of 00. A BIMS Score of 00 indicated RES #7 had severe cognitive impairment. Record review of RES # 7's CP indicated a focus area for altered cardiovascular status initiated on 6/14/2022. The goal for the Focus area, revised on 9/1/2023 with a target date of 11/11/2023, indicated RES # 35 (1) RES # 7 would be free from signs and symptoms of complications of cardiac problems to the next review date; (2) RES # 7 will exhibit reduction of cardiac symptoms through the review date; (3) and RES # 7 will have an understanding of the disease process and the importance of compliance with treatment as evidenced by verbal feedback and compliance with treatment through the review date. The intervention for the CNA, initiated on 6/14/2022 was to enforce the need to call for assistance if pain starts. Record review of RES # 7's CP indicated a focus area for ADL Self Care initiated on 1/7/2019. The goal for the Focus area, revised on 9/1/2023 with a target date of 11/11/2023, indicated RES # 7 would maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene through the next review date. The intervention for the CNA, revised on 6/2/2021, was to encourage resident to use bell to call for assistance before attempting any ADLs that resident cannot do independently. RES # 7's CP indicated a Focus area for Behavioral problems, initiated on 9/18/2023, evidenced by resident removing his call white from reach and placing it on the floor. The goals for the Focus area, initiated on 9/18/2023 with a target date of 11/11/2023, indicated Res # 7's behaviors will not interfere with the delivery of ADSL care by staff through the next review date. The interventions for the CNA, initiated on 9/18/2023, was for staff to monitor the call light placement and place within reach as needed. RES # 7's CP indicated a Focus area for Falls initiated on 6/20/2022. The goals for the Focus area, initiated on 9/1/2023 with a target date of 11/11/2023, indicated Res # 7's will not sustain a fall related injury by utilizing fall precautions through next review date. The interventions for the CNA, revised on 6/2/2021 was for staff to make sure you residents call light is within reach and encourage the resident to use it for assistance as needed. Observations on 11/28/23 at 8:35 AM reflected RES # 7's call light button was on the far end of his bed near his left shin. The call light button did was not in RES #7's reach. Observations on 11/28/23 at 11:19 AM reflected RES # 7's call light button was on the far end of his bed near his left shin. The call light button did was not in RES #7's reach. Observations and interview on 11/29/23 at 8:25 AM reflected RES # 7's call light button was on the far end of his bed near his left knee. The call light button was clipped to the blanket and was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 3 of 29 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 12/23/2023 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in reach. Res # 7 was able to verbalize that he gets mad when the call light button is not close enough for him to reach. Interview on 11/29/2023 at 10:40 AM with LVN A revealed Call lights were supposed to be in arms reach of the resident, whether they are in bed or in a chair. LVN A stated that staff have been instructed to go through the rooms every other hour to make sure the call light buttons are in the proper place. LVN A stated call lights were important so residents can call for help if they need something. Interview in 11/29/2023 at 3:45 PM with the DON revealed that call light buttons were used by the residents to call staff if they needed any help. The staff were trained to place the call button within arm's reach of the residents whether they are in bed or in a chair. If a resident could not reach their call light button, the DON stated the resident might try to reach for it and have an accident; may have wet clothes that could lead to skin breakdown; or get angry or frustrated because they could not call for help. Interview on 11/29/2023 with the ADM revealed call light buttons were used for resident to call for staff's help if they needed something. If the call light was not near the resident, the ADM stated a resident has the potential for falls and skin breakdown. The ADM stated the responsibility for call light placement is the last person in the room with the resident. Record review of the facility's Call Light Response, dated 2/10/2021 reflected that (1) all staff will be educated on the proper use of the resident call system, including how the system works in ensuring resident access to the call light; (2) all residents will be educated on how to call for help using the resident call system; (3) each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system; and (4) With each interaction in the residence room or bathroom, staff will ensure the call light is within reach of the resident and secured, as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 4 of 29 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 12/23/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, interviews, and record review, the facility failed ensure residents had the right to be free from sexual abuse for 3 of 7 residents (RES #40, RES #18, and RES #27) who were investigated for sexual abuse. 1. The facility failed to stop RES #28 from having climbed into RES #18's bed and having sexually touched RES #18 penis on 9/7/2023, which prompted to a law enforcement investigation, a facility self-reported incident of Resident Abuse, with no care plan update for behaviors to protect residents from further abuse. RES #18's LAR expressed RES #18 had no known history of homosexual behaviors. 2. The facility failed to stop RES #18 from having reached out and having grabbed RES #27's left breast on 11/20/2023, which led to a facility self-reported incident of Resident Abuse with no care plan update for RES #18's behaviors to protect residents from further abuse. RES #27 expressed that she did not remember the incident and maybe it was a good thing that I do not remember. 3. The facility failed to stop RES #28 from initially having kissed RES #40 on 8/3/2023, which did not prompt a care plan update for RES #28 inappropriate sexual behaviors to protect residents from further abuse or a facility self-reported incident for RES #28's behaviors; the facility failed to stop RES #28 from having kissed RES #40 a second time, on 9/29/2023, after the facility was aware of RES #28's previously known inappropriat sexual behaviors. While RES #40 recalled the second kissing incident but was unable to verbally express details, having had severely impaired cognitive impairment and having applied the reasonable person concept, RES #40 would not want a man having approached and kissed her on two separate occasions. An IJ, Immediate Jeopardy, was identified on 12/22/2023 at 6:30 PM. While the IJ was removed on 12/23/2023 at 4:00 PM, the facility remained out of compliance at a scope of pattern that was actual harm, due to the facility's need to protect its residents from sexual abuse. This failure placed residents in the facility at risk for sexual abuse. Findings included: Record review of the facility's PIR dated 9/7/2023, reflected RES #28 was observed in RES # 18's bed spooning, which was two bodies lying against each other, while masturbating on 9-7-2023 at 9:10 PM. The residents were immediately separated, police were called, and responded, then RES #28 was placed on ono-on-one supervision. RES #18 received a skin assessment by the ADON, which included an assessment of buttocks and penis. The assessment for RES #18 reflected no trauma. Staff were in-serviced on ANE; Residents were interviewed with no issues identified; Staff were interviewed with no issues identified; and RES #28 voluntarily admitted to a psych hospital on 9/8/2023. Attached to the PIR were signed statements from the ADM, DON, ADON, and SS. The narrative of the statements reflected CNA A entered RES #28 and RES #18's room on 9-7-2023 around 9:00 PM to 9:15 PM and discovered RES #28 laying behind RES #18 in RES #18's bed. RES #28 was observed masturbating with one hand and grabbing RES #18's penis with his other hand. The narrative continued where LVN D was notified and responded to enter RES #28 and RES #18's room. Upon entering, LVN D observed RES #28 laying behind RES #18 spooning. LVNA told RES #28 to get up and go back to bed, which he did. The narrative continued where the ADON was notified and responded to enter RES #28 and RES #18's room. RES #18 allegedly stated that someone crawled in bed with him, but could not remember who, and that he denied being in any pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 5 of 29 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 12/23/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some RES #28 stated that he and RES #18did not have sex, but that he, RES #28, only masturbated. Residents were separated, medically assessed, RES #28 placed on one-to-one, and police were notified. The narrative continued as the ADM wrote RES #18 showed no signs of psychological distress or pain since the incident. After multiple interviews, the ADM believed RES #28 was masturbating (on his own admission) and that RES #28 inappropriately touched RES #18. The narrative closed as the ADM stated disbelief that anything else happened between the two residents. The facility's PIR contained written interviews with CNA A, LVN D, SS, ADON, DON and the ADM. The PIR also contained RES #18's skin assessment performed by the ADON post incident on 9-7-2023. Record review of the facility's PIR dated 11/20/23 at 5:45 PM reflected RES #18 was observed reaching out and grabbing RES #27's left breast on 11/20/2023 at 4:15 PM on the facility's secure unit. The nurse immediately intervened and separated them; and no injuries for either resident. Staff received in-service for ANE; and RES #18 was to be kept more than an arms distance from other residents. Record review of RES # 27's AR, dated 11/28/2023, reflected RES # 27 was an [AGE] year-old female who was admitted to the facility on [DATE]. RES # 27 was diagnosed with (1) Alzheimer's Disease, which was a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment; and (2) Schizoaffective Disorder, which was a mental health disorder that is marked by a combination of hallucinations, delusions, depression, and mania. Record review of RES # 27's Quarterly MDS, dated [DATE], reflected RES # 27 had a BIMS of 8. A BIMS of 8 indicated RES # 27 had moderate cognitive impairment. Section E- Behaviors, RES #18 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #27 did not exhibit these behaviors. Record review of RES #27 CP, dated 7/10/2021, indicated RES #27 add a focus plan for behavior problems exhibited by problems associated with the cognitive decline related to Alzheimer's disease; (2) ineffective means to cope with individuals with moderate dementia; and (3) aggressive behaviors towards others due to confusion and related to dementia. Record review on 11/28/2023 of RES #27's medical records did not indicate and documentation that would suggest RES #27 possessed the cognitive ability to consent to sexual activity. Interview on 11/27/2023 at 2:28 PM with CNA B revealed staff were instructed to keep RES #18 separated from other residents after RES #18 reached out and grabbed Res #27's breast on 11/20/2023. CNA B stated staff keep a good eye on all the residents, since they were on the secure unit. Men were not allowed in women's rooms and women were not allowed in men's rooms. CNA B has been instructed that residents were not allowed to have sex. She had been instructed to intervene with residents engaged in sexual behaviors and redirect them to an alternate activity; also, to let the charge nurse know for follow up assessments. Interview on 11/27/2023 at 2:40 PM with RES #27 revealed she did not remember the incident where (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 6 of 29 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 12/23/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some RES #18 reached out and touched her breast. RES #27 stated maybe it was a good thing that I do not remember. RES #27 did not demonstrate anger and she stated she felt safe at the facility. RES #27 resided in the facility's secure unit. Record review of RES #18's AR, dated 11/28/2023, reflected RES #18 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #18 was diagnosed with (1) Transient Cerebral Ischemic Attack (a brief interruption of blood flow to the brain), Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), Vascular Dementia(a description for problems with reasoning, planning, judgment, memory and other thought processes R/T impaired blood flow to the brain), Unspecified Dementia (a description for when a person lost the ability to think, remember, learn, make decisions, and solve problems). Record review of RES #18's Quarterly MDS, dated [DATE], reflected RES #18 had a BIMS of 7. A BIMS of 7 indicated RES #18 had severe cognitive impairment. Section E- Behaviors, RES #18 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #18 did not exhibit these behaviors. Section GG- Functional Abilities and Goals, RES #18 was coded as an 88, eighty-eight, for lying to sitting on side of bed. A code of 88, eighty-eight, indicated RES #18 did not attempt this procedure due to medical condition of safety concerns. Record Review of RES #18's CP initiated a Focus for a behavioral problem on 9/20/2023 which indicated RES #18 inappropriately touched staff's breasts, buttocks, or used sexually inappropriate verbiage. The goal, with a target date of 2/01/2024, indicated RES #18's's behavior would not interfere with the delivery of care or services, or result in harm to self or others through the target date, 2/1/2024, called for interventions such as (1) administer medications as ordered. Monitor and document for effectiveness and potential side effects- initiated 9/20/2023; (2) assess and anticipate resident's needs; food, thirst, toileting needs, comfort level, body positioning, and pain- initiated 9/20/2023; (3) approach resident in calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing care, allow tie for a response, and do not rushinitiated 9/20/2023; (4) and give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the residents as possible- initiated9/20/2023. Record review of RES #18's medical records did not indicate any documentation that would suggest RES #18 possessed the cognitive ability to consent to sexual activity. Interview on 11/28/2023 at 8:24 AM with RES # 18 revealed RES #28, crawled into his bed. When RES #28 was in his bed touching his penis, he said he asked RES #28 to stop, but RES #28 did not stop. RES #18 stated he did not get hurt and he was only touched. RES #18 denied his anus was penetrated by RES #28's body parts. RES #18 felt safe at the facility. RES #18 remembered the incident where he reached out and grabbed RES #27's breast. RES #18 stated that he was sitting next to her and felt like grabbing her breast, so he did it. RES#18 and RES #27 both resided in the facility's secure unit on 11/20/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 7 of 29 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 12/23/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of RES #28's AR, dated 11/27/2023, reflected RES #28 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #28 was diagnosed with Schizophrenia (a serious mental illness that affected how a person thought, felt, and behaved), and Cognitive Communication Deficit (described as difficulty with a person's thought or how a person used language). Record review of RES #28's Quarterly MDS, dated [DATE], reflected RES #28 had a BIMS of 14. A BIMS of 14 indicated RES #28 was cognitively intact. Section E- Behaviors, RES #28 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #28 did not exhibit these behaviors. Section G- Functional Status , RES #28 was coded as 0, zero, for (1) bed mobility, which was how a resident moved to and from the lying position, turning side to side, and positioned body while in bed or alternative sleep furniture; (2) transfer, which was how a resident moved between surfaces to and from bed, chair, wheelchair, and standing; and (3) locomotion off the unit, which is how a resident move between locations in his room and adjacent corridor on same floor. A code of 0, zero, indicated RES #28 did not exhibit these behaviors performed independent, which meant no help or staff oversight needed. Record review of RES #28's CP did not reflect an intervention for resident-on-resident sexual abuse, which occurred on 9/7/2023 with RES #18. RES #28's CP did not reflect any interventions, for any sexual behaviors, directed towards any other residents for any previous incidents. Record review of RES #28's medical records did not indicate any documentation that would suggest RES #28 possessed the cognitive ability to consent to sexual activity. Interview on 11/28/2023 at 9:05 AM with RES #28 he revealed remembered the night when he crawled into his roommate's bed, RES #18, to engage in sexual activity. He stated, his penis did not penetrate his roommate; furthermore, there was only consensual touching. He thought it was ok to have sex in a nursing home. He stated no one ever told him he was not allowed to have sex or that he did not have the ability to consent. RES #28 did not think he was doing anything wrong. Afterwards, he thought he might have made a bad decision because everyone was asking questions, so he figured he was not supposed to do it again. He stated the DON told him he was not allowed to display sexual behaviors with anyone. RES #28 resided in his own private room since the resident-on-resident sexual abuse, with RES #18, on 9/7/2023. RES #28 stated he went to the psych hospital on 9/8/2023 and returned on 9/20/2023. Record review of RES #28's PN reflected (1) on 9/7/2023 at 9:20 PM entered by RN N, the PN indicated RES #28 was placed on one-to-one monitoring until further notice after the incident on 9-7-2023 with RES #18; (2) on 9/7/2023 at 2:00 AM entered by RN N, the PN indicated RES #28 was monitored one-to-one; (3) on 9/8/2023 at 11:13 entered by the DON, the PN indicated RES #28 continued one-to-one monitoring; (4) on 9/12/2023 at 6:04 PM entered by the SS, the PN indicated SS spoke to RES #28 on 9/8/2023, which regarded RES #28 and RES #18 being in bed on 9/7/2023. The PN reflected a discussion with RES #28 that addressed understanding of the events on 9/7/2023, mental confusion, and urges. The PN reflected the decision to send RES #28 to a psych hospital; (5) on 9/8/2023 at 9:37 PM entered by LVN M, the PN indicated RES #28 departed the facility to a psych hospital; and (6) on 9/20/2023 at 4:24 PM entered by LVN M, the PN indicated RES #28 readmitted to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 8 of 29 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 12/23/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview and record review on 11/28/2023 at 2:00 PM with CNA A revealed she entered RES #28 and RES #18's room on 9-7-2023 around 9:00 PM or 9:15 PM. CNA A stated she observed RES #28 and RES #18 spooning. RES #28's hand was on RES #18's penis. CNA A stated she immediately went to LVN D to let her know what happened in the resident's room. CNA A was presented with her written interviews with the ADM on 9/8/2023 and 9/13/2023 and concurred the interviews were accurate. Interview on 11/28/2023 2:35 PM with LPN A revealed residents on the secure unit were not allowed to have sexual contact. Men and women were not allowed in each other's rooms. RES #18 was supposed to be kept separated from other residents. LPN A has been instructed that residents are not allowed to have sex. The residents were constantly watched. Interview and record review on 11/28/2023 at 3:00 PM with LVN D revealed she responded to RES #28 and RES #18's room on 9/7/2023 after being told there was an incident by CNA A. LVN D stated she went to the room, saw RES #28 and RES #18 spooning with RES #28's hand on RES #18's penis. LVN D stated she separated the residents and informed the ADON of what had occurred. LVN D was presented with her written interviews with the ADM from 9/8/2023 and 9/12/2023 and concurred the interview were accurate. The last time LVN D saw RES #28 and RES #18 was at 8:30 PM, 9-7-2023, during med pass on the night of the incident. RES #28 and RES #18 were roommates up until that night. Res #18 moved to another hall the night of the incident. Interview on 11-29-2023 with the ADON at 3:30 PM revealed she worked on 9-7-2023 and responded to the incident with RES #18 and RES #28. She stated she made sure the residents were separated immediately and checked RES #18 for any harm, she stated she placed RES #28 on a one-to-one while she performed a skin check of RES #18's body, which revealed no trauma. The ADON stated she called the police, who responded. The ADON stated the officer learned of RES #18 and RES #28's diagnosis and determined it would be too hard to try to determine consent. The ADON stated RES# 28 had not demonstrated similar behaviors prior to 9/7/2023. Interview and record review on 11/29/23 at 3:45 PM with the DON revealed there was no mention of an intervention for RES #28's behavior on 9/7/2023 with RES #18 in RES #28's current CP. The DON stated there was an intervention in RES #28's CP, but it must have been deleted when he discharged to the psych hospital on 9/8/2023 at 9:27 PM. The DON stated his orders and CP were updated upon his return on 9-20-2023 at 4:24 PM, but the intervention for what happened on 9-7-2023 (between RES #28 and RES #18) must not have been added back. The DON revealed the ADM did not want to make every detail of the incident known to everyone who had access to RES #28's CP and wanted to protect RES #28's privacy. The DON stated the interventions put in place for RES #28, which were not in RES #28's CP current care plan on 11/28/2023, were for him to have his own private room, keep him out of other people's rooms, continued psychological services, and be watched for behaviors and redirect as needed. The DON stated that the interventions in place were working. The DON stated RES #28 was placed on a medication, on 9-29-2023, called Medroxy Progesterone Acetate 5 MG by mouth daily for impulse control (a libido reducing medication.) RES #28 and RES #18 had not been evaluated, prior to 9/7/2023, for the cognitive ability to consent to sexual activity. During the interview, the DON entered a Focus, Goal, and Intervention in RES #28's CP directed at Sexual Behaviors and how RES #28's Goal, having pertained to sexual behaviors, would not interfere with the delivery of ADL care by staff. The interventions were to (1) administer medications as ordered by the physician and monitor for effectiveness and potential adverse side effects; (2) monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log; (3) approach resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing care, allow time for a response, and do not rush.; and (4) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 9 of 29 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 12/23/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the resident as possible. The Focus, Goal, and Interventions, added to RES #28's CP on 11/29/2023 by the DON, were not the result of an IDT collaboration. The DON added them during the interview. The interview further revealed there was no intervention for RES #18's sexual behavior exhibited on 11/20/2023 in RES #18's CP. The DON stated RES #18 had exhibited groping behaviors with staff in the past and the behavior was annotated his CP on 9/20/2023; however, RES #18 having groped a resident on 11/20/2023 was a new behavior, and was not updated in RES #18's CP. The DON felt the interventions in place from 9/20/2023 would continue to provide safety to the resident, staff, and other residents. During the interview on 11/29/2023, the DON updated RES #18's CP, which addressed the Focus for behavioral problems evidenced by sexually inappropriately behaviors with a female resident witnessed by staff groping resident breast. The existing Goal from 9/20/2023 was that RES #18's behavior will not interfere with the delivery of care or services or result in harm to self or others, was not edited. The interventions, initiated on 11/29/2023, were to (1) provide resident with as many choices as possible with their daily cares and activities. Provide a program of activities that accommodates the residents cognitive and functional abilities; (2) intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others; and (3) Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. The Focus, Goal, and Interventions, added to RES #18's CP on 11/29/2023, were not the result of an IDT collaboration. The DON added them during the interview. Interview on 11/29/2023 at 4:43 PM with the ADM revealed he did not want to enter detailed information about RES #28's sexual behavior with RES #18, in his (RES #28) CP. The ADM stated he did not want everyone in the facility, with access to RES #28's CP, to have access to confidential information. The ADM stated he did not know PCC (which was the electronic platform to record facility documentation) very well and did not know why the intervention placed in RES #28's CP prior to his discharge to the psych hospital, on 9-8-2023, was not still on the care plan upon his return, on 9-20-2023. The ADM stated he feels the interventions in place, such as monitoring and redirecting as needed, were effective. The ADM considered the interaction with RES #18 and RES #28 on 9/7/2023 was consensual. Interview further revealed that the interventions in place for RES #18, such as keeping RES #18 at arm's length from other residents was working and was adequate to keep the staff and residents safe. The ADM was not aware that RS #18's care plan had not been updated for RES #18's recent behavior of groping a RES #27 on 11/20/2023. Interview on 11/30/2023 at 4:00 PM with LAR # 18 revealed the facility called her on the night on 9-7-2023 to let her know about the incident between RES# 18 and RES #28. LAR # 18 stated the initial call was made by an employee, whose name she could not recall, that stated RES #18 was heard calling out from the room on 9-7-2023; LAR # 18 stated that a secondary phone call, with the DON, also described RES #18 as having called out for help from his room on 9-7-2023. LAR # 18 expressed, to the best of her knowledge, that RES #18 had no known history of homosexual relations; furthermore, LAR # 18 expressed she did not believe that RES #18 consented to RES #28 having been in his bed and having touched his penis. Record Review on 11/30/2023 of RES #28's PN, entered on 10/2/2023 at 11:10 AM by the SS, reflected RES #28 was observed kissing a female resident (RES #40) on the mouth on 9/29/2023. The PN reflected the SS and the Administration spoke with RES #28 and RES #28 admitted he pecked a female resident (RES #40) on the mouth on 9/29/2023. A PN (regarded the kissing incident on 9/29/2023), entered on 10/2/2023 at 11:28 AM by the SS, reflected the SS gave RES #28 specific instructions on things that were not acceptable between him and other residents in the facility. SS informed RES #28 he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 10 of 29 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 12/23/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some was not allowed to kiss, touch, hug or have physical contact at any time. RES # 28 was educated to ask nursing staff, or management, questions about anything he thought of doing with another resident. RES #28 was made aware that more inappropriate incidents could initiate a transfer to another facility. RES # 28 acknowledge he understood and stated he did not want to leave the facility. A PN (regarded the kissing incident on 9/29/2023), entered on 10/2/2023 at 11:46 AM by the SS, reflected PS DR was contacted for a medication intervention and RES #28 moved to another room, away from the female resident he encountered (RES #40.) Record review of the facility's Abuse, Neglect, and Exploitation Policy dated, 10/24/2022, indicated it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. III. Prevention of Abuse, Neglect, and Exploitation The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a residence consensual sexual relationship and to the extent possible prevent sexual abuse. (1) The consent to sexual contact will be made by the social worker / designee completing an evaluation that determines the resident has capability to engage in consensual sexual contact, or (2) the residents representative agrees to the resident's participation in consensual sex contact, and (3) the documentation of a resident's capacity for consensual sex contact is located in the medical record. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident's property is suspected or identified by. (1) taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to residents or other residents, and (2) review and evaluation of like instances to determine if the appropriate actions to correct the noncompliance was taken and documented. V. Investigations of alleged Abuse, Neglect, and Exploitation A. An immediate thorough investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or exploitation occur. B. Abuse investigation procedure include, (1) Identifying staff responsible for the investigation, (2) exercising caution in handling evidence that could be used in a criminal investigation, (3) investigating different types of alleged violations, (4) identifying and interviewing all involved parties, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, (5) focusing the investigation on determining if the abuse, neglect, exploitation, and or mistreatment has occurred, the extent, and cause, and (6) providing complete and thorough documentation of the investigation. VI. Protection of Resident With facility makes efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 11 of 29 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 12/23/2023 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 0600 A. Responding immediately to protect the alleged victim and integrity of the investigation. Level of Harm - Immediate jeopardy to resident health or safety B. Physical exam of the alleged victim for any sign of injury. Residents Affected - Some D. Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator. C. Increase supervision of the alleged victim and residents. E. Protection from retaliation. F. Providing emotional support and counseling to the resident during and after the investigation, as needed. G. Revision of the residence care plan if the residents medical, nursing, physical, mental, or psychosocial needs or preferences change as the result of an incident of abuse. Record review of the facility's Abuse and Prevention and Reporting training, dated 9/8/2023, reflected 30 staff participated in the training. Record review of the facility's Resident's Rights and Sexual Survey, dated 9/8/2023, reflected 41 staff participated in the training. Record review of the facility's Safety Patient Questionnaire, dated 9-8-23, reflected the census for 9-8-2023 was 100 residents. The QAA Patient Questionnaire reflected a sample of twenty-seven residents who responded Yes- Do you feel safe at the facility; and responded No- Has a resident ever touched you in a manner that made you feel uncomfortable. Record review of the facility Quality Assurance Staff Questionnaire, dated 9-18-23, reflected 64 facility employees who responded No-have you ever seen a resident touch a female or male in an inappropriate manner; No-Are there any patients that touch another patient in an inappropriate manner; and No- Are there any patients that say sexually inappropriate things to another. Records review of RES #28's Order Summary Report indicated RES #28 was prescribed Medroxy Progesterone Acetate 5 MG by mouth every morning for impulse control disorder, which began on 9/29/2023. Record review of Local Police Department, Report #23-02094, dated 9/7/2023 at 10:15 PM reflected a visit by Police Officer A to the facility in response to sexual assault of a [AGE] year-old male. The report indicated that RES #18 was asked if he wanted RES #28 in his bed and RES #18's response was |I think so. | The report indicated that RES #18 has a long list of mental deficits to include Alzheimer's, dementia, cognitive communication; and RES #28 has also been diagnosed with a list of disorders to include Schizophrenia, cognitive communication deficit, and major depressive disorder. The closing statement on the report stated |With these disorders it was determined that it would be difficult to determine if there was consent or not. RES #18 was not given a sexual assault exam. Print out of each party`s diagnoses have been included with this report. My report has been uploaded; I have nothing further at this time. | Observations on 12/22/2023 at 8:29 AM of RES #28 reflected him having sat quietly on his bed, in his room watching TV, alone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 12 of 29 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 12/23/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 12/22/2023 at 8:30 AM with RES #28 revealed he had kissed RES #40 on 9/29/2023. After the kissing incident, which occurred on 9/29/2023, he stated he was approached by the SS, who explained that his behaviors were not acceptable. RES # 28 stated he was moved to a different room and that he started a new medication. RES # 28 thought the medication had helped him by reducing feelings of [NAME] and sexual desire, but he was still able to attain an erection and masturbate. RES #28 did not feel sedated, or different, because of the medication; in fact, RES #28 stated that his quality of life had improved. He denied any desires to kiss, or sexually touch, another resident since he started the medication on 9/29/2023. Record review on 12/22/2023 of RES #28's Medication Administration Record for December 2023, indicated RES #28 had received his Medroxy Progesterone Acetate 5 MG by mouth every morning for impulse control disorder. Interview on 12/22/2023 at 9:30 AM with NA A revealed that she had been working at facility as a NA since 12/18/2023. She was informed that there were residents in the facility that have displayed sexual behaviors in the past and that it could still happen. If she observed sexual behavior, she was instructed to get help immediately and report it to a charge nurse or the ADM. Interview on 12/22/2023 at 10:00 AM with the SS revealed RES #18, in general, possessed the cognitive faculties to consent to sexual activity; however, the SS was unable to determine if the interaction between RES #28 and RES #18, on the night of 9/7/2023, was consensual or not consensual. The SS stated she knew about the incident on 9/7/2023 but did not participate in an IDT meeting for an CP update. The SS stated that the incident, which occurred on 9/7/2023, between RES #28 and RES #18, should have received a CP update, to include a Focus, Goal, and Intervention. The SS stated she checked on RES #28 often, after the incident on 9/7/2023, and would redirect as needed. When asked, the SS was unable to elaborate on other staff's methods of intervention. When asked if resident #28 had displayed inappropriate FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 13 of 29 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 12/23/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for 1 (Resident #90) of 5 residents reviewed for baseline care plans. The facility failed to develop baseline care plans within the required 48-hour timeframe for Resident #90. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Review of Resident #90's face sheet dated 11/29/23 reflected Resident #90 was a [AGE] year-old female admitted on [DATE] with diagnoses including dysphagia (difficulty in swallowing), muscle wasting and atrophy (when muscles waste away, hypertension (high blood pressure), and pneumonitis (lung inflammation due to inhalation of food and vomit). Review of the admission MDS dated [DATE] reflected Resident #90 had a BIMS score of 11 indicating Resident #90 was moderately cognitively impaired. Resident # 90 was dependent on staff for toileting hygiene, showers, and upper and lower body dressing. Review of Resident #90's clinical record reviewed on 11/29/23 reflected a baseline care plan was not completed in the 48-hour timeframe. Baseline care plan was completed on 10/31/23. During an observation on 11/27/23 at 10:50 AM, Resident #90 was resting quietly in bed. Resident #90 appeared clean and comfortable with no sign of pain or distress noted. Resident #90 did not respond to verbal stimuli. Resident #90's room was clean and clutter free and the temperature was good. Resident #90's call light was in reach and head of bed was elevated. In an interview on 11/29/23 at 1:18 PM with the DON, she stated every resident that admitted to the facility should have had a baseline care plan completed within 24 to 48 hours. She stated she was responsible for completing the baseline care plans and the MDS nurse or charge nurses sometimes initiated a baseline care plan which she checked to ensure was done. She stated Resident #90's baseline care plan was completed late, and it should have been completed per policy. She stated staff responsible for completing care plans had been trained on baseline care plans. She stated if a baseline care plan was not completed in the expected timeframe, staff may not know the amount of care needed to be provided to care for residents correctly. In an interview on 11/29/23 at 1:25 PM with MDS A, she stated baseline care plans should have been completed for every resident that admitted to the facility. She stated baseline care plans should have been done within 24 to 48 hours after a resident admitted . She stated Resident #90's baseline care plan was completed on 10/31/23 and resident was admitted on [DATE] which meant the baseline care plan was done late. She stated the nurses completed the baseline care plans when they initiated an initial admission assessment after residents admitted into the facility. She stated if a baseline care plan was not completed for a resident it could be detrimental to the resident and an injury or health issue could have occurred. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 14 of 29 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 12/23/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 11/29/23 at 1:29 PM with MDS B, she stated baseline care plans should be completed within 24 to 48 hours for every resident that admitted into the facility. She stated if a resident did not have a baseline care plan completed, staff would not know what to do to care for the resident correctly and the baseline care plan was used as a guideline for the plan of care for the residents. In an interview on 11/29/23 at 1:35 PM with LVN C, she stated she completed baseline care plans for newly admitted residents which were assigned to her when she did the residents initial admission assessments. She stated if she could not get to a baseline care plan to complete it, the nurse on the following shift would try to get it done. She stated baseline care plans should have been done as soon as possible. She stated she had been trained on completing baseline care plans. She stated if a baseline care plan was not completed in a timely manner, the staff might have missed out on if a resident could feed themselves, if a resident was incontinent or not, or how much care a resident may have needed. Record review of the facility policy titled Baseline Care Plans dated 11/8/16 with a revision date of 05/13/21 Resident person centered baseline care plans are developed and implemented for new admission and readmission residents. Fundamental Information: Resident person centered baseline care plans communicate fundamental care approaches and goals for resident related clinical diagnosis, identified concerns and as a result of the admission evaluation/assessment of each healthcare discipline. The baseline care plans are inclusive to support effective individualized resident care that meet professional standards of quality care and services. Baseline care plans are developed and implemented within 48 hours of a resident new admission and/or readmission. The baseline care plans includes measurable objectives to address the residents' immediate medical, clinical, functional, mental, and psychosocial person centered needs. Process: The baseline care plans will be developed and implemented from minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders, admission evaluation/assessments, physician orders, dietary orders, therapy services, social services, and resident choices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 15 of 29 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 12/23/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop, update, and implement a comprehensive person-centered care plan for each resident, after four separate instances of resident abuse, that included measurable objectives and time frames to meet a resident medical, nursing, mental, and psychosocial needs for 2 of 7 residents (Resident #28 and RES #18) whose CPs were reviewed for regulatory compliance. The facility failed to update RES #28 and RES #18's CP after four separate incidents of sexual abuse: 1. The facility failed to update RES #28's CP after having climbed into RES #18's bed and having sexually touched RES #18 penis on 9-7-2023. 2. The facility failed to update RES #28's CP after having kissed RES #40 on 8-3-2023 and after having kissed RES #40 on 9-29-2023. 3. The facility failed to update RES #18's CP after having reached out and having grabbed RES #27's left breast on 11-20-2023. An IJ, Immediate Jeopardy, was identified on 12/22/2023 at 6:30 PM. While the IJ was removed on 12/23/2023 at 4:00 PM, the facility remained out of compliance at a scope of pattern that was actual harm, due to the facility's need to protect its residents through measurable Focus, Goals, and Interventions in Comprehensive Care Plans for residents who exhibited inappropriate sexual behavior. This failure placed residents in the facility at risk for sexual abuse. Findings included: Record review of the facility's PIR dated 9/7/2023, reflected RES #28 was observed in RES # 18's bed spooning, which was two bodies lying against each other, while masturbating on 9-7-2023 at 9:10 PM. The residents were immediately separated, police were called, and responded, then RES #28 was placed on ono-on-one supervision. RES #18 received a skin assessment by the ADON, which included an assessment of buttocks and penis. The assessment for RES #18 reflected no trauma. Staff were in-serviced on ANE; Residents were interviewed with no issues identified; Staff were interviewed with no issues identified; and RES #28 voluntarily admitted to a psych hospital on 9/8/2023. Attached to the PIR were signed statements from the ADM, DON, ADON, and SS. The narrative of the statements reflected CNA A entered RES #28 and RES #18's room on 9-7-2023 around 9:00 PM to 9:15 PM and discovered RES #28 laying behind RES #18 in RES #18's bed. RES #28 was observed masturbating with one hand and grabbing RES #18's penis with his other hand. The narrative continued where LVN D was notified and responded to enter RES #28 and RES #18's room. Upon entering, LVN D observed RES #28 laying behind RES #18 spooning. LVNA told RES #28 to get up and go back to bed, which he did. The narrative continued where the ADON was notified and responded to enter RES #28 and RES #18's room. RES #18 allegedly stated that someone crawled in bed with him, but could not remember who, and that he denied being in any pain. RES #28 stated that he and RES #18did not have sex, but that he, RES #28, only masturbated. Residents were separated, medically assessed, RES #28 placed on one-to-one, and police were notified. The narrative continued as the ADM wrote RES #18 showed no signs of psychological distress or pain since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 16 of 29 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 12/23/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the incident. After multiple interviews, the ADM believed RES #28 was masturbating (on his own admission) and that RES #28 inappropriately touched RES #18. The narrative closed as the ADM stated disbelief that anything else happened between the two residents. The facility's PIR contained written interviews with CNA A, LVN D, SS, ADON, DON and the ADM. The PIR also contained RES #18's skin assessment performed by the ADON post incident on 9-7-2023. Record review of the facility's PIR dated 11/20/23 at 5:45 PM reflected RES #18 was observed reaching out and grabbing RES #27's left breast on 11/20/2023 at 4:15 PM on the facility's secure unit. The nurse immediately intervened and separated them; and no injuries for either resident. Staff received in-service for ANE; and RES #18 was to be kept more than an arms distance from other residents. Record review of RES # 27's AR, dated 11/28/2023, reflected RES # 27 was an [AGE] year-old female who was admitted to the facility on [DATE]. RES # 27 was diagnosed with (1) Alzheimer's Disease, which was a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment; and (2) Schizoaffective Disorder, which was a mental health disorder that is marked by a combination of hallucinations, delusions, depression, and mania. Record review of RES # 27's Quarterly MDS, dated [DATE], reflected RES # 27 had a BIMS of 8. A BIMS of 8 indicated RES # 27 had moderate cognitive impairment. Section E- Behaviors, RES #18 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #27 did not exhibit these behaviors. Record review of RES #27 CP, dated 7/10/2021, indicated RES #27 add a focus plan for behavior problems exhibited by problems associated with the cognitive decline related to Alzheimer's disease; (2) ineffective means to cope with individuals with moderate dementia; and (3) aggressive behaviors towards others due to confusion and related to dementia. Record review on 11/28/2023 of RES #27's medical records did not indicate and documentation that would suggest RES #27 possessed the cognitive ability to consent to sexual activity. Interview on 11/27/2023 at 2:28 PM with CNA B revealed staff were instructed to keep RES #18 separated from other residents after RES #18 reached out and grabbed Res #27's breast on 11/20/2023. CNA B stated staff keep a good eye on all the residents, since they were on the secure unit. Men were not allowed in women's rooms and women were not allowed in men's rooms. CNA B has been instructed that residents were not allowed to have sex. She had been instructed to intervene with residents engaged in sexual behaviors and redirect them to an alternate activity; also, to let the charge nurse know for follow up assessments. Interview on 11/27/2023 at 2:40 PM with RES #27 revealed she did not remember the incident where RES #18 reached out and touched her breast. RES #27 stated maybe it was a good thing that she did not remember. RES #27 did not demonstrate anger and she stated she felt safe at the facility. RES #27 resided in the facility's secure unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 17 of 29 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 12/23/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of RES #18's AR, dated 11/28/2023, reflected RES #18 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #18 was diagnosed with (1) Transient Cerebral Ischemic Attack (a brief interruption of blood flow to the brain), Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), Vascular Dementia(a description for problems with reasoning, planning, judgment, memory and other thought processes R/T impaired blood flow to the brain), Unspecified Dementia (a description for when a person lost the ability to think, remember, learn, make decisions, and solve problems). Record review of RES #18's Quarterly MDS, dated [DATE], reflected RES #18 had a BIMS of 7. A BIMS of 7 indicated RES #18 had severe cognitive impairment. Section E- Behaviors, RES #18 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #18 did not exhibit these behaviors. Section GG- Functional Abilities and Goals, RES #18 was coded as an 88, eighty-eight, for lying to sitting on side of bed. A code of 88, eighty-eight, indicated RES #18 did not attempt this procedure due to medical condition of safety concerns. Record Review of RES #18's CP initiated a Focus for a behavioral problem on 9/20/2023 which indicated RES #18 inappropriately touched staff's breasts, buttocks, or used sexually inappropriate verbiage. The goal, with a target date of 2/01/2024, indicated RES #18's's behavior would not interfere with the delivery of care or services, or result in harm to self or others through the target date, 2/1/2024, called for interventions such as (1) administer medications as ordered. Monitor and document for effectiveness and potential side effects- initiated 9/20/2023; (2) assess and anticipate resident's needs; food, thirst, toileting needs, comfort level, body positioning, and pain- initiated 9/20/2023; (3) approach resident in calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing care, allow tie for a response, and do not rushinitiated 9/20/2023; (4) and give a clear explanation of daily care activities prior to and as they occur during each contact. Encourage as much participation and interaction by the residents as possible- initiated9/20/2023. RES #18's CP did not contain an update after the incident on 11/20/2023, after RES #27 reached out and grabbed RES #27's left breast. Record review of RES #18's medical records did not indicate any documentation that would suggest RES #18 possessed the cognitive ability to consent to sexual activity. Interview on 11/28/2023 at 8:24 AM with RES # 18 revealed RES #28, crawled into his bed. When RES #28 was in his bed touching his penis, he said he asked RES #28 to stop, but RES #28 did not stop. RES #18 stated he did not get hurt and he was only touched. RES #18 denied his anus was penetrated by RES #28's body parts. RES #18 felt safe at the facility. RES #18 remembered the incident where he reached out and grabbed RES #27's breast. RES #18 stated that he was sitting next to her and felt like grabbing her breast, so he did it. RES#18 and RES #27 both resided in the facility's secure unit on 11/20/2023. Record review of RES #28's AR, dated 11/27/2023, reflected RES #28 was a [AGE] year-old male who was admitted to the facility on [DATE]. RES #28 was diagnosed with Schizophrenia (a serious mental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 18 of 29 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 12/23/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some illness that affected how a person thought, felt, and behaved), and Cognitive Communication Deficit (described as difficulty with a person's thought or how a person used language). Record review of RES #28's Quarterly MDS, dated [DATE], reflected RES #28 had a BIMS of 14. A BIMS of 14 indicated RES #28 was cognitively intact. Section E- Behaviors, RES #28 was coded as 0, zero, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0, zero, indicated RES #28 did not exhibit these behaviors. Section G- Functional Status , RES #28 was coded as 0, zero, for (1) bed mobility, which was how a resident moved to and from the lying position, turning side to side, and positioned body while in bed or alternative sleep furniture; (2) transfer, which was how a resident moved between surfaces to and from bed, chair, wheelchair, and standing; and (3) locomotion off the unit, which is how a resident move between locations in his room and adjacent corridor on same floor. A code of 0, zero, indicated RES #28 did not exhibit these behaviors performed independent, which meant no help or staff oversight needed. Record review of RES #28's CP did not reflect an intervention for resident-on-resident sexual abuse, which occurred on 9/7/2023 with RES #18. RES #28's CP did not reflect any interventions, for any sexual behaviors, directed towards any other residents for any previous incidents. Record review of RES #28's medical records did not indicate any documentation that would suggest RES #28 possessed the cognitive ability to consent to sexual activity. Interview on 11/28/2023 at 9:05 AM with RES #28 he revealed remembered the night when he crawled into his roommate's bed, RES #18, to engage in sexual activity. He stated, his penis did not penetrate his roommate; furthermore, there was only consensual touching. He thought it was ok to have sex in a nursing home. He stated no one ever told him he was not allowed to have sex or that he did not have the ability to consent. RES #28 did not think he was doing anything wrong. Afterwards, he thought he might have made a bad decision because everyone was asking questions, so he figured he was not supposed to do it again. He stated the DON told him he was not allowed to display sexual behaviors with anyone. RES #28 resided in his own private room since the resident-on-resident sexual abuse, with RES #18, on 9/7/2023. RES #28 stated he went to the psych hospital on 9/8/2023 and returned on 9/20/2023. Record review of RES #28's PN reflected (1) on 9/7/2023 at 9:20 PM entered by RN N, the PN indicated RES #28 was placed on one-to-one monitoring until further notice after the incident on 9-7-2023 with RES #18; (2) on 9/7/2023 at 2:00 AM entered by RN N, the PN indicated RES #28 was monitored one-to-one; (3) on 9/8/2023 at 11:13 entered by the DON, the PN indicated RES #28 continued one-to-one monitoring; (4) on 9/12/2023 at 6:04 PM entered by the SS, the PN indicated SS spoke to RES #28 on 9/8/2023, which regarded RES #28 and RES #18 being in bed on 9/7/2023. The PN reflected a discussion with RES #28 that addressed understanding of the events on 9/7/2023, mental confusion, and urges. The PN reflected the decision to send RES #28 to a psych hospital; (5) on 9/8/2023 at 9:37 PM entered by LVN M, the PN indicated RES #28 departed the facility to a psych hospital; and (6) on 9/20/2023 at 4:24 PM entered by LVN M, the PN indicated RES #28 readmitted to the facility. Interview and record review on 11/28/2023 at 2:00 PM with CNA A revealed she entered RES #28 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 19 of 29 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 12/23/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some RES #18's room on 9-7-2023 around 9:00 PM or 9:15 PM. CNA A stated she observed RES #28 and RES #18 spooning. RES #28's hand was on RES #18's penis. CNA A stated she immediately went to LVN D to let her know what happened in the resident's room. CNA A was presented with her written interviews with the ADM on 9/8/2023 and 9/13/2023 and concurred the interviews were accurate. Interview on 11/28/2023 2:35 PM with LPN A revealed residents on the secure unit were not allowed to have sexual contact. Men and women were not allowed in each other's rooms. RES #18 was supposed to be kept separated from other residents. LPN A has been instructed that residents are not allowed to have sex. The residents were constantly watched. Interview and record review on 11/28/2023 at 3:00 PM with LVN D revealed she responded to RES #28 and RES #18's room on 9/7/2023 after being told there was an incident by CNA A. LVN D stated she went to the room, saw RES #28 and RES #18 spooning with RES #28's hand on RES #18's penis. LVN D stated she separated the residents and informed the ADON of what had occurred. LVN D was presented with her written interviews with the ADM from 9/8/2023 and 9/12/2023 and concurred the interview were accurate. The last time LVN D saw RES #28 and RES #18 was at 8:30 PM, 9-7-2023, during med pass on the night of the incident. RES #28 and RES #18 were roommates up until that night. Res #18 moved to another hall the night of the incident. Interview on 11-29-2023 with the ADON at 3:30 PM revealed she worked on 9-7-2023 and responded to the incident with RES #18 and RES #28. She stated she made sure the residents were separated immediately and checked RES #18 for any harm, she stated she placed RES #28 on a one-to-one while she performed a skin check of RES #18's body, which revealed no trauma. The ADON stated she called the police, who responded. The ADON stated the officer learned of RES #18 and RES #28's diagnosis and determined it would be too hard to try to determine consent. The ADON stated RES# 28 had not demonstrated similar behaviors prior to 9/7/2023. Interview and record review on 11/29/23 at 3:45 PM with the DON revealed there was no mention of an intervention for RES #28's behavior on 9/7/2023 with RES #18 in RES #28's current CP. The DON stated there was an intervention in RES #28's CP, but it must have been deleted when he discharged to the psych hospital on 9/8/2023 at 9:27 PM. The DON stated his orders and CP were updated upon his return on 9-20-2023 at 4:24 PM, but the intervention for what happened on 9-7-2023 (between RES #28 and RES #18) must not have been added back. The DON revealed the ADM did not want to make every detail of the incident known to everyone who had access to RES #28's CP and wanted to protect RES #28's privacy. The DON stated the interventions put in place for RES #28, which were not in RES #28's CP current care plan on 11/28/2023, were for him to have his own private room, keep him out of other people's rooms, continued psychological services, and be watched for behaviors and redirect as needed. The DON stated that the interventions in place were working. The DON stated RES #28 was placed on a medication, on 9-29-2023, called Medroxy Progesterone Acetate 5 MG by mouth daily for impulse control (a libido reducing medication.) RES #28 and RES #18 had not been evaluated, prior to 9/7/2023, for the cognitive ability to consent to sexual activity. During the interview, the DON entered a Focus, Goal, and Intervention in RES #28's CP directed at Sexual Behaviors and how RES #28's Goal, having pertained to sexual behaviors, would not interfere with the delivery of ADL care by staff. The interventions were to (1) administer medications as ordered by the physician and monitor for effectiveness and potential adverse side effects; (2) monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log; (3) approach resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing care, allow time for a response, and do not rush.; and (4) Give a clear explanation of daily care activities prior to and as they occur during each contact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 20 of 29 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 12/23/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Encourage as much participation and interaction by the resident as possible. The Focus, Goal, and Interventions, added to RES #28's CP on 11/29/2023 by the DON, were not the result of an IDT collaboration. The DON added them during the interview. The interview further revealed there was no intervention for RES #18's sexual behavior exhibited on 11/20/2023 in RES #18's CP. The DON stated RES #18 had exhibited groping behaviors with staff in the past and the behavior was annotated his CP on 9/20/2023; however, RES #18 having groped a resident on 11/20/2023 was a new behavior, and was not updated in RES #18's CP. The DON felt the interventions in place from 9/20/2023 would continue to provide safety to the resident, staff, and other residents. During the interview on 11/29/2023, the DON updated RES #18's CP, which addressed the Focus for behavioral problems evidenced by sexually inappropriately behaviors with a female resident witnessed by staff groping resident breast. The existing Goal from 9/20/2023 was that RES #18's behavior will not interfere with the delivery of care or services or result in harm to self or others, was not edited. The interventions, initiated on 11/29/2023, were to (1) provide resident with as many choices as possible with their daily cares and activities. Provide a program of activities that accommodates the residents cognitive and functional abilities; (2) intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others; and (3) Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. The Focus, Goal, and Interventions, added to RES #18's CP on 11/29/2023, were not the result of an IDT collaboration. The DON added them during the interview. Interview on 11/29/2023 at 4:43 PM with the ADM revealed he did not want to enter detailed information about RES #28's sexual behavior with RES #18, in his (RES #28) CP. The ADM stated he did not want everyone in the facility, with access to RES #28's CP, to have access to confidential information. The ADM stated he did not know PCC (which was the electronic platform to record facility documentation) very well and did not know why the intervention placed in RES #28's CP prior to his discharge to the psych hospital, on 9-8-2023, was not still on the care plan upon his return, on 9-20-2023. The ADM stated he feels the interventions in place, such as monitoring and redirecting as needed, were effective. The ADM considered the interaction with RES #18 and RES #28 on 9/7/2023 was consensual. Interview further revealed that the interventions in place for RES #18, such as keeping RES #18 at arm's length from other residents was working and was adequate to keep the staff and residents safe. The ADM was not aware that RS #18's care plan had not been updated for RES #18's recent behavior of groping a RES #27 on 11/20/2023. Interview on 11/30/2023 at 4:00 PM with LAR # 18 revealed the facility called her on the night on 9-7-2023 to let her know about the incident between RES# 18 and RES #28. LAR # 18 stated the initial call was made by an employee, whose name she could not recall, that stated RES #18 was heard calling out from the room on 9-7-2023; LAR # 18 stated that a secondary phone call, with the DON, also described RES #18 as having called out for help from his room on 9-7-2023. LAR # 18 stated, to the best of her knowledge, that RES #18 had not previously engaged in homosexual activity; furthermore, LAR # 18 stated she did not believe that RES #18 consented to RES #28 having been in his bed and having touched his penis. Record Review on 11/30/2023 of RES #28's PN, entered on 10/2/2023 at 11:10 AM by the SS, reflected RES #28 was observed kissing a female resident (RES #40) on the mouth on 9/29/2023. The PN reflected the SS and the Administration spoke with RES #28 and RES #28 admitted he pecked a female resident (RES #40) on the mouth on 9/29/2023. A PN (regarded the kissing incident on 9/29/2023), entered on 10/2/2023 at 11:28 AM by the SS, reflected the SS gave RES #28 specific instructions on things that were not acceptable between him and other residents in the facility. SS informed RES #28 he was not allowed to kiss, touch, hug or have physical contact at any time. RES # 28 was educated to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 21 of 29 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 12/23/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety ask nursing staff, or management, questions about anything he thought of doing with another resident. RES #28 was made aware that more inappropriate incidents could initiate a transfer to another facility. RES # 28 acknowledge he understood and stated he did not want to leave the facility. A PN (regarded the kissing incident on 9/29/2023), entered on 10/2/2023 at 11:46 AM by the SS, reflected PS DR was contacted for a medication intervention and RES #28 moved to another room, away from the female resident he encountered (RES #40.) Residents Affected - Some Record review of the facility's Abuse, Neglect, and Exploitation Policy dated, 10/24/2022, indicated it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. III. Prevention of Abuse, Neglect, and Exploitation The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a residence consensual sexual relationship and to the extent possible prevent sexual abuse. (1) The consent to sexual contact will be made by the social worker / designee completing an evaluation that determines the resident has capability to engage in consensual sexual contact, or (2) the residents representative agrees to the resident's participation in consensual sex contact, and (3) the documentation of a resident's capacity for consensual sex contact is located in the medical record. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident's property is suspected or identified by. (1) taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to residents or other residents, and (2) review and evaluation of like instances to determine if the appropriate actions to correct the noncompliance was taken and documented. V. Investigations of alleged Abuse, Neglect, and Exploitation A. An immediate thorough investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or exploitation occur. B. Abuse investigation procedure include, (1) Identifying staff responsible for the investigation, (2) exercising caution in handling evidence that could be used in a criminal investigation, (3) investigating different types of alleged violations, (4) identifying and interviewing all involved parties, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, (5) focusing the investigation on determining if the abuse, neglect, exploitation, and or mistreatment has occurred, the extent, and cause, and (6) providing complete and thorough documentation of the investigation. VI. Protection of Resident With facility makes efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 22 of 29 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 12/23/2023 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 0656 A. Responding immediately to protect the alleged victim and integrity of the investigation. Level of Harm - Immediate jeopardy to resident health or safety B. Physical exam of the alleged victim for any sign of injury. Residents Affected - Some D. Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator. C. Increase supervision of the alleged victim and residents. E. Protection from retaliation. F. Providing emotional support and counseling to the resident during and after the investigation, as needed. G. Revision of the residence care plan if the residents medical, nursing, physical, mental, or psychosocial needs or preferences change as the result of an incident of abuse. Record review of the facility's Abuse and Prevention and Reporting training, dated 9/8/2023, reflected 30 staff participated in the training. Record review of the facility's Resident's Rights and Sexual Survey, dated 9/8/2023, reflected 41 staff participated in the training. Record review of the facility's Safety Patient Questionnaire, dated 9-8-23, reflected the census for 9-8-2023 was 100 residents. The QAA Patient Questionnaire reflected a sample of twenty-seven residents who responded Yes- Do you feel safe at the facility; and responded No- Has a resident ever touched you in a manner that made you feel uncomfortable. Record review of the facility Quality Assurance Staff Questionnaire, dated 9-18-23, reflected 64 facility employees who responded No-have you ever seen a resident touch a female or male in an inappropriate manner; No-Are there any patients that touch another patient in an inappropriate manner; and No- Are there any patients that say sexually inappropriate things to another. Records review of RES #28's Order Summary Report indicated RES #28 was prescribed Medroxy Progesterone Acetate 5 MG by mouth every morning for impulse control disorder, which began on 9/29/2023. Record review of Local Police Department, Report #23-02094, dated 9/7/2023 at 10:15 PM reflected a visit by Police Officer A to the facility in response to sexual assault of a [AGE] year-old male. The report indicated that RES #18 was asked if he wanted RES #28 in his bed and RES #18's response was |I think so. | The report indicated that RES #18 has a long list of mental deficits to include Alzheimer's, dementia, cognitive communication; and RES #28 has also been diagnosed with a list of disorders to include Schizophrenia, cognitive communication deficit, and major depressive disorder. The closing statement on the report stated |With these disorders it was determined that it would be difficult to determine if there was consent or not. RES #18 was not given a sexual assault exam. Print out of each party`s diagnoses have been included with this report. My report has been uploaded; I have nothing further at this time. Record review of the facility's Comprehensive Care Plan Policy, dated 2/10/2021, reflected (4) the comprehensive care plan will be prepared by an IDT, that includes, but is not limited to: attending physician, a nurse with knowledge of resident, the residents representative if applicable, other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 23 of 29 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 12/23/2023 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some appropriate staff such as RAI coordinator, activities director, social services director/social worker, licensed therapist, administration, and a mental health professional; and (8) qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Observations on 12/22/2023 at 8:29 AM of RES #28 reflected him having sat quietly on his bed, in his room watching TV, alone. Interview on 12/22/2023 at 8:30 AM with RES #28 revealed he had kissed RES #40 on 9/29/2023. After the kissing incident, which occurred on 9/29/2023, he stated he was approached by the SS, who explained that his behaviors were not acceptable. RES # 28 stated he was moved to a different room and that he started a new medication. RES # 28 thought the medication had helped him by reducing feelings of [NAME] and sexual desire, but he was still able to attain an erection and masturbate. RES #28 did not feel sedated, or different, because of the medication; in fact, RES #28 stated that his quality of life had improved. He denied any desires to kiss, or sexually touch, another resident since he started the medication on 9/29/2023. Record review on 12/22/2023 of RES #28's Medication Administration Record for December 2023, indicated RES #28 had received his Medroxy Progesterone Acetate 5 MG by mouth every morning for impulse control disorder. Interview on 12/22/2023 at 9:30 AM with NA A revealed that she had been working at facility as a NA since 12/18/2023. She was informed that there were residents in the facility that have displayed sexual behaviors in the past and that it could still happen. If she observed sexual behavior, she was instructed to get help immediately and report it to a charge nurse or the ADM. Interview on 12/22/2023 at 10:00 AM with the SS revealed RES #18, in general, possessed the cognitive faculties to consent to sexual activity; however, the SS was unable to determine if the interaction between RES #28 and RES #18, on the night of 9/7/2023, was consensual or not consensual. The SS stated she knew about the incident on 9/7/2023 but did not participate in an IDT meeting for an CP update. The SS stated that the incident, which occurred on 9/7/2023, between RES #28 and RES #18, should have received a CP update, to include a Focus, Goal, and Intervention. The SS stated she checked on RES #28 often, after the i[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 24 of 29 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 12/23/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for two of six residents (Residents #11 and #8) reviewed for respiratory care. Residents Affected - Few A) The facility failed to ensure Resident #11's oxygen concentrator filter was clean, humidifier was dated, and tubing were dated. B) The facility failed to ensure Resident #8's oxygen concentrator filter was clean, humidifier was dated, and her oxygen tubing were dated. This failure could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: A) Record review of Resident #11's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing related problems) Record review of Resident #11s quarterly MDS dated [DATE] reflected resident had a BIMS score of 15 showing she was cognitively intact. Resident #11 required extensive assistance with activities of daily living, personal hygiene, toilet use, and dressing. Record Review of Resident #11s Care plan dated 12/1/21 reflected Resident required oxygen therapy routinely and is at risk for ineffective gas exchange. This is related to Chronic Obstructive Pulmonary Disease. Record review of Resident 11's Physicians Order Summary Report dated 11/28/2023 reflected an order for Oxygen at three (3) Liters per minute around the clock for treatment of shortness of breath. There were no orders to reflect the policy process of changing the tubing, washing the filter, or dating and ensuring the humidifier was full of water. Observation on 11/27/2023 at 10:30 AM revealed Resident #11 had oxygen in place on her nose. Resident #11's oxygen concentrator filter was full of white dust. Her humidifier bottle was empty and undated. Her oxygen tubing was undated. Observation on 11/28/23 at 09:53 AM Resident #11s humidifier on oxygen concentrator remained empty and undated, oxygen tubing was not dated, and the filter was full of white dust. B) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 25 of 29 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 12/23/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #8's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing related problems). Record review of Resident #8's annual MDS dated [DATE] reflected she required extensive assistance with activities of daily living, personal hygiene, toilet use, and dressing. Record review of Resident #8's Treatment Administration Record dated 11/29/2023 reflected an order to change O2 tubing and date every night shift every Sunday. This order was signed as having been completed on 11/26/2023. There was an order to clean the O2 concentrator filters every night shift every Sunday. This order was initialed as having been completed on 11/26/2023. There was an order to change humidifier bottle every night shift every Sunday. This order was initialed as having been completed on 11/26/2023. Record review of Resident #8's Physicians Order Summary Report dated 11/28/2023 reflected Resident #8 required Oxygen at 3 liters per minute around the clock for Chronic Obstructive Pulmonary Disease. Record review of Resident #8's Order Summary Report also reflected Resident #8 had an order to change humidifier bottle on Sunday every Sunday night, change oxygen tubing every Sunday night, and clean oxygen concentrator filter every Sunday night. Observation on 011/27/2023 at 10:38 AM in Resident #8 was using her oxygen. Resident #8's room observation reflected her oxygen tubing was not dated, the oxygen concentrator filter was covered in white dust and the humidifier bottle was empty of water and undated. Interview on 11/28/2023 at 10:31 AM LVN A stated she had worked in the facility for 4 months. She stated the staff do check the oxygen tanks every shift to ensure they were on and in place. She stated staff were expected to clean the concentrators and change the tubing if needed. She stated she was not aware of any specific orders to change and date the tubing or humidifiers or clean oxygen filters. She stated she was not sure if she has been in serviced on the oxygen policy. She stated the risk to the resident for having dirty oxygen equipment would be respiratory distress. Interview on 11/29/2023 at 11:45 AM LVN B stated she had worked at the facility for 4 months. She stated she was trained to ensure oxygen tubing and tanks were clean. She stated tubing and humidifier should have a date and initials in place to reflect the most recent change. She stated the oxygen tank care was completed weekly on night shift. She stated the risk to resident for unclean oxygen equipment would be infection respiratory illness. Interview on 11/29/2023 at 12:23 PM the DON stated the tubing to respiratory equipment should be changed on Sundays and the filters washed on Sunday nights. She stated the risk to the resident if these procedures were not followed was respiratory infections. She further stated it was their policy to change tubing, clean filters and ensure humidifiers are clean and full. The DON stated she was responsible for educating and overseeing the staff regarding the oxygen administration policy. Interview on 11/29/2023 at 1:45 PM the ADM stated the expectation for the cleaning and care of the oxygen equipment was to follow facility policy. He stated the risk to the Resident for dirty filters and equipment was that it could potentially drop a residents oxygen level. He stated it was the responsibility of nursing management to ensure the staff were educated on the oxygen administration policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 26 of 29 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 12/23/2023 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 0695 Record review of facility policy titled Oxygen Administration dated 9/12/14 and revised 1/5/20 reflected: Level of Harm - Minimal harm or potential for actual harm A) humidification 1.use prefilled humidifier bottle label bottle with date, change bottle when empty. Residents Affected - Few B) completion of procedure 3.Change disposable parts once a week and label with date. C) Concentrator 1. clean filter weekly 2. remove filter from back of concentrator 3. rinse filter with water 4. shake off excess water FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 27 of 29 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 12/23/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm 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 food under sanitary conditions for 1 of 1 kitchens reviewed for dietary services. Residents Affected - Many The facility failed to safely store food containers in the facility's only pantry, walk-in cooler, and freezer with labels to signify the date a product was open and a date to signify expiration. The facility failed to store food in properly sealed containers to prevent the growth of food borne pathogens. These failures could place residents at risk of exposure to food-borne pathogens. Finding include: Observations on 11/27/2023 at 8:56 AM of the facility's refrigerator revealed: 1 package of sliced luncheon meat stored in an unsealed plastic bag without the date it was opened or the date it expired; 2 slices of a pie stored in its original pie tin loosely covered without the date it was opened or the date it expired; 1 chicken breast in a plastic bag without the date it was opened or the date it expired; a plastic tub of beef without the date it was opened or the date it expired; 1 gallon BBQ sauce without the date it was opened or the date it expired; 1 gallon of Italian dressing without the date it was opened or the date it expired; 1 plastic container of cranberries without the date it was opened or the date it expired; 1 plastic container of vegetable soup without the date it was opened or the date it expired; and 1 plastic bag of hard-boiled eggs without the date it was opened or the date it expired. Observations on 11/27/2023 at 9:00 AM of the facility's freezer revealed: 1 clear plastic bag of frozen burritos removed from its original container without name of the product, the date it was opened or the date it expired; 1 blue plastic bag of frozen hamburger patties removed from its original container without the name of the product, the date it was opened, or the date it expired; 1 blue plastic bag of fish patties removed from its original container without the name of the product, the date it was opened, or the date it expired; 1 clear plastic bag of frozen eggrolls removed from its original container without name of the product, the date it was opened, or the date it expired; and 1 clear plastic bag of frozen sausage patties removed from its original container without the name of the product, the date it was opened, or the date it expired. Observations on 11/27/2023 at 9:10 AM of the facility's pantry revealed: 1 open bag of dry elbow macaroni twisted to close at the top, which was not sealed properly, without the date it was opened, or the date it expired; 1 open bag of dry spaghetti twisted to close at the top, which was not sealed properly, without the date it was opened, or the date it expired; 1 open bag of tri-color pasta twisted to close, which was not sealed properly, without the date it was opened, or the date it expired; and 1 open package of lemon gelatin stored in a zip lock bag without the date it was opened or the date it expired. Interview on 11/29/2023 at 2:47 PM with a DA revealed food stored in the facility needed to have a label with the name of the product, the date it was opened, and the date it was due to expire. The DA stated the label system was utilized for foods in the pantry, the refrigerator, and the freezer. The DA stated she was trained to label and date all food items. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 28 of 29 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 12/23/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 11-29-2023 at 2:58 with the KM revealed the foods in the pantry, the refrigerator, and the pantry needed labels that signified the product name, the date the product was open, and the date the product was to expire. The KM stated the dates on the labels were important to avoid the growth of foodborne pathogens. Foods that were not consumed by the end of the day on the use by date were thrown away. The KM stated food-borne pathogens would make people sick and caused diarrhea, vomiting, and unintended weight loss. KM was responsible for the daily operations in the kitchen. Interview on 11/29/2023 at 3:45 PM with the DON revealed food storage was important to keep out bugs, dirt, and other pathogens. The DON stated the facility dated its food to keep it fresh and to avoid food-borne pathogens such as salmonella, E. coli, Norovirus. Food-borne pathogens would cause diarrhea, intestinal problems, unintended weight loss. The DON stated improper food labeling was a failure of management and lack of training. Interview on 11/29/2023 at 4:34 PM with the ADM revealed food safety was important the residents because it reduced the opportunity for food-borne pathogens to grow. Some of the negative outcomes of residents getting sick because of food-borne pathogens were diarrhea, stomach issues, and the potential for other health concerns. Record review of the facility's policy for Frozen and Refrigerated Food Storage, dated 08/2005, reflected (9) items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, cell by, best by date, or a date delivered. They must also be dated with an expiration date unless they have one from the manufacturer. (10) packaged frozen items that are open and not used in their entirety must be properly sealed, labeled, and dated for continued storage. (11) all refrigerated and frozen items in storage would contain a minimum label of common name of product and a date as noted above. Record review of the facility's policy for Dry Food and Supplies Storage, dated 11/2006, reflected (9) all opened products must be sealed effectively and properly labeled, dated, and rotated for use. This may require storage in an approved container or food grade storage bag. Record review of FDA Food Code 2022 indicated [(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 29 of 29