Colonial Manor Nursing Center
2035 N Granbury St, Cleburne, TX 76031 · Johnson County · 137 certified beds · avg 78 residents/day · certified since Jan 23, 1986
Abuse citation flag (CMS)
Part of chain: RUBY HEALTHCARE (7 facilities, chain avg rating 2.9★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Dec 23, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 26, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Dec 23, 2023 · F-0656
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 26, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 13, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 15, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (15)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 9, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 13, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Feb 13, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Feb 6, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 23, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 23, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Dec 23, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 23, 2023 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Dec 23, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Dec 23, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Sep 21, 2023 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 18, 2023 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Aug 18, 2023 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Aug 18, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (1 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 10 | 2 | K ▲ |
| 2025 | 2 | 0 | E |
| 2026 | 3 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $51,594.
| Date | Type | Amount / length |
|---|---|---|
| Feb 13, 2026 | Fine | $16,055 |
| Dec 23, 2023 | Fine | $35,539 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.37 | 3.46 | 3.95 | top 9% in Texas; top 27% in the U.S. |
| Registered Nurse hours | 0.48 | 0.44 | 0.69 | top 28% in Texas; bottom 35% in the U.S. |
| Weekend total nurse staffing | 3.91 | 3.04 | 3.50 | top 8% in Texas; top 26% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.40 | 0.34 | 0.48 | top 26% in Texas; top 48% in the U.S. |
| Total nursing staff turnover (%) | 52.8 | 55.3 | 45.8 | bottom 48% in Texas; bottom 30% in the U.S. |
| RN turnover (%) | 50.0 | 54.6 | 42.9 | top 41% in Texas; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.78, RN 0.42, weekend 3.38. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Coryell County Memorial Hospital Authority | Organization | 5% or Greater Indirect Ownership Interest | — | 09/01/2014 |
| Advanced HCS LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2014 |
| Byrom, David | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/01/2014 |
| Byrom, David | Individual | Corporate Director | NOT APPLICABLE | 09/01/2014 |
| Byrom, David | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2014 |
| Byrom, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2014 |
| Lichtschein, Teddy | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2021 |
| Meisner, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2021 |
| Scheiner, Eliezer | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Heritage Trails Nursing and Rehabilitation Center | 1.5 mi | Cleburne, TX | ★★★★☆ | 4/5 | |
| Ridgeview Rehabilitation and Skilled Nursing | 3.0 mi | Cleburne, TX | ★★★★☆ | 4/5 | |
| Town Hall Estates Keene INC | 4.8 mi | Keene, TX | ★★★☆☆ | 4/5 | |
| Advanced Rehabilitation & Healthcare of Burleson | 11.1 mi | Burleson, TX | ★★☆☆☆ | 2/5 | |
| Alvarado Meadows Nursing & Rehabilitation | 11.3 mi | Alvarado, TX | ★★★☆☆ | 3/5 | |
| 600 Maple Ave. | 12.5 mi | Burleson, TX | ★★★☆☆ | 4/5 | |
| Grandview Nursing and Rehabilitation Center | 14.5 mi | Grandview, TX | ★★★★★ | 4/5 | |
| Crowley Nursing and Rehabilitation | 14.5 mi | Crowley, TX | ★★★★★ | 4/5 | |
| Allegiant Wellness and Rehab | 15.3 mi | Crowley, TX | ★★★★★ | 5/5 | |
| Park Bend Rehabilitation and Healthcare Center | 15.9 mi | Burleson, TX | ★★☆☆☆ | 1/5 | |
| Avir at Fort Worth | 19.1 mi | Fort Worth, TX | ★★☆☆☆ | 1/5 | abuse |
| Estates Healthcare and Rehabilitation Center | 19.3 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 455631.