Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coal Creek Post Acute & Assisted Living during CMS and state inspections, most recent first.
Staff failed to follow sanitary food handling practices by using the same gloves to touch both ready-to-eat foods and non-food items without changing gloves or performing hand hygiene, and by wiping food residue from gloves onto food contact surfaces. Additionally, mold was observed on the floor of the walk-in refrigerator and on baking sheets used for food storage, with the mold on the floor persisting over several days despite staff awareness.
Several residents who were cognitively intact and dependent on staff for care reported being spoken to rudely or inappropriately by nursing staff, including being called derogatory names and having their concerns dismissed. In some cases, grievances were filed regarding disrespectful communication and improper care, but the facility's records did not show that the staff's inappropriate behavior was addressed. Staff also discussed residents in areas where conversations could be overheard, violating residents' rights to dignity and privacy.
Staff failed to consistently wear required gowns and gloves during high-contact care activities for residents on enhanced barrier precautions, including those with wounds, indwelling catheters, and surgical sites. Despite clear signage and existing protocols, several CNAs and a physical therapy assistant provided direct care without proper PPE, and interviews revealed confusion and lack of knowledge about EBP requirements among staff.
A resident's medical records were inaccurately completed, with documentation indicating that pain reassessment and indwelling catheter care had been performed when, in fact, these actions did not occur. Observation and resident interview confirmed that the nurse did not return to reassess pain or provide catheter care after administering as-needed pain medication, despite records showing otherwise.
Two residents, one cognitively intact and one with severe cognitive impairment, were not offered the COVID-19 vaccine as required, and there was no documentation in their medical records indicating that the vaccine was offered or administered. Staff interviews confirmed the absence of documentation for both residents.
A resident at high risk for falls was not provided with a fall prevention plan or adequate supervision, resulting in a fall and head injury. Despite being assessed as a high fall risk, the resident's care plan did not include necessary interventions. The resident fell after reportedly being denied assistance by a CNA, leading to a head laceration requiring emergency care. The facility's investigation was incomplete, lacking interviews with key staff present during the incident.
The facility failed to administer medications on time for two residents, leading to delays beyond the allowed window. A resident with Alzheimer's and hypertension received medications nearly two hours late, while another with osteomyelitis and diabetes experienced similar delays. The issue arose due to a nurse's absence, as confirmed by the DON and RCR.
A resident with Parkinson's disease did not receive their prescribed Carbidopa-Levodopa medication at three scheduled times due to it being out of stock. The nursing staff failed to audit the medication cart and reorder the medication in time, and did not order it as STAT when it was found missing. There was no documentation of notifying the physician or monitoring the resident for symptoms, leading to a significant deficiency in care.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving three residents. One resident was neglected when requesting bathroom assistance, leading to his departure from the facility. Another resident, with Alzheimer's, was often found in poor hygiene despite communicated care preferences, prompting her family to remove her from the facility. A third resident filed a grievance after a CNA refused to assist with changing a soiled brief, using inappropriate language. These incidents highlight ongoing issues with staff treatment and grievance handling.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure that food was prepared, distributed, and served under sanitary conditions in the main kitchen. During lunch meal service, kitchen staff were observed handling ready-to-eat foods with gloved hands that had also been used to touch non-food items such as meal tickets, serving utensils, and equipment handles. Staff did not change gloves or perform hand hygiene between tasks, and gloved hands were used to touch both food and potentially contaminated surfaces. Additionally, one staff member wiped food residue from a glove onto the inner rim of a steam table bin containing food, further compromising food safety. Observations in the main kitchen's walk-in refrigerator revealed a persistent patch of green-grey mold on the floor near the freezer door, which remained present over several days despite staff awareness. Baking sheets used to hold cheese products were found with small spots of mold along their edges and corners. Although the baking sheets were eventually cleaned, the mold on the refrigerator floor was not addressed in a timely manner, and staff interviews indicated that deep cleaning of the refrigerator had been delayed due to staffing shortages and equipment issues. Facility policies required the use of single-use gloves for one task only, with gloves to be discarded after each use and hand hygiene performed between glove changes. Policies also mandated that food be stored in clean, dry locations and that all kitchen surfaces and equipment be kept clean and in good repair. Despite these policies, staff practices and the condition of the kitchen environment did not meet these standards, resulting in the deficiencies cited.
Failure to Ensure Resident Dignity and Respectful Communication
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as required by policy and federal regulations. Multiple residents who were cognitively intact and dependent on staff for various activities of daily living reported or were observed to have experienced disrespectful or inappropriate communication from staff. One resident, who was unable to reach her call light, used her cell phone to request assistance and was spoken to rudely by a registered nurse, who told her to stop calling. The resident was unaware of her right to file a grievance and did not report the incident to facility leadership. Another resident reported that a registered nurse spoke loudly in the hallway, referring to residents as "drug addicts," and was rude and dismissive when administering medication. This resident reported the incident to the DON, but was unsure of the outcome. Additional grievances reviewed included a resident who experienced an argument with a nurse regarding IV line care, resulting in the resident developing blisters after the use of chlorhexidine, and another resident who was spoken to inappropriately by a CNA during a transfer, being told that other staff would not help because she was "too difficult to work with." The facility's grievance records did not indicate that the inappropriate communication by staff was addressed in the resolutions provided. Staff interviews confirmed awareness of some, but not all, of the allegations, and indicated that investigations were ongoing. The incidents demonstrate a pattern of staff failing to communicate respectfully with residents and discussing residents in areas where conversations could be overheard, in violation of residents' rights to dignity and privacy.
Failure to Ensure Proper PPE Use for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP). Surveyors observed multiple instances where staff did not wear the required gowns and gloves during high-contact care activities for residents with wounds, indwelling devices, or recent surgeries. For example, during direct care activities such as transferring, catheter care, clothing changes, and colostomy care, several staff members either wore only gloves or did not wear any PPE, despite clear signage on residents' doors indicating the need for both gowns and gloves. Residents involved in these deficiencies included individuals with indwelling urinary catheters, surgical wounds with staples, and multiple wounds with devices such as colostomies and intravenous lines. Staff members, including CNAs, a physical therapy assistant, and an unidentified nursing staff member, were observed providing direct care without adhering to the required PPE protocols. In some cases, staff expressed uncertainty or lack of knowledge about the necessity of wearing gowns in addition to gloves, or believed PPE was only needed for certain tasks, despite the residents' high risk for infection due to their medical conditions. Interviews with staff, including RNs, CNAs, the LPN, the DON, and the infection preventionist, revealed gaps in understanding and communication regarding EBP requirements. Some staff were unsure about the specific PPE needed for residents on EBP, while others acknowledged they should have worn gowns but failed to do so. The infection preventionist and DON confirmed that education on EBP and PPE use was provided, but the observed lapses indicated inconsistent adherence to infection control protocols during resident care activities.
Inaccurate Documentation of Pain Reassessment and Catheter Care
Penalty
Summary
The facility failed to maintain accurate medical records for one resident, specifically regarding pain reassessment and indwelling catheter care. During a continuous observation period, it was noted that the resident's medication administration record (MAR) and treatment administration record (TAR) were incomplete at the start of the observation. Although the records were later marked as completed for both pain reassessment and catheter care, direct observation confirmed that the nurse did not return to the resident's room to perform a pain reassessment or provide catheter care after the initial administration of as-needed pain medication. The resident confirmed in an interview that no catheter care was provided that morning and that pain reassessment was not consistently performed after receiving pain medication. A review of the progress notes indicated documentation of a pain reassessment that, according to both observation and the resident's account, did not actually occur. The director of nursing acknowledged that the time care was documented in the TAR did not necessarily reflect when the care was provided and that staff were encouraged to document as accurately as possible. However, the evidence showed that documentation was completed for care and assessments that were not actually performed, resulting in inaccurate medical records for the resident.
Failure to Offer and Document COVID-19 Vaccination for Two Residents
Penalty
Summary
The facility failed to develop and implement policies and procedures related to COVID-19 immunizations for two of five residents reviewed for immunizations. Specifically, the facility did not offer the COVID-19 vaccine to two residents, as required by CDC guidelines. One resident, under 65 years old with a history of traumatic brain injury and multiple fractures, was cognitively intact and did not recall being offered the COVID-19 vaccine. Review of his electronic medical record confirmed there was no documentation that the vaccine was offered or administered. Another resident, over 65 years old with diagnoses including femur fracture, joint replacement, anemia, dementia, and generalized weakness, had severe cognitive impairment and was dependent on staff for most activities of daily living. There was no documentation in her medical record that the COVID-19 vaccine was offered or administered. Staff interviews confirmed that there was no record of either resident being offered or declining the vaccine, and the DON stated it was the admitting nurse's responsibility to document such offers and refusals.
Failure to Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident who was at high risk for falls. Upon admission, the resident was assessed and identified as a high fall risk due to her medical conditions, including a compression fracture, diabetes, and difficulty walking. Despite this assessment, the baseline care plan did not reflect the resident's fall risk, nor did it include person-centered interventions to prevent falls. On the day following her admission, the resident sustained a fall resulting in a head laceration that required emergency department treatment. The fall occurred after the resident reportedly asked a CNA for assistance to the bathroom but was told to manage on her own. The resident attempted to use the bathroom independently, resulting in a fall. The facility's investigation into the incident was incomplete, lacking interviews with key staff present during the incident. The CNA involved was suspended and later dismissed for not responding to the facility's calls. The investigation did not substantiate neglect, as there was no conclusive evidence that the CNA refused assistance. The facility's failure to implement a fall prevention plan and provide adequate supervision contributed to the resident's fall and injury.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed during medication administration for two residents. Specifically, Resident #9 and Resident #8 did not receive their medications as scheduled according to the physician's orders. For Resident #9, the medications were scheduled for 8 a.m., but were administered at 9:50 a.m., which is one hour and 50 minutes past the scheduled time and 50 minutes after the allowed medication administration window. Resident #9, who is over 65 years old, has diagnoses including Alzheimer's dementia and hypertension, and was receiving an antidepressant, opioid, and hypoglycemic medications. Similarly, Resident #8, who is also over 65 years old and has diagnoses including osteomyelitis and type 2 diabetes, received medications late. The B-complex, Finasteride, and Aspirin were scheduled for 8:00 a.m. but were administered at 10:06 a.m., two hours and six minutes past the scheduled time and one hour after the medication administration window. Additionally, the lactobacillus, quetiapine, and omeprazole were scheduled for 9:00 a.m. but were administered one hour and six minutes past the scheduled time. The delay in medication administration was attributed to a morning nurse calling off and not coming to work, as confirmed by the Director of Nursing and the Regional Clinical Resource.
Failure to Administer Parkinson's Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was free from significant medication errors. The resident was prescribed Carbidopa-Levodopa to be administered four times a day at specific times. However, on a particular day, the resident did not receive the medication at three scheduled times due to the medication being out of stock. The medication administration record indicated the absence of the medication, and nursing progress notes confirmed that the pharmacy was contacted but did not deliver the medication as expected. The nursing staff did not audit the medication cart adequately to reorder the medication before it ran out. Additionally, once the medication was found to be missing, the staff failed to order it as STAT, which would have expedited its delivery. There was also no documentation that the resident's physician was notified about the missed doses, nor was there any record of monitoring the resident for symptoms related to missing the medication. Interviews with the nursing staff and administration revealed that there were expectations for auditing medication carts and reordering medications, which were not met in this instance. The staff acknowledged the importance of administering Parkinson's medication as prescribed and the potential consequences of missed doses. However, the necessary steps to prevent and address the medication error were not taken, leading to a significant deficiency in the resident's care.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to promote and maintain resident dignity by not providing care in a dignified, respectful, and individualized manner for three residents. Resident #1, who was alert and oriented, requested assistance to use the bathroom but was told by a CNA to use his brief instead. This led to the resident feeling neglected and ultimately leaving the facility, calling the police, and being taken to the hospital. The facility's investigation confirmed that the CNA did not respond to the resident in a dignified and respectful manner. Resident #5, diagnosed with Alzheimer's disease, was dependent on staff for daily living activities and had specific care preferences, such as being up before lunch and attending church services. Despite these preferences being communicated, the resident was often found in poor hygiene, wearing the same clothes for days, and left in soiled conditions. The resident's representative voiced concerns multiple times, but the facility failed to address these issues adequately, leading to the resident's family deciding to remove her from the facility. Resident #6, who had intact cognition, filed a grievance after a CNA refused to assist her with changing a soiled brief, using inappropriate language. The facility's investigation revealed that this CNA had previous complaints from other residents, leading to her termination. Interviews with other residents and a frequent visitor highlighted ongoing issues with staff not treating residents respectfully and taking a long time to address grievances, indicating a broader problem with the facility's approach to resident care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adara Living | 3.6 mi | ★★★★★ | 2 | 0 |
| Center At Northridge, Llc, The | 6.1 mi | ★★★★★ | 0 | 0 |
| Village Care And Rehabilitation Center, The | 7.5 mi | ★★★★★ | 0 | 0 |
| Malley Transitional Care Center | 7.5 mi | ★★★★★ | 2 | 0 |
| Frasier Meadows Health Care Center | 7.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.