Cycle 1
Health 2025-02-06 · Fire 2025-02-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cleburne, TX
Colonial Manor Nursing Center
4-star overall rating with 3-star inspections with $35,539 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2035 N Granbury St, Cleburne, TX
(817) 645-9134
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
137
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ruby Healthcare
Operator or chain grouping
Approved since
1986-01-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 3 overall / 2 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.30
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.34
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
4.47
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,348
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.96% · Performance 21.56% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.30
Baseline 5.95% · Performance 5.95% · Measure score 6.30 · Achievement 6.30 · Improvement 0
Total nurse turnover
4.41
Baseline 92.86% · Performance 59.46% · Measure score 4.41 · Achievement 1.03 · Improvement 4.41
Adjusted total nurse staffing
2.57
Baseline 3.51 hours · Performance 3.81 hours · Measure score 2.57 · Achievement 2.57 · Improvement 0.82
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.33% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 6.99% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 10 · Denominator 23 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 11 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 1 · Denominator 33 · Adjusted rate 2.21% |
| Healthcare-associated infections requiring hospitalization | 5.95% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 0% · Lower 95% interval 3.28% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 79 |
| Staff flu vaccination coverage | 40.17% |
42%
1.8 pts worse
|
Numerator 47 · Denominator 117 |
| Discharge function score | 65.22% |
56.45%
8.8 pts better
|
Numerator 15 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.3%
2.5 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.3% · Q3 7.7% · Q4 5.6% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
2.7%
1.5 pts worse
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.5% · Q3 5.6% · Q4 5.1% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
3.3%
0.3 pts worse
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.3% · Q3 3.7% · Q4 6.2% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
18.9%
6.9 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 12.1% · Q3 8.8% · Q4 14.9% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
10.8%
1.6 pts worse
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 13.0% · Q3 11.1% · Q4 10.4% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.6% |
15.4%
6.8 pts better
|
16.3%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 11.4% · Q3 3.4% · Q4 9.6% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
16.1%
6.6 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 11.5% · Q3 5.7% · Q4 15.9% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.0% |
15.0%
6 pts better
|
19.8%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 9.9% · Q3 7.7% · Q4 13.9% · 4Q avg 9.0% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.2%
2.4 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 4.0% · Q3 1.6% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
89.7%
9.4 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
12.0%
3.9 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 8.3% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.7% |
25.9%
13.2 pts better
|
23.9%
11.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 12.5% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-23 · Fire 2023-12-23
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-30 · Fire 2022-09-30
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-06
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-05-01
F · Potential for more than minimal harm
2023-12-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-29
E · Potential for more than minimal harm
2022-09-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-11-28
E · Potential for more than minimal harm
2022-09-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-09-30
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-12-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-04
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-09-22
E · Potential for more than minimal harm
2025-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-21
K · Immediate jeopardy
2023-12-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-26
K · Immediate jeopardy
2023-12-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-26
F · Potential for more than minimal harm
2023-12-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-24
E · Potential for more than minimal harm
2023-12-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-24
D · Potential for more than minimal harm
2023-12-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-12-24
D · Potential for more than minimal harm
2023-12-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-24
E · Potential for more than minimal harm
2023-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-22
E · Potential for more than minimal harm
2023-08-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-19
D · Potential for more than minimal harm
2023-08-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-19
D · Potential for more than minimal harm
2023-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-21
E · Potential for more than minimal harm
2022-09-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-30
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-09-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-09-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-09-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-09-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-13
C · Minimal harm
2022-09-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-11-13
Penalties and ownership
What sits behind the stars
$35,539
2023-12-23
Fine
Fine · fine $35,539
Fine
Ownership
Advanced Hcs LLC
Operational/Managerial Control · Organization
Byrom, David
Operational/Managerial Control · Individual
Byrom, David
Corporate Director · Individual
Byrom, David
Corporate Officer · Individual
Byrom, David
W-2 Managing Employee · Individual
Coryell County Memorial Hospital Authority
5% Or Greater Indirect Ownership Interest · Organization
Lichtschein, Teddy
Operational/Managerial Control · Individual
Meisner, Michael
Operational/Managerial Control · Individual
Scheiner, Eliezer
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Heritage Trails Nursing And Rehabilitation Center
Cleburne, TX
4-star overall rating with 4-star inspections with $67,124 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Ridgeview Rehabilitation And Skilled Nursing
Cleburne, TX
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Town Hall Estates Keene, Inc.
Keene, TX
3-star overall rating with 3-star inspections with $78,402 in total fines with 8 recent health deficiencies
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