Alliance Health at Coleman

In the surveyor’s words

From the most serious findings on record at Alliance Health at Coleman, in the surveyor’s own words.

• Actual harm, isolatedF656Oct 26, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required extensive assistance of two staff members for all transfers, the Facility failed to ensure staff implemented and followed interventions from his/her plan of care, when on 10/01/21 during the evening shift, Certified Nurse Aide (CNA) #3 transferred Resident #1 into bed without another staff person to help. Resident #1 was observed, at the end of the shift, to have bruises to his/her left forehead and left hip, an x-ray was taken which revealed a left hip fracture and he/she was transferred to the Hospital Emergency Department and admitted . […]

• Actual harm, isolatedF689Oct 26, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who required extensive assistance of two staff members for all transfers, the Facility failed to ensure Resident #1 was provided the necessary level of assistance to maintain his/her safety, when on 10/01/21, Certified Nurse Aide (CNA) #3 transferred him/her into bed without the assistance of another staff member. Resident #1 was observed, at the end of the shift, to have bruises to his/her left forehead and left hip, an x-ray was taken which revealed a left hip fracture and he/she was transferred to the Hospital Emergency Department and admitted . […]

• No harm, potential for more than minimal, patternF685Sep 9, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure proper treatment was provided to maintain hearing abilities for two Residents (#4 and #18) out of a total sample of 17 residents, increasing the risk of both Residents for impaired communication abilities.Specifically, the facility failed to:1.Follow-up with Resident #4's Physician relative to the Audiologist's recommendation for ear wax removal, so that the Resident's hearing could be adequately assessed when the Resident exhibited decreased responsiveness.2.Obtain a hearing device for Resident #18 when the Audiologist recommended replacement of the right hearing aid, after the Resident's right hearing aid was lost during a hospitalization. […]

• No harm, potential for more than minimal, patternF699Sep 9, 2025

  Based on observations, interviews, and record reviews, the facility failed to provide trauma-informed care for one Resident (#33) out of a total sample of 17 residents.Specifically, the facility failed to recognize Resident #33's past history of sexual abuse and identify triggers (psychological stimuli that prompt recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening), placing the Resident at risk for re-traumatization. Findings include:Review of the facility policy titled Trauma Informed Care Program effective 11/21/19 and revised 8/1/25, indicated but was not limited to the following:-Policy:>To provide holistic, culturally sensitive, trauma-informed care in accordance with professional standards to our residents who are trauma survivors.>To… […]

• No harm, potential for more than minimal, patternF761Apr 19, 2023

  Based on policy review, observation, and interview, the facility failed to ensure medications were appropriately stored in two out of two medication carts. Specifically, the facility staff failed to store topical medications separately from oral medications. Findings include: Review of the facility's policy, titled Medication Storage in the Facility, dated 2017, indicated the following: -Procedure: Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, etc. 1. […]