Inspection Reports for
Coal Creek Post Acute & Assisted Living
329 EXEMPLA CIR, LAFAYETTE, CO, 80026-3463
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
48% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident rights, food safety, medical record accuracy, infection prevention and control, and COVID-19 vaccination policies at Coal Creek Post Acute & Assisted Living.
Findings
The facility was found deficient in multiple areas including failure to respect residents' dignity and rights, improper food handling and storage practices, inaccurate medical record documentation, inadequate infection prevention practices including improper use of personal protective equipment, and failure to offer COVID-19 vaccinations to eligible residents.
Deficiencies (5)
F 0550: The facility failed to ensure residents were treated with dignity and respect, including speaking respectfully to residents and preventing staff from discussing residents in overheard areas.
F 0812: The facility failed to ensure ready-to-eat foods were handled in a sanitary manner and failed to safely store food items in the main kitchen walk-in refrigerator, including presence of mold.
F 0842: The facility failed to maintain accurate medical records for pain reassessments and indwelling catheter care for Resident #28.
F 0880: The facility failed to ensure staff wore appropriate personal protective equipment when providing care to residents on enhanced barrier precautions, risking infection transmission.
F 0887: The facility failed to offer COVID-19 vaccination to two eligible residents and failed to properly document vaccination status.
Report Facts
Residents reviewed: 36
Residents affected: 4
Residents affected: 1
Residents affected: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Named in findings related to rude communication and disrespectful behavior toward residents #3 and #28 | |
| RN #2 | Registered Nurse | Named in findings related to incomplete pain reassessment and catheter care documentation for Resident #28 |
| DON | Director of Nursing | Interviewed regarding investigations, infection prevention, and COVID-19 vaccination policies |
| DM | Dietary Manager | Interviewed regarding food handling and kitchen sanitation deficiencies |
| CNA #1 | Certified Nurse Aide | Named in infection prevention deficiency for failure to wear gown during care of Resident #65 |
| CNA #2 | Certified Nurse Aide | Named in infection prevention deficiency for failure to wear gown during care of Resident #29 |
| CNA #3 | Certified Nurse Aide | Named in infection prevention deficiency for failure to wear gown during care of Resident #65 |
| RN #1 | Registered Nurse | Named in infection prevention deficiency for failure to ensure staff wore gowns for Resident #65 |
| PTA #1 | Physical Therapy Assistant | Named in infection prevention deficiency for failure to wear gloves and gown during care of Resident #62 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding infection prevention signage and PPE use |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding infection prevention signage and PPE use |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding infection prevention signage and PPE use |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding infection prevention signage and PPE use |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding infection prevention signage and PPE use |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 13, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding medication administration errors, fall risk management, and medication errors at Coal Creek Post Acute & Assisted Living.
Complaint Details
The investigation was complaint-driven based on reports of medication administration errors, fall risk management failures, and medication errors. The facility was found to have failed in timely medication administration for Residents #8 and #9, failed to prevent a fall for Resident #3, and failed to administer Parkinson's medication correctly for Resident #4. The neglect allegation regarding Resident #3 was not substantiated due to lack of proof.
Findings
The facility failed to ensure professional standards during medication administration for two residents, failed to provide a safe environment and adequate supervision to prevent falls for one resident, and failed to ensure one resident was free from significant medication errors related to Parkinson's medication administration.
Deficiencies (3)
F 0658: The facility failed to ensure Resident #9 and Resident #8 received medications as scheduled according to physician orders, with medications administered late beyond the allowed one-hour window.
F 0689: The facility failed to ensure the resident environment was free from accident hazards and adequate supervision was provided for Resident #3, who sustained a fall resulting in a head laceration requiring emergency treatment.
F 0760: The facility failed to ensure Resident #4 was administered Parkinson's medication per physician orders, missing three doses due to medication not being reordered timely and lack of monitoring or provider notification.
Report Facts
Residents in sample: 9
Medication administration delay: 110
Medication administration delay: 126
Medication administration delay: 66
Fall laceration size: 2
Fall laceration size: 0.5
Fall laceration size: 0.1
Missed medication doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding medication cart auditing and medication administration responsibilities |
| CNA #2 | Certified Nurse Aide | Involved in fall incident with Resident #3; suspended and later dismissed during investigation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding fall incident and medication administration policies |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding fall incident and medication administration policies |
| Regional Clinical Resource | Regional Clinical Resource (RCR) | Interviewed regarding medication administration windows and documentation |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding fall investigation and staff disciplinary actions |
| Physical Therapist | Physical Therapist (PT) | Interviewed regarding Resident #3's therapy and mobility status |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding importance of medication adherence for Resident #4 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 27, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide dignified care and timely assistance to residents, including allegations of neglect and poor hygiene.
Complaint Details
The investigation was complaint-driven based on grievances from residents and family members about neglectful care, disrespectful treatment, and poor hygiene. The complaints were substantiated with findings of staff failing to provide timely toileting assistance and proper hygiene care. Several staff were removed due to these issues.
Findings
The facility failed to maintain resident dignity and provide timely, respectful care to several residents, resulting in minimal harm or potential for harm. Investigations substantiated neglectful care practices by staff, including failure to assist residents with toileting and hygiene, leading to resident dissatisfaction and discharge.
Deficiencies (1)
F 0550: The facility failed to honor residents' rights to dignity and respect by not providing timely assistance for toileting and personal care to Residents #1, #5, and #6, resulting in neglectful treatment and poor hygiene.
Report Facts
Residents in sample: 12
Residents affected: 3
Resident #5 length of stay: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Failed to provide hygienic environment for Resident #5; separated from employment |
| CNA #2 | Certified Nurse Aide | Failed to provide timely toileting assistance to Resident #1 |
| CNA #3 | Certified Nurse Aide | Made disrespectful comments to Resident #6; terminated after investigation |
| NHA | Nursing Home Administrator | New administrator who implemented quality improvement measures and staff training |
| DON | Director of Nursing | Interviewed regarding staff expectations and care quality |
| UM | Unit Manager | Interviewed about nurse-to-nurse report sheets and care coordination |
| CNC | Corporate Nurse Consultant | Provided facility policies and interviewed regarding care deficiencies |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 29, 2024
Visit Reason
Routine inspection to assess compliance with regulatory requirements related to resident care, medication storage, infection control, and other facility operations.
Findings
The facility failed to ensure residents were treated with dignity and respect, failed to provide appropriate restorative therapy for a resident's contracture, failed to obtain physician orders for oxygen administration for two residents, failed to properly store and secure medications including controlled substances, failed to accommodate a resident's vegetarian diet preference, and failed to implement proper infection prevention and control measures including transmission-based precautions.
Deficiencies (6)
F 0550: Facility failed to treat residents with dignity and respect, including failure to assist a resident during meals and failure to respond appropriately to a resident's request for warm coffee.
F 0688: Facility failed to assess and provide a restorative program for a resident's contracted right hand, despite awareness of the contracture.
F 0695: Facility failed to obtain physician orders for oxygen administration for two residents receiving supplemental oxygen therapy.
F 0761: Facility failed to maintain medication storage refrigerators within acceptable temperature ranges, failed to consistently monitor and document temperatures, failed to properly secure a Schedule IV controlled medication, and failed to properly dispose of expired medications.
F 0806: Facility failed to provide food that accommodated a resident's vegetarian diet preference, serving beef pot pie contrary to the documented preference.
F 0880: Facility failed to implement transmission-based precautions for residents with MRSA infections, including failure to use gowns and gloves appropriately and failure to post isolation signage and provide PPE carts.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 2
Inspection Report
Routine
Deficiencies: 8
Date: Nov 25, 2019
Visit Reason
Routine state inspection survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to honor resident bathing preferences, incomplete care plan updates after falls, inadequate wound care and monitoring, failure to provide appropriate respiratory care including oxygen use, insufficient nursing staff to meet resident needs, and failure to timely communicate and act on pharmacy recommendations.
Deficiencies (8)
F0550: Facility failed to ensure resident dignity by addressing resident by preferred name and providing a dignified dining experience.
F0561: Facility failed to honor resident bathing preferences for six residents, resulting in missed showers and inadequate assistance.
F0657: Facility failed to update Resident #97's care plan with new risks and interventions after a fall on 11/18/19.
F0684: Facility failed to provide appropriate wound care and monitoring for Resident #40, including failure to assess wound daily and timely communicate changes to physician.
F0684: Facility failed to timely monitor and document skin conditions including bruising and abrasions for Resident #20.
F0695: Facility failed to provide respiratory care per physician orders for Resident #195, including failure to ensure continuous oxygen use and lack of clear oxygen use parameters.
F0725: Facility failed to provide sufficient nursing staff to meet resident care needs, resulting in delayed call light responses, unmet ADL needs, and resident complaints.
F0756: Facility failed to timely communicate and act on pharmacy recommendations for Resident #97, resulting in delayed medication adjustments.
Report Facts
Residents in facility: 51
Call light response times: 73
Call light responses over 10 minutes: 17
Pharmacy recommendations: 4
Oxygen saturation low: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding dignity issues, oxygen use, and care plan updates. |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing, wound care, oxygen use, pharmacy recommendations, and call light audits. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding use of resident preferred names and bathing assistance. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding staffing and bathing assistance. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding staffing shortages and workload. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding staffing and skin assessments. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding skin assessments and bruising documentation. |
| Pharmacy Service Consultant | Pharmacy Service Consultant | Interviewed regarding pharmacist recommendations and follow-up. |
| Physician Assistant | Physician Assistant | Interviewed regarding receipt and review of pharmacy recommendations. |
| Occupational Therapy Assistant #1 | Occupational Therapy Assistant | Interviewed regarding oxygen use awareness during therapy sessions. |
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