Coleman Healthcare Center
2713 S. Commercial Ave, Coleman, TX 76834 · Coleman County · 54 certified beds · avg 35 residents/day · certified since Mar 17, 1992
Part of chain: NEXION HEALTH (51 facilities, chain avg rating 2.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (13)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 6, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 6, 2026 | E · Potential for harm, repeated | The facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. |
| Mar 6, 2026 | D · Potential for harm, one-off | The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training. |
| Mar 6, 2026 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Mar 6, 2026 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jul 2, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Nov 26, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Nov 26, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 27, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | F |
| 2024 | 2 | 0 | E |
| 2025 | 2 | 0 | D |
| 2026 | 5 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.17 | 3.46 | 3.95 | top 12% in Texas; top 33% in the U.S. |
| Registered Nurse hours | 0.46 | 0.44 | 0.69 | top 32% in Texas; bottom 33% in the U.S. |
| Weekend total nurse staffing | 3.75 | 3.04 | 3.50 | top 11% in Texas; top 31% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.42 | 0.34 | 0.48 | top 23% in Texas; top 45% in the U.S. |
| Total nursing staff turnover (%) | 43.9 | 55.3 | 45.8 | top 30% in Texas; top 47% in the U.S. |
| RN turnover (%) | 60.0 | 54.6 | 42.9 | bottom 42% in Texas; bottom 22% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.83, RN 0.43, weekend 3.44. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Hooper, Grady | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2021 |
| Mistretta, Cassandra | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2021 |
| SLP Coleman, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who owns and governs this facility, and how long has the current administrator been here?"
- "What training and competency checks do your nurse aides go through, and how do you keep their skills current?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Holiday Hill INC | 1.9 mi | Coleman, TX | ★★★★☆ | 4/5 | |
| Bangs Nursing and Rehabilitation | 18.9 mi | Bangs, TX | ★★★★★ | 5/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675009.