Inspection·September 4, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few health record) report as of 09/04/2025 reflected under bowel and bladder Resident #1 was incontinent and to check frequently for wetness and soiling and change as needed. Review of Resident #1 bowel and bladder program screener dated 02/12/2025 reflected Resident #1 was not continent of bladder or bowel function which has remained the same since the last three months. Resident #1 was not on a toileting plan and had not been evaluated or found appropriate for a trial toileting plan. Review of bowel and bladder program screener dated 08/14/2025 reflected Resident #1 was continent of bladder and bowel function. Review of bladder continent POC (point of care or electronica health record) response history for 14 days reflected Resident #1 had a continent episode on 08/22/2025, two episodes on 08/31/2025, two episodes on 09/01/2025 and a continent episode on 09/03/2025. Further review reflected resident had 2 incontinent episodes on 08/22/2025, three on 08/23/2025, three on 08/24/2025, two on 08/25/2025, three on 08/26/2025, two on 08/27/2025, two on 08/28/2025, one on 08/30/2025, one on 08/31/2025, one on 09/01/2025, three on 09/02/2025 and one on 09/03/2025. Review of bowel continent POC response history for 14 days reflected Resident #1 had one continent episode on 08/22/2025, one on 08/28/2025, two on 08/30/2025, two on 09/01/2025 and one on 09/03/2025. Further review reflected Resident #1 had one incontinent episode on 08/22/2025, two on 08/24/2025, one on 08/25/2025, three on 08/26/2025, one on 08/27/2025, one on 08/28/2025, one on 08/31/2025, one on 09/01/2025, two on 09/02/2025 and one on 09/03/2025. Review of care plan conference notes dated 07/15/2025 reflected meeting was held on 07/14/2025 at 11:00 AM. Nursing summary reflected there were no concerns, issues or changes and discussed resident's independence. Social services summary reflected discussed resident working towards being more independent w/ADLs as well as being more self sufficient and able to do something on her own or little assistance. Resident in agreement and states she would like to be more independent. Discussed toileting and resident states she can transfer to toilet by herself but needs [assistance] wiping after urinating or having a [bowel movement]. Review did not reflect that staff would offer toileting and leave resident in brief when she requested to be changed and return later after initial refusal to be toileted. Review of Resident #1's weekly skin assessment dated [DATE] reflected there were no impairments in skin integrity. Review of nursing progress note dated 08/22/2025 at 11:20 AM by LVN B reflected resident was incontinent of bladder and bowel. Other observations reflected resident laid in bed and refused to get up. Resident #1 at times will use toilet but frequently refuses and is incontinent and required incontinent care for bowel and bladder. Review of nursing progress note dated 08/24/2025 at 9:35 AM by LVN B reflected Resident #1 was incontinent of bladder and pads or briefs were used and resident was incontinent of bowel. Review of nursing progress note dated 08/25/2025 by LVN B reflected aides attempted to toilet Resident #1 but she refused. Review of nursing progress note dated 08/25/2025 at 10:48 AM by LVN A reflected Resident #1 was continent of bladder with no changes noted and continent of bowel. Review of nursing progress note dated 08/26/2025 at 12:07 PM by LVN A reflected Resident #1 is incontinent of bladder with pads/briefs used and that resident is incontinent of bowel. Review of nursing progress note dated 08/27/2025 at 11:04 AM by LVN A reflected Resident #1 is incontinent of bladder with pads/briefs used and that resident is incontinent of bowel. Review of nursing progress note dated 08/29/2025 at 1:06 PM by LVN A reflected Resident has refused to get up out of bed and use toilet all shift. Resident states No it is y'alls job to change me in bed and that is what y'all are going to do. Both aides turned and walked out to notify supervisors. It is care plan that resident is capable to get up to use toilet. Resident has been offered several times to get up and use toilet before trays come out and has refused. During an interview on 09/04/2025 at 9:50 AM, Resident #1 stated that she and the ADM do not get along. Resident #1 stated that the ADM told everyone she had to get up and use the toilet instead of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2025 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few brief, but she is incontinent. Resident #1 stated she has been incontinent since 2015 after her stroke. Resident #1 stated that she cannot tell when she urinates she just knows when she is wet and she wanted her brief changed. Resident #1 stated staff told her they were told that Resident #1 was supposed to get up and go to the toilet and that was in her care plan. Resident #1 stated that she can get in and out of bed to transfer if her wheelchair is next to her bed, but she cannot tell when she needs to get up and use the bathroom so she used her brief and asked staff to be changed. During an interview on 09/04/2025 at 12:28 PM, CNA C stated that she works PRN at the facility and is not often. CNA C stated that residents required brief change every hour and a half or two hours and that she checked the residents to see if they were dry and clean. CNA C stated that there are a few residents that will put on their call light to be changed. CNA C stated that Kardex or POC told her which residents used a brief and which needed assistance. CNA C stated that Resident #1 could get up and use the bathroom with assistance. CNA C stated Resident #1 wore briefs. CNA C stated they told CNA C that Resident #1 was supposed to get up and use the bathroom with assistance. CNA C stated by they she meant the ADM, charge nurses and ADONs. CNA C stated that when she did rounds because Resident #1 was a heavy wetter she went to see if Resident #1 had an accident. CNA C stated that if Resident #1 had an accident she would get Resident #1 up to the bathroom to get her cleaned up. CNA C stated it was a title war (conflict) with Resident #1 because she refused care often. CNA C stated Resident #1 was and was not incontinent. CNA C stated Resident #1 can get up with assistance. CNA C stated that Resident #1 refused to get up and go to the toilet. CNA C stated that they told CNA not to change Resident #1 in bed and that a refusal to go to the toilet meant a refusal to be changed and stated that Resident #1 was supposed to get up and go to the toilet. CNA C stated that if Resident #1 refused the first time to get up and use the toilet she would leave Resident #1 in her brief and return later to try and get Resident #1 to use the toilet. CNA C stated it was important for residents to get changed to prevent breakdown and irritation. CNA C stated it was in Resident #1's care plan that she can get up and use the toilet and she also had to go by what the ADM told her. During an interview on 09/04/2025 at 12:52 PM, CNA D stated a resident's needs were determined based on what their care plan said and it listed what the resident could and could not do for themselves. CNA D stated the Kardex told staff if a resident was incontinent or if they could get up and go to the toilet and what assistance from staff was needed. CNA D stated that Resident #1 was not incontinent and refused when asked to get up and go to the toilet and Resident #1 stated she did not want to sit on the toilet and wanted to use her brief. CNA D stated she knows Resident #1 is not incontinent because Resident #1 told staff when she was wet or had a BM and stated residents who are incontinent don't know that they've gone to the bathroom. CNA D stated that rounds were done at least every two hours and it included to provide anything the resident needed and check and change residents, unless they call before and ask to be changed. CNA D stated that if Resident #1 stated she was wet and refused to get up and use the toilet CNA D would leave for a few minutes and then ask Resident #1 a second time and if Resident #1 refused to get up and use the toilet again then CNA D would change Resident #1. CNA D stated that she knew residents had the right to refuse.During an interview on 09/04/2025 at 1:09 PM, COTA E stated she had worked with Resident #1 from 08/04/2025 to 08/27/2025 when Resident #1 was getting occupational therapy. COTA E stated that she was not sure if Resident #1 was continent or incontinent. COTA E stated Resident #1 was physically able to get up and go to the toilet but could not clean herself and Resident #1 was offered a tool to assist with cleaning. During an interview on 09/04/2025 at 1:10 PM, OT F stated Resident #1 was at her highest practicable level which is why she was discharged from therapy. Resident #1 was able to walk to the bathroom with aide supervision, but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2025 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few required max encouragement to get up. OT F stated she asked Resident #1 why she did not get up and go to the bathroom and Resident #1 told OT F it was a hassle. OT F stated that cognitively Resident #1 knows when she needs to go to the bathroom. During an interview on 09/04/2025 at 1:15 PM, LVN A stated that she has worked at the facility on and off for 17 years. LVN A stated that bowel and bladder screenings are done quarterly and with any kind of change. LVN A stated that Resident #1's recent assessment said she was continent because Resident #1 was able to go to the bathroom. LVN A stated Resident #1 used the call light and said ‘I had a bowel movement I need you to change me' or calls the aides and says she is wet. LVN A stated that Resident #1 stated several times she is able to use the toilet but chose not to. LVN A stated that she was educated to try and help Resident #1 keep her independence as much as she can. LVN A stated Resident #1 was reevaluated by therapy and Resident #1 told therapy, aides and nurses she was able to get up and use the bathroom but she did not want to. LVN A stated they had a care plan meeting with Resident #1 and that LVN A was told when staff go in and Resident #1 stated she was wet to try and get her up to the toilet, so linens can be changed if needed and Resident #1 refuses and said I'm not going anywhere. LVN A stated she knew Resident #1 had mental problems but Resident #1 was hateful and only allowed certain care when it was convenient for Resident #1. LVN A stated if Resident #1 is wet and in bed and refused to go to the toilet they had to do what is in her care plan and that Resident #1 usually did not get her brief changed 9 times out of 10 because she has gotten mad with staff and aides. LVN A stated that if she refused to get up and use the toilet, staff will leave her and do not change her brief and have to go back later. LVN A stated that if she refused a 2nd time to get up and use the toilet then staff will change her brief then. LVN A stated she had not read Resident #1's care plan, but administration said she was capable to get up and go to the bathroom. LVN A stated she received an in-service about Resident #1 getting up and going to the bathroom and was instructed if Resident #1 refused the first time try again and let the nurse know and then if she refused again to let administration know. LVN A stated rounds were done every two hours or as needed when a call light is put on. During rounds residents were checked to see if they needed to be changed, needed any drinks or whatever else they may need. LVN A stated that she knew if a resident was incontinent based on information in their chart, rounds and knowing most of the residents as she has worked with them. During an interview on 09/04/2025 at 1:45 PM, LVN B stated that she completed bowel and bladder assessments when they populated in PCC (point click care or electronic health record) to be done. LVN B stated incontinent meant that a resident frequently wet their brief. LVN B stated just because a resident could tell you they had a wet brief did not mean they were continent because they may not feel the urgency. LVN B stated that she was familiar with Resident #1 and she was usually continent and could go to the bathroom. LVN B stated on 09/04/2025 Resident #1 refused to go to the bathroom when staff tried to toilet her at 9:45 AM and 10:26 AM. LVN B stated she did not think Resident #1's brief was wet during those times. LVN B Stated Resident #1 will have times she will get up and go to the bathroom and Resident #1 will say she does not want to get up and go to the bathroom. LVN B stated that if Resident #1 lets staff know her brief is wet, staff should try to get Resident #1 to the toilet, but if she refused then they were supposed to change her brief. LVN B stated rounds were done every two hours and during rounds aides checked residents to see if they needed help to the bathroom or changed residents if they needed to be changed. During an interview on 09/04/2025 at 2:19 PM, MD stated that she was familiar with Resident #1 and Resident #1 had not complained about being incontinent and had not mentioned issues about not being able to go to the bathroom. MD Stated staff should motivate Resident #1 to sit on the commode. MD stated staff should of course change Resident #1 and check her and if she was wet staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2025 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should change Resident #1. MD stated if a resident was incontinent before and is not continent the resident should be encouraged to go to the toilet. MD stated testing a resident's incontinence required urological follow up, but she had not received information about a request for a urological follow up for Resident #1. MD stated she would refer to a urologist for issue with incontinence. During an interview on 09/04/2025 at 2:33 PM, SW stated that there was a care plan meeting held with Resident #1 recently and Resident #1 thought the facility wanted her to do more than she could actually do. SW stated Resident #1 was difficult to get along with sometimes. SW stated during the care plan Resident #1 stated she needed assistance wiping after a BM and understood to push her call light for assistance. SW stated that it was discussed that when Resident #1 needed to be changed staff would offer toileting to her, which resident was in agreement with. SW stated Resident #1 stated she could transfer to toilet, but needed help with wiping and will agree, but then chooses not to do it sometimes and demands assistance from staff. SW stated if Resident #1 asked to be changed then staff should go in and change her. During an interview on 09/04/2025 at 2:33 PM, the DON stated that Resident #1 was independent with toileting and can take herself and if she needed help getting up staff could assist with that. The DON stated that on the Kardex staff marked incontinent to indicate the resident had an incontinent episode. The DON stated that a resident was incontinent when the resident could not tell you after they urinated or had a bowel movement. The DON stated that meant the resident did not have the sensation to know they needed to go. The DON stated that the resident may be able to tell after they went, but not while or when the needed to urinate or have a bowel movement The DON stated staff were supposed to offer to take Resident #1 to the toilet and if she refused they were supposed to leave and reapproach her again in thirty minutes to an hour and this included if the resident had a soiled or wet brief. The DON then stated she was not positive if staff were leaving and returning to change Resident #1 right away, but expected staff to go back and unsure what the time frame was for staff to go back. The DON stated if Resident #1 refused to go to the toilet staff would not change her because Resident #1 was independent. The DON stated she was unsure how often bowel and bladder screenings are redone. The DON stated that rounds were done every two hours and staff were to ensure residents were breathing and this included changing the resident if they were wet if they were incontinent. The DON stated that staff can find in PCC if a resident was incontinent. The DON stated that Resident #1's chart should say she is continent. The DON stated it was important that a resident be changed to prevent skin breakdown. The DON stated if a resident was incontinent they may be able to feel after they are wet or soiled, but they don't know when it is happening. During an interview on 09/04/2025 at 3:28 PM, the ADM stated Resident #1 being toileted was prompted by facility looking at residents who often needed help and that the facility wanted to ensure they rehabilitated not debilitated resident. The ADM stated that obviously residents would still be assisted, but wanted to promote residents independence who could do a lot of things on their own. The ADM stated that staff stated Resident #1 would sit and pee and let staff know to go and change her. The ADM stated that they met with ombudsman and set up care plan so aides can take care of residents who really need assistance and promote independence. The ADM stated that he expected if Resident #1 stated she was wet that he would ask why she did not get up and go to the bathroom because she can go. He stated staff should offer to take Resident #1 to the bathroom and she should get up. The ADM stated before the care plan meeting staff were going in and changing Resident #1's brief and also offering her to get up and get toiled and waiting on her hand and foot. The ADM stated he was not present during the care plan meeting. The ADM stated that if Resident #1 refused to get up and go to the toilet he expected staff to change her brief and if she starts cussing then care ends and staff could return (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455631 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2025 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete when she was in a better mood. The ADM stated that he did not know how often staff would go back and check on Resident #1 because two staff were required and sometimes it was quick and sometimes it was 30 minutes to an hour. The ADM stated that Resident #1 admitted she was continent otherwise to determine incontinence a physician would have to be consulted. The ADM stated Resident #1 does not have issues when she goes out on pass and takes herself to the toilet then. The ADM stated it was in the POC for staff to find if a resident was continent or incontinent. The ADM stated that Resident #1's POC should say she was continent. During exit conference interview on 09/04/2025 at 4:20 PM, the ADM and DON were notified of findings. The ADM stated that surveyor was citing that she has the right to be lazy. The ADM stated that staff provided care residents needed not wanted and asked if Resident #1 asked for a colostomy bag if he would have to provide her with one. The ADM stated, I haven't even taken the briefs away from her yet. Review of facility in-service dated 07/16/2025 reflected Resident #1 required two person assist for all interactions. Review of facility in-service titled August in-service dated 08/28/2025 reflected incontinent- difference between can't and won't. Take residents to the bathroom when possible. Review of undated facility policy titled Statement of Resident Rights reflected residents had the right to all care necessary to have the highest possible level of health, and safe, clean and decent conditions. Further review reflected The facility must encourage and assist you to fully exercise your rights. Event ID: Facility ID: 455631 If continuation sheet Page 6 of 6