Deficiency Records for Coal Creek Post Acute and Assisted Living
Updated as of March 01, 2024
A list of the most recent deficiencies for Coal Creek Post Acute and Assisted Living. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-27 | 2022-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-27 | 2022-10-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-05-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-14 | 2022-03-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-14 | 2022-03-16 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-02-14 | 2022-03-16 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-02-14 | 2022-03-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-14 | 2022-03-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-14 | 2022-03-11 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2022-02-14 | 2022-02-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-15 | 2021-04-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-15 | 2021-04-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-15 | 2021-04-21 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-03-15 | 2021-04-21 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-15 | 2021-04-21 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-03-15 | 2021-04-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-15 | 2021-04-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-15 | 2021-04-21 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-25 | 2020-01-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-25 | 2020-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-18 | 2020-01-31 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-18 | 2020-01-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-18 | 2020-01-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-18 | 2020-01-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-18 | 2020-01-27 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-12-18 | 2020-01-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-18 | 2020-01-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-18 | 2020-01-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-18 | 2020-01-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-18 | 2020-01-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-25 | 2019-12-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-25 | 2019-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-25 | 2019-12-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-11-25 | 2019-12-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-25 | 2019-12-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-18 | 2019-12-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-18 | 2019-12-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-18 | 2019-12-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-26 | 2019-01-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-26 | 2019-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-26 | 2019-01-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-26 | 2019-01-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-26 | 2019-01-07 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2018-12-26 | 2019-01-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-26 | 2019-01-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-29 | 2018-12-24 | N |
| Provide activities to meet all resident's needs. | Health | 2018-11-29 | 2018-12-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-29 | 2018-12-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-29 | 2018-12-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-11-29 | 2018-12-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-29 | 2018-12-24 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-11-29 | 2018-12-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2018-12-24 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-05-18 | 2017-06-28 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-18 | 2017-06-28 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-05-18 | 2017-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-13 | 2017-06-14 | N |
