Coleman Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteDuring 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.