Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Manor Nursing Center during CMS and state inspections, most recent first.
A resident with vascular dementia and a history of physical behaviors toward others physically assaulted his severely cognitively impaired roommate, causing facial scratches, after staff heard the roommate crying for help. Despite documented agitation and yelling whenever other residents entered his room, this same resident later followed another cognitively impaired resident down the hall and initiated a fist fight, with both residents swinging and their arms making contact. In a separate incident, an LVN yelled at a cognitively impaired female resident who repeatedly requested to use the bathroom, called her a liar about needing to void, and blocked her from getting up from her wheelchair, while the resident cried and begged to go to the bathroom. These events, corroborated by multiple staff statements, progress notes, and interviews, show that the facility did not protect residents from physical and verbal abuse as required by its abuse and neglect policy.
The facility failed to timely report an alleged resident-to-resident physical altercation as required by abuse reporting regulations and its own policy. A resident with severe cognitive impairment and a history of physical aggression became agitated after another cognitively impaired resident with a history of wandering entered his room, followed him into the hallway, and initiated a fist fight from his wheelchair. Documentation by an LVN described a brief fight, with arms making contact and no injuries, and indicated that the incident was reported internally to leadership. However, the Administrator did not submit a report to the State Survey Agency, believing there had been no physical contact, and the DON later acknowledged that the event was a physical altercation that was neither investigated nor reported as required.
A resident with a history of stroke, mental health conditions, and frequent incontinence was not allowed to exercise choice regarding incontinence care. Staff, following administrative direction, insisted the resident use the commode and delayed changing her brief when she requested to be changed in bed, resulting in inconsistent and delayed care. Interviews and documentation showed staff were unclear on the care plan and resident rights, leading to the resident remaining in soiled briefs until she agreed to use the toilet or staff returned later.
A LTC facility failed to maintain an effective infection control program, with staff not adhering to sanitation and hand hygiene protocols. A medical assistant did not sanitize a blood pressure cuff between residents, a CNA did not wash hands during incontinent care, and an LVN did not use hand sanitizer after wound care. These lapses occurred despite staff being trained on infection control practices.
Failure to Prevent Resident-to-Resident Physical Abuse and Staff Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and to prevent resident-to-resident altercations. One male resident with vascular dementia, severe cognitive impairment, and documented physical behaviors toward others was care planned for behavioral problems after he hit another resident. On one occasion, staff heard his roommate, an elderly male with Alzheimer’s disease and severe cognitive impairment, yelling for help and crying. When CNAs entered the shared room, they observed the aggressive resident standing over the roommate with his hand balled into a fist and pulled back, while the roommate was curled on his side with his hands over his face. Multiple staff statements and progress notes documented visible injuries to the roommate, including small open areas and scratches under the right eye and on the bridge of the nose, and the roommate repeatedly questioned why he had been hit. The aggressive resident denied hitting him but stated the roommate would not “shut up.” Subsequent documentation showed that the same aggressive resident continued to exhibit agitation and yelling when other residents entered his room. Progress notes on several dates described him becoming agitated and yelling at other male residents who wandered into his room, requiring redirection by staff. Despite his history of physical behavior toward others and repeated episodes of agitation when other residents entered his room, he was later involved in another altercation with a different male resident with dementia and severe cognitive impairment. In that incident, the second resident wandered into his room, was asked to leave, and the aggressive resident followed him down the hall to initiate a fist fight. Staff reported that the residents began swinging at each other, arms made contact, and they stopped when told to do so. No injuries were noted, but the event was documented as a resident-to-resident altercation with physical contact. The deficiency also includes an incident of verbal and emotional abuse toward a female resident with Alzheimer’s disease, dementia, depression, and moderate cognitive impairment. This resident had a care plan for wandering and exit seeking. On one night, a CNA reported that an LVN yelled at the resident, told her to sit in her wheelchair and not move, and blocked her from getting up while the resident repeatedly stated she needed to use the bathroom and feared she would urinate on herself. According to the CNA’s written and verbal statements, the LVN told the resident she was lying about needing the bathroom and called her “nothing but a liar,” while the resident became upset, cried, and begged to go to the bathroom. The CNA described this as verbal abuse and neglect and removed the resident from the situation. The LVN later acknowledged telling the resident she was lying about needing the bathroom, though she denied yelling or preventing her from leaving the wheelchair. Facility leadership, including the Administrator, ADON, and DON, stated that calling a resident a liar is inappropriate, abusive, and could be considered verbal or emotional abuse under the facility’s abuse, neglect, and exploitation policy, which defines physical abuse as hitting or punching and mental abuse as including humiliation and harassment. The facility’s own policy on abuse, neglect, and exploitation, dated 09/06/2024, states that it is the policy to protect residents’ health, welfare, and rights by prohibiting and preventing abuse, neglect, exploitation, and misappropriation of resident property. The policy defines physical abuse to include hitting and punching, and mental abuse to include humiliation and harassment. In the events described, residents with significant cognitive impairments and behavioral care plans were subjected to physical aggression by another resident and to verbal humiliation by a staff nurse. These actions and inactions, as documented in staff statements, progress notes, and interviews, demonstrate that the facility failed to ensure residents’ right to be free from abuse, neglect, and exploitation as required by its own policy and regulatory standards.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged resident-to-resident physical altercation as required by federal regulations, state law, and the facility’s own abuse, neglect, and exploitation policy. On 01/31/2026, a licensed vocational nurse (LVN A) documented that one resident with severe cognitive impairment and a history of physical aggression became agitated after another resident with severe cognitive impairment and a history of wandering entered his room. According to the progress note, the first resident followed the second resident down the hall from his wheelchair and initiated a fist fight, punching at the other resident, with a brief fight occurring until staff told them to stop. The note stated that the residents’ arms made contact, there were no signs or symptoms of injury, and no complaints of pain. Both residents involved had significant cognitive and behavioral issues documented in their records. The first resident, a 61-year-old male with alcoholic polyneuropathy, vascular dementia, and aphasia, had an MDS score indicating severe cognitive issues and documented physical behavioral symptoms toward others occurring 1 to 3 days, as well as a care plan focus for behavioral problems including a prior incident of hitting another resident. The second resident, a 75-year-old male with dementia, bipolar disorder, and anxiety disorder, also had an MDS score indicating severe cognitive issues and continuous delirium-related inattention and disorganized thinking, and a care plan focus for behavior problems including agitation, aggression toward staff, and punching at the air when frustrated. Care plan interventions for both residents included monitoring behaviors, anticipating needs, and intervening calmly to prevent escalation. Despite the documented altercation and the facility’s written policy requiring immediate reporting of all resident-to-resident altercations involving allegations of abuse to the Administrator and subsequent reporting by the Administrator to the state agency within specified time frames, the incident was not reported to the State Survey Agency through the TULIP portal until 02/13/2026. Review of TULIP records showed no report of the 01/31/2026 incident until that date. In interviews, LVN A stated that the residents started to hit each other but did not make contact and that he reported the incident to the Administrator, DON, and ADON. The Administrator stated he did not self-report the incident because he believed there was no physical contact and did not think it needed to be reported based on how it was explained to him, although he acknowledged that the progress note indicated an intent to hurt and potential for frightening the other resident. The DON stated the incident was a resident-to-resident physical altercation that was neither investigated nor reported to HHS, despite facility policy requiring investigation and reporting of all such allegations.
Failure to Support Resident Choice in Incontinence Care
Penalty
Summary
The facility failed to honor and facilitate a resident's right to self-determination and choice regarding incontinence care. The resident, an older adult with a history of hemiplegia, hemiparesis, bipolar disorder, schizoaffective disorder, muscle weakness, and unsteadiness, was frequently incontinent of bowel and bladder and required assistance with activities of daily living. Despite being care planned for frequent checks and changes of briefs as needed, staff insisted that the resident use the commode instead of changing her brief when soiled, even when the resident requested to be changed in bed. The care plan and Kardex indicated the use of briefs and the need for frequent checks, but staff practice was to encourage or require the resident to get up and use the toilet, and if she refused, to delay changing her until she agreed to use the commode or until a later time. Interviews with staff revealed inconsistent understanding and implementation of the resident's care plan. Some CNAs and nurses stated they were instructed by administration to prioritize toileting the resident and to withhold changing her brief in bed if she refused to get up, only returning later to attempt toileting again. Staff described a process where refusal to use the toilet was interpreted as refusal of care, resulting in the resident remaining in a soiled brief until she complied or until staff returned. Documentation and interviews confirmed that the resident was able to request changes when wet but was not always accommodated promptly if she declined to use the commode. The resident herself reported that she could not sense when she needed to urinate, only realizing after she was wet, and that she wanted her brief changed when soiled, but staff told her she had to get up and use the toilet per her care plan. Administrative and clinical leadership interviews further demonstrated a lack of consensus on the resident's continence status and the appropriate response to her requests. The DON and ADM both referenced promoting independence and rehabilitation, with the ADM stating that care should be provided based on need, not want, and that staff should encourage the resident to use the toilet. However, there was acknowledgment that if the resident refused to get up, staff would not immediately change her, and the timing of follow-up was inconsistent. The facility's own policies and in-service education highlighted the importance of resident rights and the distinction between "can't" and "won't" regarding incontinence, but the actual practice did not consistently support the resident's autonomy or timely care as outlined in her care plan.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to proper sanitation and hand hygiene protocols. Specifically, a medical assistant (MA C) did not sanitize a blood pressure cuff when moving between two residents, despite being trained on infection control practices. This oversight occurred during a medication pass and was acknowledged by the medical assistant, who admitted to forgetting the procedure. Additionally, a certified nursing assistant (CNA A) did not wash or sanitize her hands when transitioning from a dirty to a clean surface while performing incontinent care on a resident. Although the CNA was aware of the proper protocol and had been trained on infection control, she failed to follow the procedure, stating she only changed gloves and washed hands if feces were present. This lapse in protocol was observed during the care of a resident who was always incontinent of bowel and bladder. Furthermore, a licensed vocational nurse (LVN B) did not wash his hands or use hand sanitizer after removing a soiled dressing during wound care for a resident. The LVN cited a non-functional sink as the reason for not washing hands, but did not consider using alcohol-based hand sanitizer as an alternative. The Director of Nursing (DON) confirmed that staff are expected to cleanse their hands between glove changes and when moving from dirty to clean surfaces, and that the blood pressure cuff should be cleaned between residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 340 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cleburne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Trails Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 4 | 0 |
| Ridgeview Rehabilitation And Skilled Nursing | 3.1 mi | ★★★★★ | 6 | 0 |
| Town Hall Estates Keene, Inc. | 4.8 mi | ★★★★★ | 0 | 0 |
| Advanced Rehabilitation & Healthcare Of Burleson | 11.1 mi | ★★★★★ | 13 | 1 |
| Alvarado Meadows Nursing & Rehabilitation | 11.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Colonial Manor Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.