Colonial Manor Nursing Center: Dignity Violations - TX
That was his explanation for why staff had been leaving a resident, identified in inspection records as Resident 1, sitting in disposable briefs rather than taking her to the toilet.
Inspectors from the Centers for Medicare and Medicaid Services visited Colonial Manor Nursing Center on September 4, 2025, responding to a complaint. What they found, and what the administrator said in response, is documented in a CMS inspection report.
Resident 1 was continent. She could take herself to the bathroom when she went out on a pass. The facility's own plan of care said she was continent. An in-service training the facility ran in July 2025 noted she required two-person assist for all interactions, which is why staff said they sometimes couldn't get to her quickly. An in-service from August 28, 2025, titled with the phrase "incontinent, difference between can't and won't," included the instruction to take residents to the bathroom when possible.
The facility trained its own staff on exactly this distinction. Then, when an inspector raised it, the administrator called it laziness.
During the exit conference on the afternoon of September 4, the administrator and the director of nursing were told what inspectors had found. The administrator's response was to ask whether, if Resident 1 requested a colostomy bag, he would be required to provide her with one. He said staff provided care residents needed, not care they wanted.
Then he said: "I haven't even taken the briefs away from her yet."
The administrator told inspectors he didn't know how often staff went back to check on Resident 1 after she declined care, because the timing varied. Sometimes it was quick, he said. Sometimes it was 30 minutes to an hour.
He said that Resident 1 admitted she was continent, and that to formally determine incontinence a physician would need to be consulted. He said she had no issues when she went out on pass and used the toilet herself. He acknowledged her plan of care should reflect that she was continent.
The facility's own resident rights policy, reviewed during the inspection, stated that residents have the right to all care necessary to achieve the highest possible level of health, and to safe, clean, and decent conditions. The same policy stated the facility must encourage and assist residents to fully exercise their rights.
CMS cited the violation under F0561, which covers the right of residents to self-determination and dignity. The level of harm was assessed as minimal harm or potential for actual harm, affecting a few residents.
The citation is on the lower end of the federal penalty scale. It will not close the facility. It may not cost the facility a dollar. But the administrator's words at that exit conference are now part of the public record, and they are worth reading twice.
He did not dispute that Resident 1 was continent. He did not dispute that she wanted to use the toilet. He did not dispute that staff sometimes left an hour between check-ins. His argument was that wanting to use the toilet, when you are physically capable of using the toilet, is a want rather than a need, and that the facility was only obligated to meet needs.
Resident 1, according to the inspection record, sometimes declined care when she was not in a good mood. The administrator offered this as context. A continent woman, living in a nursing home, sometimes didn't want to interact with staff. When she said no, staff left. When they came back, the timing was unpredictable. In the meantime, she sat in a brief.
The August training the facility ran for its own staff drew the line plainly: incontinent means can't. This resident could.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Manor Nursing Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
Colonial Manor Nursing Center in Cleburne, TX was cited for violations during a health inspection on September 4, 2025.
Inspectors from the Centers for Medicare and Medicaid Services visited Colonial Manor Nursing Center on September 4, 2025, responding to a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.