Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alliance Health At Coleman during CMS and state inspections, most recent first.
Failure to address hearing services needs for two residents. One resident with cognitive decline and decreased responsiveness had an audiology consult showing occluded cerumen and a need for right ear wax removal, but the physician was not contacted for orders and the hearing could not be fully assessed. Another resident with severe hearing loss lost a right HA in the hospital; audiology recommended replacement and medical clearance, but the facility did not obtain the replacement HA or complete the required medical consult paperwork.
Failure to provide trauma-informed care for a resident with a history of childhood sexual abuse. The resident had vascular dementia, depression, anxiety, Parkinson's disease, and behavioral symptoms, but the care plan did not include trauma-informed interventions or identified triggers. Although the PNP documented the abuse history and referred the resident to therapy, the SW was not aware of the history and the interdisciplinary team was not notified of each behavioral health encounter.
Locked wheelchair brakes restricted two residents’ movement when staff left their brakes engaged while they were seated in wheelchairs and trying to move. One resident with dementia, agitation, and wheelchair mobility goals repeatedly pushed against a table and later tried to propel the chair toward the exit after the brakes were unlocked. Another resident with severe cognitive impairment was later observed in the hallway with both brakes locked, using the feet and hands to push and pull while the chair remained in place. The DON stated that locked brakes should not be kept in place because residents should be able to move if they want to, and an LPN said locking brakes at meals was a habit done for safety.
A resident with cognitive impairment, hearing loss, and back pain was not consistently assisted with ADLs as ordered. Staff failed to ensure the resident had dentures before breakfast, and the resident later coughed and vomited while eating; staff also did not ensure the resident’s hearing aids were in place each morning or that the LSO back brace was worn when out of bed.
A resident with urinary retention, BPH, obstructive/reflux uropathy, UTI, and dementia had an indwelling Foley catheter, but the chart lacked physician orders for the catheter size and balloon size. The care plan and catheter assessment also did not document these details, and nursing staff and the UM confirmed there was no order for the 16 Fr catheter with a 10 ml balloon that was in place.
Failure to Post Required Nurse Staffing Information: The facility posted nurse staffing information in the resident dining area, but the postings only listed the facility name, date, census, and the number of CNAs and LPN/RNs on each shift. The postings did not include the actual hours worked by licensed and unlicensed nursing staff, and both the Payroll Personnel and ED stated they were unaware that additional information was required.
Failure to Address Hearing Services Needs
Penalty
Summary
The facility failed to follow up with the physician after an audiology consult recommended ear wax removal for a resident with age-related cognitive decline and decreased responsiveness. The resident had an audiology referral for new signs and symptoms, including family and staff noticing recent decreased responsiveness. The audiology consult found that hearing loss could not be established bilaterally because of visibly occluded cerumen, removed a large amount of wax, and stated that deep wax could not be removed. The audiologist specifically noted that right ear wax removal was needed and asked that the physician be contacted for wax removal orders so the resident could be re-evaluated after wax removal. A nursing progress note documented that the resident was seen by audiology and that the audiologist recommended contacting the physician for wax removal orders for the right ear. During observation, the resident did not respond when greeted and later told a staff member that he or she could not understand what was being said. The Unit Manager reviewed the record and stated that the audiologist’s recommendation had not been followed up on and that orders for ear wax removal had not been obtained. The Unit Manager also stated that staff should have obtained the orders the same day the recommendation was made. The facility also failed to obtain a replacement hearing device for another resident after the resident’s right hearing aid was lost during a hospitalization. That resident had diagnoses including type 2 diabetes mellitus, hyperlipidemia, and heart failure, and the care plan identified the resident as hard of hearing and at risk for impaired communication, social isolation, and injury due to hearing deficit. The audiology consult documented that the right hearing aid had been lost in the hospital, that severe to profound sensorineural hearing loss was present in the right ear, and that a hearing aid was recommended for both ears with a medical consult needed for medical clearance. The resident later reported waiting to see audiology and said staff had been telling him or her month after month that the appointment would occur the following month, while the Unit Manager stated the facility had not received the replacement hearing aid and could not locate evidence that the required medical consult and form had been completed.
Failure to Provide Trauma-Informed Care for Resident with Sexual Abuse History
Penalty
Summary
The facility failed to provide trauma-informed care for one resident with a history of sexual abuse as a child. The resident was admitted with diagnoses including vascular dementia, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, Parkinson's disease, constipation, and restlessness and agitation. The facility policy required residents to be screened for past trauma and for the interdisciplinary team to create a culturally sensitive plan of care that identified triggers and addressed traumatic stress, but the resident's comprehensive care plan did not include a trauma-informed care plan. Review of the resident's trauma informed care assessment indicated the resident did not have a traumatic experience that had lasting effects. However, a Behavioral Health Psychiatric Assessment and Progress Note written by the Psychiatric Nurse Practitioner documented that the resident had a history of sexual abuse as a child. The resident's MDS also showed moderate cognitive impairment, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and feeling down, depressed, or hopeless during the assessment period. During interview, the resident cried and stated he/she had been sexually abused as a child and wanted to speak with a therapist about it. The Psychiatric Nurse Practitioner stated the resident informed her of the history of sexual abuse and that she referred the resident to therapy. The Social Worker stated she was not aware of the resident's history of sexual abuse and said trauma screening and a trauma-informed care plan were important when a resident had a trauma history. The Unit Manager stated behavioral health notes were placed in the provider folder for review, but the interdisciplinary team was not notified each time there was a behavioral health encounter with the resident.
Locked wheelchair brakes restricted resident movement
Penalty
Summary
The facility failed to ensure that two residents were free from physical restraint when their wheelchair brakes were left locked while they were seated in wheelchairs and attempting to move. The facility policy stated that physical restraints were to be used only when required to treat a resident’s medical symptoms, and defined a restraint as any manual, physical, or mechanical device that restricts freedom of movement and cannot be easily removed by the resident. Resident #38 was admitted with diagnoses including dementia, weakness, restlessness, and agitation. Records showed severe cognitive impairment, daily wandering, and use of a wheelchair. Occupational therapy documentation indicated the resident was being evaluated for wheelchair positioning and mobility, with a goal of being independent with wheelchair use in the room and on the unit. Resident #35 was admitted with diagnoses including dementia, unsteadiness on feet, restlessness, and agitation. Records showed severe cognitive impairment, use of a wheelchair, impaired communication, inability to make needs known, and staff direction to anticipate needs. During breakfast in the Small Dining Room, both residents were observed seated in wheelchairs with their brakes locked and anti-rollback devices in place. Resident #35 repeatedly pushed forcefully against the tabletop, grunted, and pulled on the table while saying, “This is odd.” Resident #38 pushed backward and side to side with the feet, moved the wheelchair away from the table, and then attempted to propel the wheelchair toward the exit after the ADON unlocked the brakes. Later that morning, Resident #38 was again observed in the hallway with both brakes locked, using the feet and hands to push and pull while the wheelchair remained in the same place. Staff were observed passing by, and Nurse #2 later unlocked the brakes and assisted the resident to the dining room. The ADON and DON stated that locked wheelchair brakes should not be kept in place because residents should be able to move if they want to, and that leaving either resident with brakes locked should not have occurred. Nurse #2 stated that locking brakes at meals was a habit and was done for safety, but also said residents should be free to move and that neither resident should have been left with brakes locked.
Failure to Provide Dentures, Hearing Aids, and Back Brace Assistance
Penalty
Summary
The facility failed to provide appropriate ADL-related care for one resident with spinal stenosis, low back pain, memory deficit, and conductive hearing loss. The resident’s MDS indicated moderate cognitive impairment and a need for staff assistance with ADLs. Physician orders required the resident to wear an LSO back brace when out of bed and to have bilateral hearing aids inserted in the morning and removed in the evening. The care plan also directed staff to apply the back brace when out of bed and to use the hearing aids as ordered. The resident’s CNA care card noted upper and lower partial dentures. During interview and observation, the resident stated staff did not always assist with the back brace and that hearing was difficult without the hearing aids. The surveyor observed the resident without hearing aids and without the back brace. On the morning of the meal, the resident told the CNA, “Oh I forgot to put my teeth in,” and the CNA did not respond. The resident was observed eating breakfast without dentures and later coughed and vomited while seated at the table; the resident stated this occurred because the dentures were not in place. Nursing staff and the unit manager stated CNAs were responsible for oral care and ensuring dentures were provided, and acknowledged the resident should have had dentures, hearing aids, and the back brace but did not.
Missing Physician Orders for Foley Catheter Size and Balloon Size
Penalty
Summary
The facility failed to provide appropriate treatment and services related to an indwelling urinary catheter for one resident, Resident #8, out of 2 residents reviewed for catheter care. Resident #8 was admitted in August 2025 with diagnoses including urinary retention, BPH with lower urinary tract symptoms, obstructive and reflux uropathy, UTI, and unspecified dementia. The MDS indicated the resident was moderately cognitively impaired with a BIMS score of 10 out of 15, had an indwelling urinary catheter, and was dependent on staff for ADLs. On 9/3/25, the surveyor observed the resident in bed with a Foley catheter and drainage bag in a privacy bag. Review of the resident’s September 2025 physician orders did not show an order for the Foley catheter size, and the care plan and Foley catheter assessment also did not identify the catheter size or balloon size. During observation and interviews, nursing staff identified the catheter in place as a size 16 Fr with a 10 ml balloon, but Nurse #2 and the Unit Manager stated there was no physician order for the catheter size or balloon size. The Unit Manager stated there should have been physician orders for the Foley catheter size and balloon size from admission, but there were no physician orders.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis with the actual hours worked by licensed and unlicensed nursing staff for three days. Surveyor observation found staffing information posted in the resident dining area on 9/3/25, 9/4/25, and 9/5/25, and the postings listed the facility name, date, census, and the number of CNAs and LPN/RNs working on each shift. The postings showed Day shift RN/LPN 3 and CNA 5, Evening shift RN/LPN 2 and CNA 4, and Night shift RN/LPN 2 and CNA 2, but further review showed that the postings did not include the actual hours worked by licensed and unlicensed nursing staff. During interview, the Payroll Personnel said she was unaware that additional information was required on the staffing posting, and the Executive Director said she was also unaware that the actual working hours were not being posted.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Northborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaumont Rehab & Skilled Nursing Ctr - Northboro | 0.6 mi | ★★★★★ | 0 | 0 |
| Shrewsbury Rehabilitation And Nursing At Southgate | 3.3 mi | ★★★★★ | 6 | 0 |
| Beaumont Rehab & Skilled Nursing Ctr - Westboro | 3.4 mi | ★★★★★ | 10 | 0 |
| Westborough Healthcare | 3.7 mi | ★★★★★ | 6 | 0 |
| Marlborough Hills Rehabilitation & Health Care Cen | 3.7 mi | ★★★★★ | 1 | 0 |
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