Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

COAL CREEK POST ACUTE & ASSISTED LIVING

LAFAYETTE, CO · 70 certified beds · Last Life Safety survey February 29, 2024

CMS Certification Number 065414 · first certified April 2015

Ownership

Operated by PACS GROUP · For profit - Corporation

Ownership changed September 1, 2023 (change of ownership)from 329 EXEMPLA CIRCLE OPERATIONS II LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within CO

24 citations — more than 75% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 4 citations; the earlier surveys in the window averaged 10. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (August 2025 to March 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was February 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	24
Median facility in CO	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
November 29, 2018	7
November 25, 2019	13
February 29, 2024	4

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2024-02-29
K-0363	Install corridor and hallway doors that block smoke.	2	2019-11-25
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2019-11-25
K-0712	Have simulated fire drills held at unexpected times.	2	2024-02-29
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	2	2019-11-25
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2019-11-25
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	2	2024-02-29
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	1	2019-11-25

What the citations cover

Citations by CMS category

Smoke Deficiencies 10
Egress Deficiencies 4
Gas, Vacuum, and Electrical Systems Deficiencies 4
Miscellaneous Deficiencies 4
Other 2

Citations by CMS category
Category	Citations
Smoke Deficiencies	10
Egress Deficiencies	4
Gas, Vacuum, and Electrical Systems Deficiencies	4
Miscellaneous Deficiencies	4
Services Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

February 29, 2024 — 4 citations

Citations issued on February 29, 2024
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (April 15, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (April 1, 2024)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (April 23, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (March 30, 2024)

November 25, 2019 — 13 citations

Citations issued on November 25, 2019
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (December 24, 2019)
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (January 27, 2020)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (January 27, 2020)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (December 26, 2019)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (January 27, 2020)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 20, 2020)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 31, 2020)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (January 20, 2020)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (January 27, 2020)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (January 27, 2020)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (January 27, 2020)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (December 24, 2019)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 27, 2020)

November 29, 2018 — 7 citations

Citations issued on November 29, 2018
Tag	What the surveyor checks	Status
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 17, 2019)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 7, 2019)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (January 7, 2019)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (January 7, 2019)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (January 22, 2019)
K-0751	Have restrictions on the use of flammable curtains.	Deficient, Provider has date of correction (January 7, 2019)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 7, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.