Cycle 1
Health 2024-11-26 · Fire 2024-11-26
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Coleman, TX
Coleman Healthcare Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2713 S Commercial Ave, Coleman, TX
(325) 625-4105
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexion Health
Operator or chain grouping
Approved since
1992-03-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.40
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.75
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
3.37
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,914
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.22
Performance 46.43% · Measure score 4.22 · Achievement 4.22 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.40
Baseline 3.93 hours · Performance 4.05 hours · Measure score 3.40 · Achievement 3.40 · Improvement 0.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.48% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 23.33% · Lower 95% interval 7.95% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.83% |
95.27%
0.6 pts better
|
Numerator 23 · Denominator 24 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 1 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 12.5% |
2.29%
10.2 pts worse
|
Numerator 3 · Denominator 24 · Adjusted rate 10.52% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 51 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 58 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · 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 | 4.3 |
2.1
2.2 pts worse
|
1.9
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 5.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 6.1 |
2.1
4 pts worse
|
1.8
4.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 6.1 · Observed 7.5 · Expected 2.1 · 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 | 3.8% |
3.3%
0.5 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.6% · Q3 5.7% · Q4 2.5% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
2.7%
1.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
3.3%
1.5 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 3.1% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
18.9%
5.8 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 14.8% · Q3 3.1% · Q4 17.6% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
10.8%
1.7 pts worse
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.0% · Q4 20.0% · 4Q avg 12.5% · 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 | 4.5% |
15.4%
10.9 pts better
|
16.3%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
16.1%
9.1 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 7.7% · Q3 6.7% · Q4 9.7% · 4Q avg 7.0% · 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 | 4.9% |
15.0%
10.1 pts better
|
19.8%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 4.5% · Q3 5.2% · Q4 0.0% · 4Q avg 4.9% |
| 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 0.0% · Q2 5.7% · Q3 0.0% · Q4 2.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
89.7%
7.3 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 95.0% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.7% |
12.0%
9.7 pts worse
|
12.0%
9.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 25.0% · Expected 12.9% · 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 | 95.5% |
88.0%
7.5 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.4% |
25.9%
11.5 pts worse
|
23.9%
13.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.4% · Observed 37.5% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-27 · Fire 2023-09-27
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-07-28 · Fire 2022-07-28
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-26
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-11-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-27
C · Minimal harm
2024-11-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-27
C · Minimal harm
2024-11-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-27
F · Potential for more than minimal harm
2023-09-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-09-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-09-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-28
C · Minimal harm
2023-09-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-28
C · Minimal harm
2023-09-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-28
C · Minimal harm
2022-07-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-19
C · Minimal harm
2022-07-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-07-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-07-03
E · Potential for more than minimal harm
2024-11-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-11-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-27
F · Potential for more than minimal harm
2023-09-27
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 2023-09-28
E · Potential for more than minimal harm
2023-09-27
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-09-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-09-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-28
F · Potential for more than minimal harm
2022-07-28
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 2022-07-29
D · Potential for more than minimal harm
2022-07-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-28
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-08-19
Penalties and ownership
What sits behind the stars
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Hooper, Grady
Corporate Officer · Individual
Mistretta, Cassandra
Operational/Managerial Control · Individual
Slp Coleman, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Holiday Hill Inc
Coleman, TX
4-star overall rating with 4-star inspections with $133,025 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Bangs Nursing And Rehabilitation
Bangs, TX
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Brownwood Nursing And Rehabilitation
Brownwood, TX
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out