Coal Creek Post Acute & Assisted Living

In the surveyor’s words

From the most serious findings on record at Coal Creek Post Acute & Assisted Living, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Feb 14, 2022

  Based on observation, interviews, and record review, the facility failed to provide care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers, for three (#1, #7 and #12) of four residents reviewed for wounds, out of 12 sample residents. The facility failed to prevent, assess, monitor and timely treat a facility acquired sacral pressure injury for Resident #1, who had been assessed as being at risk for pressure ulcers. Additionally, the facility failed to notify the physician of changes to the pressure injury, including signs of infection. […]

• Actual harm, isolatedF689Aug 11, 2026

  Based on record review and interviews, the facility failed to prevent accidents and hazards for one (#5) of three residents reviewed for falls out of 23 sample residents. Resident #5 was admitted to the facility on [DATE] after pacemaker placement on 4/27/26 due to episodes of sinus pauses (a brief moment when the natural pacemaker of your heart, the sinus node, stops sending electrical signals for a short time), difficulty walking and progressive dementia. Upon admission to the facility, Resident #5 was assessed to be at a high fall risk. The baseline care plan, initiated 4/29/26, documented the resident was confused and very forgetful. […]

• Actual harm, isolatedF689Nov 13, 2024

  Based on record review and interviews, the facility failed to ensure the resident environment was free from accident hazards and adequate supervision was provided for one (#3) of three residents reviewed out of nine sample residents. Resident #3 was admitted to the facility on [DATE] for rehabilitation after surgery on her back. Upon admission, the resident was assessed for fall risk and was identified as a high risk for falls. However, the baseline care plan, initiated on 10/11/24, failed to identify the resident was at risk for falls and person-centered interventions were not put in place to prevent falls for Resident #3. […]

• Actual harm, isolatedF867Feb 14, 2022

  Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to: -Identify and address concerns related to wound care; -Notify the physician timely of changes in wounds and of injuries; and, -Identify infection control concerns with wound care. […]

• Actual harm, isolatedF600Mar 15, 2021

  Based on record review and interviews, the facility failed to prevent neglect for one (#5) of three residents reviewed for injuries out of 25 sample residents. Resident #5 was admitted to the facility on [DATE]. Resident #5 reported to therapy on 1/4/21 she had a fall on 1/3/21 and she had increased back/hip pain. The facility neglected to complete a thorough investigation after she reported she had fallen which included the causation of her increased complaint of pain and decreased mobility (cross-reference F610 for failure to complete a thorough investigation). […]