Inspection·February 6, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident # 20 face sheet, dated 2/5/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included atherosclerotic heart disease (a hardening of the arteries), Hypertension (elevated blood pressure), Type 2 Diabetes (elevated blood sugar), and bipolar disorder (a disorder affecting mood and behavior). Record review of Resident #20 quarterly MDS, dated [DATE], reflected he had a BIMS score of 9, which indicated he was cognitively impaired. Resident #20 required set-up or clean up assist with eating and personal hygiene, required partial to moderate assist with bathing, and was dependent on staff with toileting. Record review of Resident #20's care plan, dated 04/02/24, reflected: The resident requires Enhanced Barrier Precautions due to Vascular ulcer. Goal The resident will remain free from active infection with MDROs through the review date. Interventions: Notify the physician of any Signs and symptoms of active infection. Wear gown and gloves during high-contact resident care activities. In an observation of medication pass on 02/05/25 at 8:50 AM revealed MA C did not sanitize the blood pressure cuff when going from Resident #20 to Resident #6. In an interview on 02/05/25 at 9:27 AM, MA C stated she normally cleaned the blood pressure cuff between residents. She stated she just forgot to do it this time. MA C stated she was trained on infection control by the DON by in-services. She stated negative effects for not cleaning the blood pressure cuff between residents would be cross contamination. 3. Record review of Resident #40's face sheet, dated 02/05/25, reflected Resident #40 was an [AGE] year-old female with an admission date of 03/08/21. Resident #40's diagnoses included atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and osteoarthritis (a degenerative joint disease that causes the cartilage and bone in a joint to break down over time). Record review of Resident #40's most recent quarterly MDS assessment, dated 12/20/24, reflected Resident #40 had a BIMS score of 11, which indicated Resident #40 was moderately cognitively impaired. Resident #40 required set-up or clean up assist with eating and personal hygiene, required partial to moderate assist with bathing, and was dependent on staff with toileting. Resident #40 was always incontinent of bowel and bladder. Record review of Resident #40's care plan, dated 04/21/21 and revised on 07/26/21, reflected: [Resident #40] was incontinent of bowel and bladder. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through next review date. Interventions: Check frequently for wetness and soiling and change as needed. Monitor for and report to Medical Doctor signs and symptoms of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an interview on 02/05/25 at 9:35 AM, Resident #40 stated she was doing well, and the staff took good care of her. She stated she had no concerns for her care and her needs were met. Resident #40 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 was in bed with blankets that covered her to her chest area and her call light was in reach. Level of Harm - Minimal harm or potential for actual harm In an observation on 02/05/25 at 09:20 AM, CNA A performed incontinent care for Resident #40. CNA A washed her hands, applied gloves, and began the incontinent care. CNA A began by cleansing the perineal area on the front of the resident then turned the resident to the side and continued incontinent care to the resident's backside. CNA A removed the residents dirty brief and applied a clean brief. CNA A did not wash her hands when she went from a dirty to clean surface. Residents Affected - Some In an interview on 02/05/25 at 09:29 AM, CNA A stated she had not washed her hands when she performed incontinent care on Resident #40. She stated she usually only changed her gloves and washed or sanitized her hands during incontinent care if there was feces present. She stated she was trained on infection control, hand washing, and incontinent care, and she knew she was supposed to change her gloves and wash her hands when she went from a dirty to clean surface. She stated if incontinent care was done incorrectly or she had not washed her hands and changed her gloves when going from a dirty to clean surface, it could cause cross contamination. 4. Record review of Resident # 42 face sheet, dated 2/5/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #42 had diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Rights Dominant Side (paralysis of the right side after a stroke or brain bleed), encounter for surgical aftercare following surgery on the digestive system, Type 2 Diabetes Mellitus (elevated blood sugar), Hypertension (elevated blood pressure), and Morbid Obesity. Record review of Resident #42 quarterly MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated she was cognitively intact. Resident #42 was independent with eating and required substantial/maximal assistance with personal hygiene bathing, dressing and toileting. Resident #42 had a surgical wound that required wound care. Record review of Resident #42's care plan, dated 05/23/24 and revised on 08/28/24, reflected: Surgical Wound: Post surgical wounds of anterior abdomen Resident has a surgical wound and is at risk for infection, pain, and a decrease in functional abilities. Goal: Resident's surgical wound will show signs of healing through the next review date. Interventions: Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. In an observation of wound care on 02/05/25 at 9:37 AM revealed LVN B did not wash his hands or use hand sanitizer after he removed a soiled wound dressing, cleansed the wound, changed his gloves, and applied a clean dressing to Resident #42's abdominal wound. In an interview on 02/05/25 at 10:04 AM, LVN B stated he normally would have washed his hands between changing gloves, but the sink in the residents' room was out of order. It had a been temporarily shut off due to a leak this morning. He stated normally it was a non-issue but with the sink out he didn't think about having alcohol-based hand sanitizer in the room with him. He stated he was in serviced on infection control by the DON. He stated the risk for residents for not washing hands would be wound infection. In an interview on 02/06/25 at 12:27 PM, the DON stated it was her expectation all staff cleansed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Manor Nursing Center 2035 N Granbury St Cleburne, TX 76031 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some their hands in-between gloving, during peri care and wound care. She expected staff to clean hands with either soap and water or alcohol-based hand sanitizer when going from a dirty or soiled surface to a clean surface area. She stated she expected the blood pressure cuff to be cleaned in-between residents. The DON stated she in-services staff monthly and as needed on infection control. She stated the department head staff made rounds and monitored for infection control practices through observations and checking competency yearly and as needed. She stated the risk placed on residents for not washing hands and cleaning the blood pressure cuff between residents included the introduction of pathogens to staff and residents' leading to infections. Record review of the facility's Infection Prevention and Control Program policy, dated 03/26/24, reflected the following: All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . Reusable items potentially contaminated with infectious material shall be placed in an impervious clear plastic bag. Label bag as 'Contaminated' and placed in soiled utility room for pickup and processing. The central supply clerk will decontaminate equipment with a germicidal detergent prior to storing for reuse. Record review of the facility's Hand Hygiene policy, dated 11/12/2017, reflected the following: Policy Statement: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 3. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table Record review of the facility's, undated, facility form Hand Hygiene Table reflected the following for when hand hygiene should be performed: Before performing resident care procedures. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. When, during resident care, moving from a contaminated body site to a clean body site. After assistance with personal body functions (elimination, hair grooming, smoking) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 4 of 4