Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coleman Healthcare Center during CMS and state inspections, most recent first.
Kitchen staff failed to follow food safety practices when a DA entered the kitchen without a hair net and a cook touched bread with a bare hand while serving food. The CCS, DM, and dietician all stated staff in the kitchen should have worn hair restraints and gloves when handling ready-to-eat food, and the facility policy prohibited bare hand contact with food.
Unlicensed Administrator Oversaw Facility Operations: The facility failed to ensure that a state-licensed Administrator was responsible for management. The Assistant Administrator stated she had failed the licensure exam and was waiting to retest, while the RDO stated the facility had been without a licensed Administrator for several months. The RDO said the Assistant Administrator had been hired to become the licensed Administrator, and the DON stated he was the designated Abuse Coordinator if there was not an Administrator. The facility could not provide a policy regarding facility administration.
The facility failed to ensure 2 nurse aides were certified within the required timeframe. Record review showed one aide had worked full time since hire without CNA certification, and another had worked full time with no evidence of certification. The DON and ADON stated they knew both aides had not been tested; one aide had taken the CNA class twice without passing and needed special testing accommodation, while the other had completed NA training and was waiting for a test date.
Menu items and condiments not provided with lunch meal. A resident with a history of psychotic disturbance, mood disturbance, anxiety, and lack of coordination was on a regular, mechanical soft diet and had a care plan for nutritional risk. During a lunch meal observation, he was served soup and a baked potato but did not receive the dinner roll or requested condiments, and he stated he would not eat the potato without the sour cream and cheese he had asked for. Staff stated the condiments should have been on the tray and that the kitchen did not have the items for the alternate meal.
A resident’s pureed lunch was reheated in a microwave, and the pureed bread was observed dry, too thick, and too hot to serve. A CNA chose not to assist with feeding the bread because of the texture and temperature. The cook stated the meal was kept covered in the microwave until serving, while the CCS and Dietician stated hot foods should be held on the steam table and temperatures monitored; no temp log was found for the pureed food.
A resident with an indwelling urinary catheter was observed without a privacy cover on the catheter bag, despite physician orders and care plan requirements for such a cover to maintain dignity. The bag was visible from the hallway, and the resident reported never having seen a privacy cover. Facility staff, including an LVN, DON, and Administrator, acknowledged that the catheter bag should have been covered as ordered.
Surveyors found that two resident rooms were not thoroughly cleaned or sanitized, with sticky floors, trash, and food particles present under beds and behind furniture. Residents reported that housekeeping cleans several times a week but could not recall when the rooms were last swept or mopped, and none had reported the issue to staff. Facility staff confirmed that rooms should be cleaned daily or as needed, but were unaware of the unclean conditions in these rooms.
The facility reported an 8% medication error rate, exceeding the acceptable 5% threshold. Two residents received incorrect dosages due to LVNs not verifying medication orders properly. One resident with anxiety received an insufficient dose of buspirone, while another with bowel issues received an incorrect dose of dicyclomine. The DON attributed these errors to inattention, despite clear medication orders.
The facility failed to properly label and store insulin pens, leading to expired medications being available for administration. Insulin pens for three residents were found to be past their 28-day expiration period, with some lacking proper pharmacy labels. Staff interviews revealed a lack of adherence to medication storage and administration policies, potentially risking the administration of expired medications.
Kitchen Staff Failed to Use Hair Restraints and Gloves
Penalty
Summary
Food was not properly stored, prepared, distributed, and served in accordance with professional standards in the kitchen. During an observation on 03/03/2026 at 9:59 AM, the DA was wearing a baseball cap with hair pulled through the back in a ponytail and did not have a hair net on while in the kitchen. During the same observation, the [NAME] was seen touching bread with a bare hand while serving food. During interviews, the CCS stated all staff in the kitchen should have been wearing a hair net and that even if a ball cap was worn, no hair should have been uncontained. The CCS also stated staff touching food had to be gloved and that the DM should have monitored kitchen staff better. The DM stated all staff entering or working in the kitchen should have a hairnet on before entering the food preparation and serving area, and that food should not have been touched without gloves. The dietician stated staff entering the kitchen should have a hairnet, that a ball cap alone was not appropriate if hair was out, and that ready-to-eat food should not have been touched without gloves. Record review of the facility policy stated bare hand contact with food is prohibited, gloves are worn when handling food directly, and food service staff wear hair restraints so hair does not contact food.
Unlicensed Administrator Oversaw Facility Operations
Penalty
Summary
The facility failed to ensure that it had an Administrator licensed by the state who was responsible for facility management. During interview on 3/06/2026 at 3:30 p.m., the Assistant Administrator stated that she had failed the test to become a licensed Administrator and was waiting for a retest date. She stated that the Regional Director of Operations was the licensed Administrator covering the building and that she could call her if needed. She also stated there was no negative outcome for residents due to her lack of a valid Administrator license. During interview on 03/06/2026 at 3:45 p.m., the RDO stated the facility had been without a licensed Administrator for several months. She stated the Assistant Administrator had been hired to move into the licensed Administrator position after passing the licensure exam, but she failed the examination and had applied to test again. She stated she had not been actively seeking a licensed Administrator because the job had been promised to the Assistant Administrator. During interview on 03/07/2026 at 4:15 p.m., the DON stated he was the designated Abuse Coordinator if there was not an Administrator. Record review of the facility's Active Employee Report showed the Assistant Administrator was hired on 07/23/2024, and during the exit conference on 03/06/2026 at 5:00 p.m., the facility was unable to provide a policy regarding facility administration.
Uncertified nurse aides worked beyond required timeframe
Penalty
Summary
The facility failed to ensure that nurse aides were certified within the required time frame for 2 of 5 nurse aides reviewed, NA C and NA D. Record review showed NA C had a hire date of 4/08/2024, worked full time, and had no evidence of nurse aide certification. NA D had a hire date of 03/21/2025, worked full time, and also had no evidence of nurse aide certification. The report states that both aides had worked in the facility longer than four months without being enrolled in or having completed an approved training course. During interview, the DON and ADON stated the expectation was 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 stated there had been no certified applicants and the facility had only been able to hire NAs. She also stated that NA C had previously been terminated for not having CNA certification, had taken the CNA class twice without passing the test, and required special accommodation for testing. NA D had completed NA training on 06/25/2025 and was waiting on a test date. The facility policy titled The Role of the Hospitality Aide described duties for hospitality aides, including non-nursing, non-direct care duties under supervision of licensed nursing personnel.
Menu items and condiments not provided with lunch meal
Penalty
Summary
The facility failed to ensure the menu was followed for 1 observed lunch meal. Resident #11, an [AGE]-year-old male with diagnoses including psychotic disturbance, mood disturbance, anxiety, and lack of coordination, had a care plan addressing nutritional risk related to protein-calorie malnutrition. His physician orders included a regular diet with mechanical soft texture and thin liquids. The facility menu for the lunch meal listed shrimp fettuccini alfredo, green beans, a dinner roll, gelatin with whipped topping, tableside condiments, a beverage, and water, with an alternative of baked potato with condiments, soup, and hamburger. During the noon meal observation, Resident #11 was served soup, a baked potato, and no roll. He stated he had requested the roll and extra sour cream with his baked potato, and that because he had not received the requested sour cream and cheese, he was not going to eat it. The dietary manager stated the condiments should have been on the tray and that the kitchen had no sour cream or cheese for the baked potato alternative during lunch service. She also stated it was her responsibility to order enough food and condiments. The CCS stated all residents should have received all products listed on the menu, including condiments, and the dietician stated all residents should always receive all food listed on the menu unless there was an allergy.
Pureed Meal Reheated Improperly and Served Too Hot
Penalty
Summary
The facility failed to provide a lunch meal that was flavorful and palatable because the pureed meal and pureed bread were prepared and reheated in a microwave. During an observation at 12:00 PM, the cook placed the pureed meal and pureed bread in the microwave for reheating. Later, at 12:35 PM, a CNA was assisting residents with a pureed meal and observed that the pureed bread looked dry and too thick, and the CNA did not assist the resident with eating the pureed bread. During interviews, the cook stated she prepared the one resident’s pureed meal and kept it covered in the microwave until serving time, then reheated it in the microwave. The CNA stated she decided not to assist feed the resident the pureed bread because it was too thick and too hot to serve, and she stated there was a possibility of the resident getting burned or choking. The CCS stated food should have been placed on the steam holding table prior to serving and was not sure why the cook used the microwave instead. The DM stated all food should be temped correctly prior to transport to the resident, and the Dietician stated all food temperatures should be held on the steam table, not the microwave. Record review showed no temperature log for the pureed food, and the facility policy required mechanically altered hot foods to remain above 135 degrees Fahrenheit during preparation or be reheated to 165 degrees Fahrenheit for at least 15 seconds.
Failure to Provide Privacy Cover for Catheter Bag Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a male resident with a history of kidney disease, heart failure, ureteral obstruction, and cerebral infarction was observed with an indwelling urinary catheter bag that was not covered by a privacy bag. The resident's care plan and physician's orders specifically required the use of a privacy bag to cover the catheter bag for dignity. During the observation, the catheter bag was visible from the hallway due to the resident's open door, and the resident reported never having seen a privacy bag cover for his catheter. He expressed that having the bag covered would be preferable and more dignified. Interviews with facility staff, including an LVN, the DON, and the Administrator, confirmed awareness that catheter bags should be covered with a privacy bag as per care plan and physician orders. The LVN was unsure why the privacy bag was not in place and acknowledged the importance of covering the catheter bag for dignity. Both the DON and Administrator stated that failing to cover the catheter bag could result in dignity issues for residents, especially when it is part of the care plan and physician's orders.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
Surveyors observed that resident rooms #302 and #306 were not thoroughly cleaned or sanitized, with sticky and stained floors, trash, candy wrappers, and food particles found under beds, behind dressers, and nightstands. Both rooms also had a foul odor. Residents occupying these rooms reported that housekeeping generally cleans several times a week, but could not recall when the rooms were last swept or mopped. Residents expressed a preference for a clean environment and noted that the floors were sticky, with one resident mentioning a recent tea spill that had not been cleaned. None of the residents had reported the unclean conditions to staff. Interviews with facility staff, including a CNA, LVN, and the Housekeeping Director, confirmed that rooms are expected to be cleaned daily or as needed, including sweeping and mopping under beds and behind furniture. Staff stated that they notify housekeeping if a room needs attention, but were unaware of the unclean conditions in these specific rooms. The Housekeeping Director acknowledged the expectation for thorough cleaning and recognized the importance of maintaining a clean and sanitary environment for residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. This was based on two errors out of 25 opportunities involving two residents. One resident, a male with a history of brain bleed, cognitive decline, and diabetes, was administered only one tablet of buspirone 5mg instead of the prescribed two tablets. The error occurred because the LVN did not pay attention and failed to verify the correct dosage, which could lead to inadequate anxiety relief for the resident. Another resident, a female with diagnoses including abdominal hernia with obstruction, lung disease, and heart failure, was given one tablet of dicyclomine 20mg instead of the prescribed two tablets. The LVN responsible admitted to being nervous and not checking the dosage, and was unaware of the medication's purpose. The Director of Nursing acknowledged that the errors were due to inattention, despite clear orders, and emphasized that the residents did not receive the intended therapeutic doses.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed in the Hall 300/400 medication cart. Specifically, insulin pens for three residents were found to be improperly labeled and expired. A Humulin R flex pen for one resident was opened on 10/20/2024, an Insulin Glargine flex pen for another resident was opened on 10/18/2024, and a Lantus flex pen for a third resident was opened on 10/12/2024, all of which were past the 28-day expiration period. Additionally, the Lantus and Insulin Lispro pens for the third resident lacked proper pharmacy labels and were marked with the resident's name in marker, with the Insulin Lispro pen missing an open date entirely. Interviews with staff revealed a lack of adherence to the facility's medication storage and administration policies. LVN A acknowledged that insulin vials and pens should be dated when opened and discarded after 28 days, and that all medications should have the original pharmacy label. The Director of Nursing (DON) confirmed that it was the nurse's responsibility to ensure medications were not expired before administration. The facility's policies require that drug containers with missing or incorrect labels be returned to the pharmacy for proper labeling and that expired medications be removed. The failure to comply with these policies could lead to residents receiving expired medications.
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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.
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Nursing homes near Coleman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holiday Hill Inc | 1.9 mi | — | 0 | 0 |
| Bangs Nursing And Rehabilitation | 18.9 mi | — | 0 | 0 |
| Brownwood Nursing And Rehabilitation | 26.7 mi | — | 11 | 0 |
| Songbird Lodge | 26.8 mi | — | 15 | 0 |
| Oak Ridge Manor | 26.8 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.