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Coleman Healthcare Center: Dignity Violations - TX

Healthcare Facility
Coleman Healthcare Center
Coleman, TX  ·  4/5 stars

The resident at Coleman Healthcare Center told state inspectors on September 9 that he had never seen a privacy bag cover for his catheter. "It would look better covered than letting everyone see a bag full of pee," he said. "A privacy bag would be nice to have."

His door was open during the inspection, and the urine collection bag was viewable from the hall.

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The elderly male resident was admitted with kidney disease, heart failure, stroke, and ureteral obstruction. His physician had specifically ordered catheter privacy bag coverage "for dignity" in August 2025, according to inspection records.

The doctor's consolidated orders were detailed: catheter care every shift with soap and water, proper function checks, and explicit instructions for a "catheter privacy bag over urine collection for dignity."

When inspectors questioned Licensed Vocational Nurse E about the uncovered bag, she admitted uncertainty about why it wasn't covered. "She said she knew it should be covered, and she would place a privacy cover on bag right now," according to the inspection report.

The nurse acknowledged it was a dignity issue for catheter bags to be covered.

The facility's Director of Nursing confirmed the violation two days later during interviews. The catheter bag should always be covered with a privacy bag if care planned, she told inspectors, and this resident had orders requiring coverage.

"The DON stated the failure could place residents at risk for dignity issues if it was not covered," inspectors wrote.

The administrator echoed the same concern, telling inspectors that catheter bags should always be covered with privacy bags. The failure "could place residents at risk for dignity issues if it is not covered," the administrator stated.

Federal regulations require nursing homes to honor each resident's right to dignified existence. The inspection found Coleman Healthcare Center failed this standard for the catheter patient.

The resident's comprehensive care plan from July included detailed monitoring instructions for urinary tract infections, tracking symptoms like pain, burning, blood-tinged urine, cloudiness, fever, and behavioral changes. But nowhere in the extensive medical protocols was basic dignity being maintained.

State inspectors documented that the facility's deficient practices "could affect residents who had indwelling urinary catheters by contributing to poor self-esteem, lack of information, and unmet needs."

The violation occurred despite clear medical orders and facility policies. Staff knew the requirement existed but failed to follow through on implementation.

During the September inspection, the licensed vocational nurse's immediate response to place a privacy cover revealed the solution was readily available. The oversight appeared to be one of execution rather than resources.

The resident's frank assessment captured the human impact of the dignity violation. His comment about not wanting "everyone see a bag full of pee" illustrated how exposed medical equipment affects patient self-esteem and comfort.

Federal inspectors classified the harm level as minimal with few residents affected, but the violation represents a broader failure to maintain basic dignity standards for vulnerable patients requiring medical devices.

The resident remains at Coleman Healthcare Center, where his catheter bag now presumably carries the privacy cover that should have been in place all along.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Coleman Healthcare Center from 2025-09-11 including all violations, facility responses, and corrective action plans.

Additional Resources


Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 20, 2026  ·  Our methodology

Quick Answer

COLEMAN HEALTHCARE CENTER in COLEMAN, TX was cited for violations during a health inspection on September 11, 2025.

The resident at Coleman Healthcare Center told state inspectors on September 9 that he had never seen a privacy bag cover for his catheter.

Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.

Frequently Asked Questions

What happened at COLEMAN HEALTHCARE CENTER?
The resident at Coleman Healthcare Center told state inspectors on September 9 that he had never seen a privacy bag cover for his catheter.
How serious are these violations?
Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
What should families do?
Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in COLEMAN, TX, (5) Report any new concerns directly to state authorities.
Where can I see the full inspection report?
The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from COLEMAN HEALTHCARE CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 675009.
Has this facility had violations before?
To check COLEMAN HEALTHCARE CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.


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