Cycle 1
Health 2025-08-21 · Fire 2024-02-29
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lafayette, CO
Coal Creek Post Acute & Assisted Living
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
329 Exempla Cir, Lafayette, CO
(720) 639-2200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2015-04-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.33
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.97
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
4.02
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
7.33
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
3.31
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
6.58
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.15
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
6.06
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
81%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,146
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0147
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.57
Baseline 17.07% · Performance 18.39% · Measure score 6.57 · Achievement 6.57 · Improvement 0
Healthcare-associated infections
5.55
Baseline 4.77% · Performance 6.18% · Measure score 5.55 · Achievement 5.55 · Improvement 0
Total nurse turnover
3.66
Baseline 90.54% · Performance 63.23% · Measure score 3.66 · Achievement 0 · Improvement 3.66
Adjusted total nurse staffing
8.01
Baseline 4.65 hours · Performance 5.36 hours · Measure score 8.01 · Achievement 8.01 · Improvement 5.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 181 · Observed rate 7.18% · Lower 95% interval 6.79% |
| Discharge to community | 61.41% |
50.57%
10.8 pts better
|
Better than the National Rate · Eligible stays 174 · Observed rate 61.49% · Lower 95% interval 53.5% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 97 · Denominator 97 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 97 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 63 · Denominator 84 |
| Discharge mobility score | 53.57% |
50.94%
2.6 pts better
|
Numerator 45 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 3.09% |
2.29%
0.8 pts worse
|
Numerator 3 · Denominator 97 · Adjusted rate 3.82% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 3.23% · Lower 95% interval 3.47% |
| Staff COVID-19 vaccination coverage | 4.92% |
8.2%
3.3 pts worse
|
Numerator 6 · Denominator 122 |
| Staff flu vaccination coverage | 89.42% |
42%
47.4 pts better
|
Numerator 93 · Denominator 104 |
| Discharge function score | 71.43% |
56.45%
15 pts better
|
Numerator 60 · Denominator 84 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 70 · Denominator 70 |
| Resident COVID-19 vaccinations up to date | 12% |
25.2%
13.2 pts worse
|
Numerator 6 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
93.5%
2.6 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 13.7% |
3.4%
10.3 pts worse
|
3.3%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.0% |
7.4%
2.6 pts worse
|
11.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
5.0%
1.8 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.8% |
11.2%
4.4 pts better
|
19.6%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.2% |
20.6%
13.6 pts worse
|
16.7%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.5% |
15.2%
10.7 pts better
|
16.3%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
14.6%
5.5 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.5%
0.5 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.4% |
22.4%
6 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.4% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
3.7%
0.9 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.4% |
76.4%
9 pts better
|
81.7%
3.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 69.9% · Q2 76.0% · Q3 97.6% · Q4 100.0% · 4Q avg 85.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
12.8%
0.1 pts better
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 12.3% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.7% · Q3 2.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.9% |
75.6%
14.7 pts worse
|
79.7%
18.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
20.3%
0.3 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 19.3% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2019-11-25
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-11-25 · Fire 2018-11-29
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-02-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-02-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-30
F · Potential for more than minimal harm
2019-11-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-01-27
F · Potential for more than minimal harm
2019-11-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-12-26
F · Potential for more than minimal harm
2019-11-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-20
F · Potential for more than minimal harm
2019-11-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-31
F · Potential for more than minimal harm
2019-11-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-27
F · Potential for more than minimal harm
2019-11-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-11-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-12-24
D · Potential for more than minimal harm
2019-11-25
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-11-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-11-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-01-20
D · Potential for more than minimal harm
2019-11-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-11-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2020-01-27
D · Potential for more than minimal harm
2019-11-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-12-24
E · Potential for more than minimal harm
2018-11-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-01-17
E · Potential for more than minimal harm
2018-11-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-07
D · Potential for more than minimal harm
2018-11-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-01-07
D · Potential for more than minimal harm
2018-11-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-01-07
D · Potential for more than minimal harm
2018-11-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-11-29
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2019-01-07
D · Potential for more than minimal harm
2018-11-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-01-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-11
E · Potential for more than minimal harm
2025-08-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-20
E · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-21
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-09-20
G · Actual harm
2024-11-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-08-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-02-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-29
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-29
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-23
E · Potential for more than minimal harm
2019-11-25
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2020-01-31
E · Potential for more than minimal harm
2019-11-25
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-12-29
D · Potential for more than minimal harm
2019-11-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-12-29
D · Potential for more than minimal harm
2019-11-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-12-29
D · Potential for more than minimal harm
2019-11-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-29
D · Potential for more than minimal harm
2019-11-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-01-31
D · Potential for more than minimal harm
2019-11-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-12-29
Penalties and ownership
What sits behind the stars
$0
2024-11-13
Payment Denial
Payment Denial · denial start 2024-12-11 · 5 days
5 day denial
Ownership
Panther Master Tenant, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Bader, Carly
W-2 Managing Employee · Individual
Esfahani, Reza
Contracted Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Adara Living
Broomfield, CO
2-star overall rating with 1-star inspections with abuse icon flag with $72,937 in total fines with 14 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Center At Northridge, LLC, The
Westminster, CO
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Village Care And Rehabilitation Center, The
Westminster, CO
4-star overall rating with 4-star inspections with 3 recent health deficiencies
Jump out