Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Coon Memorial Home during CMS and state inspections, most recent first.
The facility failed to maintain a homelike environment for four residents, as surveyors observed walls in disrepair with gouges, scratches, and peeling paint. Residents with various medical conditions, including dementia and depression, were affected. Staff interviews revealed a lack of awareness and action regarding the wall conditions, with some attributing the damage to beds being pushed against the walls. The DON acknowledged the potential negative impact on residents' comfort.
The facility failed to provide meals that were palatable, at a safe temperature, and appropriately prepared for residents with specific dietary needs. Observations showed food carts left in hallways, leading to cold meals. Residents reported tough, unappetizing food, with inappropriate textures for those on mechanical diets. The acting DM and ADM acknowledged these issues, but effective measures were not implemented, as ongoing complaints were documented.
A facility failed to maintain a resident's dignity by not using a privacy bag for her catheter, leaving it visible from the hallway and dining area. Staff interviews revealed a lack of awareness about the importance of privacy bags, with a CNA unaware of the bag's whereabouts and an RN acknowledging the need for privacy to prevent discomfort among other residents. The DON confirmed the importance of proper catheter storage to uphold resident dignity.
A resident's DNR form was not fully completed, rendering it invalid and risking the resident's end-of-life wishes not being honored. The facility staff, including LVNs, RNs, ADON, and ADM, acknowledged the oversight and the responsibility of the DON in ensuring the completion of advance directives.
Two residents in the facility received improper respiratory care, with nasal cannulas improperly stored on the floor and oxygen administered at incorrect doses. One resident, with severe cognitive impairment and multiple chronic conditions, had her oxygen set above the prescribed dose without documented need. Another resident with COPD had her oxygen equipment improperly stored and not dated for change. Staff interviews revealed non-compliance with facility policies on respiratory equipment maintenance.
A facility failed to assess and obtain informed consent for a bed rail for a resident with dementia and major depressive disorder. The resident's records lacked documentation of bed rail use, yet a bed rail was observed on her bed. Interviews with staff revealed a lack of awareness and documentation, with suggestions that the resident's partner may have installed the rail without authorization.
The facility failed to maintain an effective infection prevention and control program. A CNA did not ensure a resident's catheter bag remained off the floor, risking contamination. Another CNA failed to perform proper hand hygiene during incontinent care, changing gloves without washing hands. These actions were contrary to the facility's policies, potentially exposing residents to infections.
The facility failed to maintain a safe and comfortable environment in Halls L and CYNS, with flooring issues posing tripping hazards. Observations showed black tape securing the floor in Hall L and red tape marking raised, cracked areas in Hall CYNS. Staff interviews confirmed awareness of these issues, with concerns about the impact on residents' comfort and safety. The facility's policy emphasizes a homelike environment, but the flooring problems remain unaddressed.
A resident with dementia and multiple health issues was improperly transferred by a CNA without assistance, leading to a fall. The LVN failed to notify the DON, physician, or family, and did not complete an incident report. The resident was later found to have a fractured femur, requiring hospital transfer.
A resident who required two-person assistance for transfers was improperly transferred by a single CNA, resulting in a fall and a fracture of the distal femur. The incident was not reported promptly to the DON or physician, and the family was not informed until the resident was hospitalized. The CNA and nurse involved failed to adhere to the care plan and reporting protocols, leading to the deficiency.
Several residents were placed in a secure unit without proper documentation or physician orders, confining them without consent. Interviews revealed that residents were not given access codes to exit the unit, and some were placed there for non-clinical reasons like wanting a private room. Facility staff admitted to lacking policies for secure unit placement, contributing to the deficiency.
The facility failed to document the secure unit placement in the care plans of six residents, affecting their psychosocial and mental well-being. Despite having care plans addressing various medical and behavioral needs, the secure unit placement was not discussed during care plan meetings with the interdisciplinary team. Interviews with staff and residents confirmed this oversight.
Facility Fails to Maintain Homelike Environment Due to Wall Disrepair
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four residents, as observed by surveyors. The walls in the rooms of these residents were found to be in disrepair, with issues such as gouges, scratches, peeling paint, and shredded sheetrock. These conditions were consistently observed over multiple days, indicating a lack of timely maintenance and repair. Resident #1, an elderly female with chronic congestive heart failure, vascular dementia, and depression, was observed in her room with walls that had several gouges and scratches, as well as areas where a white substance had been smeared, possibly to patch holes. Resident #19, who was on hospice care and severely cognitively impaired, had a wall with 26 areas of peeling paint. Resident #24, also on hospice care with severely impaired cognition, had walls with shredded paint and sheetrock, resembling a scratching post. Resident #27, with dementia and major depressive disorder, had walls with multiple vertical scratches and imprints. Interviews with facility staff, including CNAs, CMAs, LVNs, and the ADON, revealed a general lack of awareness or action regarding the condition of the walls. Some staff members acknowledged the disrepair but were unsure of the cause or whether maintenance requests had been submitted. The ADM suspected the damage was caused by beds being pushed against the walls and mentioned ongoing plans for a new facility, which may have contributed to the neglect of current maintenance needs. The DON acknowledged that the disrepair could negatively impact residents' sense of a homelike environment.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, at a safe temperature, and appropriately prepared for residents with specific dietary needs. Observations revealed that food carts were left in the hallway for extended periods before being served, resulting in meals being served cold. Residents reported that the food was often cold, tough, and unappetizing, with specific complaints about the toughness of corned beef and carrots, and the strong vinegar taste of potato salad. These issues were confirmed by test trays sampled by surveyors, which showed that the food was not only cold but also difficult to chew and swallow. Residents on mechanical diets were served inappropriate food textures, such as large, tough carrot slices, which posed a choking hazard. The facility's acting Dietary Manager (DM) acknowledged awareness of these issues, noting that the nursing staff delayed serving the food, contributing to the temperature problems. The DM also admitted that the corned beef was tough and that the potato salad on pureed trays was runny and overly vinegary. Despite being aware of these issues, the facility had not implemented effective measures to address them, as evidenced by ongoing resident complaints documented in resident council meeting minutes and grievance logs over several months. Interviews with residents and staff further highlighted dissatisfaction with the meals, with residents consistently reporting cold and unpalatable food. The facility's Administrator (ADM) acknowledged the complaints and the potential consequences of poor meal quality, such as poor nutrition and weight loss. However, the ADM was unaware of specific issues, such as the inappropriate serving of large, crunchy carrots to residents on mechanical soft diets. The facility lacked a policy for test trays, which could have helped identify and address these issues before meals were served to residents.
Failure to Maintain Resident Dignity with Catheter Bag Storage
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring her catheter bag was stored in a privacy bag. The resident, an elderly female with severe dementia and other medical conditions, was observed multiple times with her catheter bag visible from the hallway and dining area. This lack of privacy was noted during several observations over two days, where the catheter bag was seen hanging from the side of her bed without a privacy cover, exposing the contents to other residents and staff. Interviews with staff members, including a CNA and an RN, revealed a lack of awareness and understanding of the importance of using a privacy bag for the catheter. The CNA admitted to not knowing what happened to the privacy bag and did not perceive the visibility of the catheter bag as an issue. The RN acknowledged that the catheter should be stored off the floor and in a privacy bag for hygiene and dignity purposes, expressing concern about the impact on other residents who might see the bag while eating. The Director of Nursing (DON) confirmed that catheter bags should be stored below bladder level, off the floor, and in a privacy bag to maintain resident dignity and prevent other residents from questioning or being affected by the sight of the catheter. Despite the facility's policy on promoting dignity and respect, the lack of adherence to these standards resulted in a deficiency in maintaining the resident's right to a dignified existence.
Incomplete DNR Form Renders Resident's Advance Directive Invalid
Penalty
Summary
The facility failed to ensure that a resident's advance directive was properly completed, specifically the Do-Not-Resuscitate (DNR) order for a resident with Alzheimer's disease and chronic obstructive pulmonary disease who was receiving hospice care. The DNR form was not filled out completely, as the resident's family member, who was responsible for signing the document, did not sign in the final section required for validation. This oversight rendered the DNR invalid, potentially risking the resident's end-of-life wishes not being honored. Interviews with facility staff, including Licensed Vocational Nurses (LVN), Registered Nurses (RN), Assistant Director of Nursing (ADON), and the Administrator (ADM), revealed a lack of clarity and responsibility in ensuring the completion of advance directives. Staff acknowledged that an incomplete DNR form is not valid and that the Director of Nursing (DON) was primarily responsible for ensuring these forms were correctly filled out. The facility's policy indicated that inquiries about DNR orders should be referred to the Administrator, Director of Nursing Services, or Social Services Director, but the failure to ensure the DNR was properly completed was evident.
Improper Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in the management of their oxygen therapy. Resident #12, a severely cognitively impaired female with multiple chronic conditions including Alzheimer's and congestive heart failure, was observed with her nasal cannula improperly stored on the floor, which was discolored and not dated for change. Additionally, her oxygen was administered at 3L/min, exceeding the prescribed dose of 0.5L to 2L/min, without a documented need for such titration based on her oxygen saturation levels. Similarly, Resident #36, also severely cognitively impaired with conditions such as Alzheimer's and COPD, had her nasal cannula improperly stored on the floor, with discoloration and no date of change. Observations showed that her oxygen was running at 2L/min while she was not wearing it, and the equipment was not properly dated or stored, increasing the risk of infection. Interviews with staff, including RN B and the DON, revealed a lack of adherence to facility policies regarding the storage and maintenance of respiratory equipment. The DON confirmed that oxygen equipment should be changed monthly, labeled with the date, and stored in a plastic bag when not in use. The failure to follow these protocols resulted in the improper administration and storage of oxygen therapy, constituting a medication error and increasing the risk of infection for the residents.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of a bed rail for Resident #27, who was admitted with diagnoses including dementia and major depressive disorder. The resident's records, including her care plan and active orders, did not mention bed rails, and there was no documented assessment or consent for their use. Despite this, a bed rail was observed in the upright position on the resident's bed, and the resident and her roommate/partner indicated that it was used to prevent falls and assist with getting up. Interviews with facility staff, including the LVN, RN, ADON, and DON, revealed a lack of awareness and documentation regarding the bed rail's installation. Staff members acknowledged that a doctor's order, assessment, and consent were required for bed rail use, but these were not present for Resident #27. The ADON and DON suggested that the resident's roommate/partner might have installed the bed rail without proper authorization, highlighting a lapse in the facility's adherence to its policy on the proper use of side rails.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs. CNA A did not ensure that a resident's catheter bag remained off the floor after providing care. During an observation, CNA A placed the catheter bag at the foot of the bed, allowing it to come into contact with the floor. This was confirmed by both CNA A and RN B, who acknowledged that the catheter bag should be kept off the floor to prevent contamination and infection. CNA C failed to perform proper hand hygiene while providing incontinent care to another resident. During the care, CNA C changed gloves without washing her hands or using an alcohol-based hand rub, despite being trained on proper hand hygiene procedures. CNA C believed that changing gloves was sufficient to maintain cleanliness, as she was incorrectly instructed by an agency nurse. The facility's policies on catheter care and hand hygiene were not followed by the staff, leading to potential risks of infection for the residents. The Director of Nursing confirmed the expectations for hand hygiene and catheter care, emphasizing the importance of these practices in preventing infections such as UTIs. The facility had previously trained the CNAs on these procedures, but the training was not effectively implemented in practice.
Flooring Disrepair in Halls L and CYNS
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in two of the four halls reviewed, specifically Hall L and Hall CYNS. Observations revealed that the flooring in Hall L was inadequately affixed, with 17 pieces of black tape used to secure the floor, some of which covered missing floor sections. In Hall CYNS, two rectangles of red tape marked areas where the flooring was raised and cracked, posing potential tripping hazards. Interviews with staff members, including a CNA, CMA, LVN, ADON, MS, and ADM, confirmed awareness of the flooring issues. The CNA and LVN acknowledged the potential for residents to trip over the raised areas, while the ADON and MS noted that the flooring problems had persisted for several months. The ADM and DON expressed concerns about the impact of the disrepair on residents' comfort and the homelike environment, with the DON highlighting the potential for residents, especially those with dementia, to feel uncomfortable. The facility's policy on providing a homelike environment emphasizes the importance of a clean, sanitary, and orderly setting. Despite this, the flooring issues in Hall L and Hall CYNS have not been adequately addressed, with staff indicating that maintenance is responsible for repairs. The ADM mentioned plans for a new facility, but in the meantime, the current conditions could negatively affect residents' quality of life.
Failure to Notify Physician and Family After Resident Incident
Penalty
Summary
The facility failed to immediately notify a resident's physician and family when there was a significant change in the resident's condition. This deficiency was identified for a resident who was assisted to the floor by a CNA during a transfer from a wheelchair to a bed. The resident, who had multiple diagnoses including dementia and was non-verbal, required assistance from two staff members for transfers. However, the CNA attempted the transfer alone, resulting in the resident's legs giving out and being lowered to the floor. The LVN on duty assessed the resident after the incident and noted no immediate signs of pain or injury, only some swelling in the lower extremities, which was attributed to the resident's history of edema. The LVN did not report the incident to the DON, the physician, or the resident's family, nor did they complete an incident report. The following day, the resident was found to have a swollen and bruised knee, and an x-ray revealed a fracture in the left femur, necessitating hospital transfer. Interviews with facility staff revealed that the CNA was aware that the resident required a two-person assist but chose to perform the transfer alone. The LVN did not consider the incident a fall and believed monitoring the resident was sufficient. The failure to follow the care plan and notify the appropriate parties led to a delay in addressing the resident's injury, which was only discovered after further assessment by other staff members.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, who required assistance from two staff members for transfers, was transferred safely according to her care plan. A CNA transferred the resident alone, resulting in the resident's legs giving out and her being assisted to the floor. This incident led to the resident sustaining a fracture of the distal femur in her left knee. The resident had a history of dementia, congestive heart failure, and other medical conditions, and was non-verbal, requiring full assistance for daily activities. The incident was not reported immediately to the Director of Nursing (DON) or the physician, and an incident report was not completed in a timely manner. The nurse who assessed the resident after the fall did not notify the necessary parties and failed to recognize the severity of the situation. The resident's family was not informed of the fall until the resident was sent to the hospital for further evaluation, where a fracture was confirmed. The facility's investigation revealed that the CNA was aware that the resident required a two-person assist but chose to perform the transfer alone. The nurse involved did not consider the incident a fall and did not follow the facility's protocol for reporting and documenting such events. This lack of adherence to the care plan and communication breakdown contributed to the resident's injury and the facility's deficiency.
Involuntary Seclusion of Residents Without Proper Documentation
Penalty
Summary
The facility failed to ensure that residents were free from involuntary seclusion, affecting six residents who were placed in a secure unit without proper documentation or physician orders. These residents, identified as having various cognitive impairments and other medical conditions, were placed in the secure unit without documented clinical criteria or consent from their physicians or interdisciplinary team. The lack of physician orders and updates to care plans for these residents indicates a significant oversight in the facility's procedures for managing resident placement in secure units. Observations and interviews revealed that residents were not provided with the access code to freely enter or exit the secure unit, effectively confining them without their consent. Interviews with residents and their representatives indicated that some residents were placed in the secure unit for reasons unrelated to clinical necessity, such as the desire for a private room or specific nursing care. Despite these preferences, there was no formal documentation or consent process in place to justify their placement in the secure unit, raising concerns about the residents' autonomy and freedom. Interviews with facility staff, including the Administrator and DON, highlighted a lack of policy and procedure for admitting residents to the secure unit. The staff acknowledged that most residents in the secure unit were placed there due to wandering tendencies or elopement risks, yet there was no evidence of such behaviors in the residents' progress notes. The absence of a structured process for secure unit placement and the failure to involve residents and their representatives in decision-making processes contributed to the deficiency identified in the report.
Failure to Document Secure Unit Placement in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, which included measurable objectives and time frames to meet their medical, nursing, and psychosocial needs. These residents were placed in a secure unit without documentation of this placement in their care plans. This oversight could potentially affect their psychosocial and mental well-being. The care plans lacked specific documentation regarding the secure unit placement, which was not discussed during care plan meetings with the interdisciplinary team. Resident #1, a male with Alzheimer's Disease, had a care plan addressing his risk for elopement and wandering behavior, as well as a history of inappropriate sexual acts. However, the care plan did not document his placement in the secure unit. Similarly, Resident #2, a female with unspecified dementia and behavioral disturbances, had a care plan that did not include her secure unit placement, despite being inappropriately touched by another resident. Other residents, including those with Alzheimer's Disease, tremors, Parkinson's Disease, and dementia, also had care plans that failed to document their secure unit placement. Interviews with the facility's staff, including the Rounding Provider, DON, and Administrator, revealed that the secure unit placement was not discussed during care plan meetings. Additionally, interviews with residents and their representatives confirmed that the secure unit placement was not addressed in care plan meetings. The lack of documentation and discussion regarding secure unit placement in the care plans highlights a significant deficiency in the facility's care planning process.
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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 Dalhart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coldwater Manor | 32.4 mi | ★★★★★ | 0 | 0 |
| Memorial Nursing And Rehabilitation Center | 33.4 mi | ★★★★★ | 0 | 0 |
| Great Plains Nursing And Rehabilitation | 34 mi | ★★★★★ | 0 | 0 |
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