Coleman Healthcare Center

Based on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure DA wore a hair net when he entered the kitchen.2. The facility failed to ensure the cook wore gloves while touching bread when serving food. These failures could place residents at risk for contamination and foodborne illnesses. Findings included: During an observation on 03/03/2026 at 9:59 AM the DA was wearing a baseball cap with hair pulled through the back (ponytail), without the use of a hair net . The [NAME] was observed touching the bread with her bare hand. During an interview on 03/05/2026 at 3:00 PM, the CCS stated all staff in the kitchen should have been wearing a hair net, he stated even if wearing a ball cap, no hair should be uncontained. The CCS stated if any staff were working in the kitchen, if they were going to touch food, the staff had to be gloved. He stated the DM should have monitored the staff in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure that the facility had an Administrator licensed by the state that was responsible for management for 1 of 1 facility's reviewed for governing body. The facility failed to ensure the Assistant Administrator, who was acting as the facility Administrator, had an active Texas Administrator license. The facility had not had a licensed administrator since 06/20/2025. This deficient practice could result in decreased quality of life and quality of care due to a lack of staff oversight and monitoring of care.The findings include:During Interview on 3/06/2026 at 3:30 p.m. The Assistant administrator stated she had failed her test to be a licensed Administrator. She stated she had applied to retest and was waiting for a date to test again. She stated RDO (Regional Director of Operations) was the licensed Administrator covering the building. She stated she could call her if she needed her. She stated there was no negative outcome for residents due to her lack of a valid Administrator license. During interview on 03/06/2026 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course for 2 (NA C and NA D) of 5 nurse aides reviewed. The facility failed to ensure NA C and NA D were certified within the required time frame. This failure could place residents at risk of receiving care from an individual whose skill level was unknown. Findings include: Record review of employee facilities files revealed: -NA C had a hire date of 4/08/2024, worked full time, and no evidence of nurse aide certification. -NA D had a hire date of 03/21/2025 and worked full time and no evidence of nurse aide certification. During an attempt at phone interviews on 03/06/2026 at 4:25 p.m. NA C and NA D were not available. During an interview on 03/06/2026 at 4:15 p.m. with the DON and ADON both stated that the expectation would be for the facility to have certified nurse assistants. The ADON stated that both she and the DON were aware that NA C and NA D had not been tested. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 1 (lunch meal) of 1 meal observed for nutritional adequacy. The facility failed to ensure Resident #11 received condiments and roll during the lunch. These failures could place residents at risk of poor intake, chemical imbalance and/or weight loss.The findings include: Resident #11 Review of Resident #11's Face Sheet revealed an [AGE] year-old male initially admitted on [DATE]. Resident #11's medical diagnoses included disturbance, psychotic disturbance, mood disturbance, anxiety and lack of coordination. Review of Resident #11's Annual MDS dated [DATE] revealed in Section C - C0500. BIMS Summary Score a BIMS score had not been completed. Review of Resident #11's Comprehensive Care Plan initiated 12/01/2023 and reviewed/revised 01/13/2026 revealed the following focused areas: Nutrition: Focus - Resident has the potential nutritional problem r/t DX Protein-calorie malnutrition and remains at risk for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

During an observation, interview, and record review, the facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance as well as failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal The facility failed to provide a lunch meal that was flavorful and palatable due to puree texture and thickness. This failure could place residents at risk for decreased meal satisfaction and weight loss.Findings Include: During an observation on 03/03/2026 at 12:00 PM, the [NAME] placed the puree meal and pureed bread in microwave for reheating. During an observation on 03/03/2026 at 12:35 PM, the CNA E was assisting residents with a puree meal. Observation of the pureed bread looked dry and too thick, the CNA was not assisting with feeding the pureed bread to the resident. During an interview on 03/03/2026 at 12:25 the [NAME] stated there was only on resident who received a pureed meal. The cook stated she always prepared the one residents puree meal and placed covered in the microwave…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure each resident had the right to a dignified existence for 1 of 1[TT1] resident (Resident #1) whose care was reviewed in that: Resident #1's indwelling urinary catheter bag was not covered. These deficient practices could affect residents who had indwelling urinary catheters by contributing to poor self-esteem, lack of information, and unmet needs.The findings were: Record[TT1] review of Resident #1's electronic face dated 09/9/25 sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with a diagnosis that included kidney disease (unable to remove waste), heart failure, ureteral obstruction (kidney damage), cerebral infarction (Stroke). Record review of Resident #1's physician's electronic consolidated orders for August 2025 revealed the following: *Catheter care every shift with soap and water ordered.*Access Foley catheter for proper function and ensure proper placement of catheter bag every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment for Residents #6, #7, and #8 (Resident room # 302 and #306) reviewed for environment. The facility failed to ensure resident rooms #302 and #306 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 7/1/25 at 9:45am of room [ROOM NUMBER], revealed the floor was sticky and stained, trash/candy wrappers, and food particles under beds A and B. There was also dirt, candy wrappers, and food particles behind dressers and nightstand., The room had a foul odor. Interview on 7/1/25 at 9:46am, in Resident room [ROOM NUMBER] bed A, Resident #6 stated she was well, staff were respectful., Resident #6 stated that housekeeping cleans the room., When asked when the last time it was swept and mopped, Resident #6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities which involved 2 of 14 residents (Resident #134 and Resident #22) reviewed for medication administration and medication errors. 1. LVN A on 11/24/2024 administered 1 tablet of buspirone (medication used to treat anxiety) 5mg to Resident #134 when the physicians order date 04/19/2024 called for 2 tablets. 2. LVN B on 11/24/2024 administered 1 tablet of dicyclomine (medication used to relax abdominal muscles to reduce cramping) 20mg to Resident #22 when the physicians order dated 11/14/2024 called for 2 tablets. These failures could place residents at risk for not having the intended therapeutic benefit. The findings included: 1. Review of Resident #134's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: brain bleed, cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 1 of 2 medication carts (Hall 300/400 medication cart) and 3 of 35 residents (Resident #2, #18 and #29)) reviewed for medication labeling and storage. The Hall 300/400 medication cart contained a Humulin R flex pen insulin for Resident #2 with an open date of 10/20/2024, making it past 28 days meaning the medication had expired. The Hall 300/400 medication cart contained an Insulin Glargine flex pen insulin for Resident #18 with an open date of 10/18/2024, making it past 28 days meaning the medication had expired. The Hall 300/400 medication cart on 11/24/2024 contained a Lantus flex pen insulin for Resident #29 with an open date of 10/12/2024, making it past 28 days meaning the medication had expired and no pharmacy label with the resident's name…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to: A. dispose of food items after the use by or expiration date. B. Store, seal and date food items. These failures could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: During observation on 09/25/2023 from 9:47am to 10:30am of the kitchen Dry Storage: o One unsealed open 10 pounds plastic bag containing graham cracker crust with open date 04/05/2023, o Four 32-ounce bottles of lemon juice with manufactures expire date of 09/05/2023, and o Box with approximately eight individual cheese crackers with arrive date of 08/09/2023 no open date. Refrigerator o One 10 ponds box containing individual 1.5 sausage patties in unsealed plastic bag open date 09/17/2023 and o One unsealed plastic bag containing 5 pounds of raw hamburger meat from an original 10 pound package dated open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds for 3 of 5 (Resident #10, Resident #16, and Resident #21) residents reviewed for trust funds. The facility failed to ensure Resident #'s 10, 16, and 21 personal use funds were disbursed monthly. This failure could place residents whose funds are managed by the facility at risk of not having money needed to purchase personal items. Findings Included: Record review of Resident #10's face sheet revealed an [AGE] year-old female admitted on [DATE] with medical diagnoses of high blood pressure, depression, chronic pain, heart disease, and dementia. Record review of Resident #10's quarterly MDS dated [DATE] revealed at BIMS score of 13 out of 15 indicating intact cognition. Record review of Resident #16's face sheet revealed a [AGE] year-old male admitted on [DATE] with medical diagnoses of cerebral palsy (abnormal brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property by failing to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 3 of 18 (RN-A, RN-B, and SW-C) employees reviewed for abuse and neglect. Facility staff did not have criminal history verification and/or an EMR/NAR verification prior to offering employment to the facility and/or annually for employees. These findings could place residents at risk of receiving care by someone that was unemployable. The findings included: Record review on 09/27/2023 of the CMS-807 Employee files review revealed: RN-A was hired on 05/10/2023, the facility verified his CH on 09/26/2023. RN-A's EMR was dated 05/02/2023 and was verified on 09/26/2023. RN-B was hired on 08/05/2023, her EMR verification was dated 09/27/2023 and SW-C was hired on 04/12/2023, her CH verification was dated 09/26/2023. SW-C's EMR verification was dated 09/26/2023.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain complete and accurate clinical records for 1 of 4 (Resident #2) residents reviewed for weights. The facility failed to weigh Resident #2 since 07/10/2023. These findings place residents at risk for quick interventions for weight loss. Findings included: Record review of Resident #2's Facesheet dated 09/25/23 revealed: An [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis list that included: COPD(Primary), Cognitive communication deficit, Amnesia, Dysphagia, Dementia with psychotic disturbance, Chronic pain, GERD, Vitamin B12 deficiency anemia, Vitamin D deficiency, Constipation. Record review of Resident #2's Significant Change MDS dated [DATE] revealed a BIMS of 2 meaning severe cognitive impairment. No chewing or swallowing difficulties. A weight of 137 lbs. No or unknown weight loss of 5 percent in last 6 months. Resident had a mechanically altered diet . Record review of Resident #2's Quarterly MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.