Coal Creek Post Acute & Assisted Living

A revisit survey was completed on 1/28/26 for all previous deficiencies cited on 7/23/25. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A licensure complaint, prompted by #CO40629, #CO40630, #CO40631, #CO40634, #CO40635, #CO40643, #CO40644, #CO40645, #CO40646 was completed on 7/23/25. Deficiencies were cited Based on interview and record review, the residence failed to provide the residents with 30 calendar days written notice of changes in services provided by the assisted living residence, affecting 10 (#1-#10) sample residents.Findings include:The residence' s undated Resident Rights policy, read, in part, "Staff respects each resident' s resident rights, which include, but are not limited to ... the right to thirty (30) calendar days written notice of changes in service provided by the assisted living residence."An untitled residence document, dated 7/7/25, read, in part, "It is with deep regret that we write to inform you that our contract with (External Service Provider) will officially end on August 6, 2025. This was not an easy decision and it comes after ongoing challenges related to quality of care, comm.. Based on observation, interview and record review, the residence failed to notify the department of a change in the administrator, affecting 22 current residents. Findings include:1. ObservationOn 7/22/25 at 8:00 a.m., a posting on the wall of the assisted living residence included the acting administrator' s (AA) training certification. 2. Record ReviewA review of the department' s database on 7/22/25, revealed the administrator of record was listed as the administrator since 9/27/24.An electronic message, dated 7/22/25 at 8:15 a.m. from a department representative, read in part that the residence had not submitted an application to change the administrator from the administrator of record to the AA.On 7/22/25 at 10:27 a.m., the AA provided proof of her 40-hour training, which read she had fini.. Based on record review and interview, the residence failed to establish a policy for when a practitioner' s assessment is appropriate, and contact a resident' s primary practitioner when the resident experiences a significant change in their baseline status, affecting one of ten sample residents (#3). Findings include:1. Residence PolicyOn 7/23/25 at 10:11 a.m., the residence' s policy for practitioner assessment was requested; however, the policies provided did not include the circumstances for when a practitioner' s assessment was appropriate, and the requirement for contacting a resident' s practitioner when a resident experienced a change in their baseline. 2. Resident #3 was admitted to the residence on 5/21/24.A practitioner' s order dated 7/4/24, read residence staff were to document Resident #3' s blood.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.18.8 Resident records shall contain, but not be limited to, the following items: (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident' s changing needs;(1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident..

A relicensure survey with complaint #CO35048 was completed on 3/7/24. Deficiencies were cited. A change of ownership occured on 2/1/23. Based on interview and record review the residence failed to comply with authorized practitioner' s orders associated with medication administration affecting four of four sample residents (#1-#4). (Cross-reference S1604)Findings include:1. Residence Policya. The residences, undated, medication administration policy read in part: Medication ref.. Based on interview and record review the residence failed to ensure resident' s medication administration record was accurate affecting two of four sample residents (#1, #4).Findings include:1. Residence PolicyThe residence' s undated medication administration policy read in part, medication administration records (MARs) were maintained for all med.. Based on interview and record review the residence failed to ensure there was an order for all medication that was prepared and administered to residents affecting one sample resident (#4).Findings include:1. The residence' s, undated, medication administration policy read in part: Medications were listed on the medication administration re.. Based on interview and record review the residence failed to ensure there was at least one staff member onsite at all times certified in cardiopulmonary resuscitation (CPR), affecting 20 current residents. (Cross-reference S0732, S0736).Findings include:On 3/7/24 at 7:58 a.m., CPR certification for all staff was requested from the administrator... Based on interview and record review the residence failed to ensure there was at least one staff member onsite at all times certified in first aid, affecting 20 current residents. (Cross-reference S0734,S0736).Findings include:On 3/6/24 at 7:58 a.m., first aid certification for all staff was requested from the administrator. On 3/6/24 at 12:25 p.m., certi.. Based on interview and record review the residence failed to on a quarterly basis audit the accuracy and completeness of medication administration records affecting four of four sample residents (#1-#4).Findings include:On 3/7/24 at 7:58 a.m. the last three quarterly medication audits were requested from the administrator. However, on 3/7/24 at .. Based on interview and record review, the residence failed to ensure each resident care plan reflected current personal services needs and preferences along with staff tasks necessary to meet the needs of the resident, affecting one sample resident (#2).Findings include:1. Residence PolicyThe residence' s, undated, Ongoing Residential Appraisal.. Based on observation and interview the residence failed to place in a visible location a list of all staff who had current certification in first aid and cardiopulmonary resuscitation (CPR), affecting 20 current residents. (Cross-reference S0732, S0734)Findings include:During an environmental tour at approximately 7:30 a.m., there was no evidence of a .. Based on observation, interview and record review the residence failed to ensure each staff member who provided assisted living services completed orientation prior to providing care and services affecting 20 current residents.Findings include:During morning medication pass on 3/7/24 at approximately 7:30 a.m., Contracted Staff #.. Based on observation, interview and record review the residence failed to ensure residents comprehensive assessment included information regarding the resident' s overall health and physical functioning ability affecting two of three residents that self administered insulin (#1, #2).Findings include:1. Residence PolicyThe residence' s, undated, Ongoin.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.9.2 The assisted living residence shall have written policies and procedures regarding the vis..