Inspection Reports for The Center at Cordera, LLC
9208 GRAND CORDERA PKWY, COLORADO SPRINGS, CO, 80924-
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Census: 21
Deficiencies: 5
Date: Jul 23, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, resident rights regarding room changes, pain medication orders, accident prevention, feeding tube care, and overall quality of services provided to residents.
Findings
The facility was found deficient in multiple areas including failure to ensure clinical appropriateness and physician orders for self-administration of medications for three residents, failure to provide written notice of room changes for two residents, incomplete pain medication orders lacking pain level parameters for two residents, inadequate supervision related to wheelchair foot pedals for three residents, and improper feeding tube medication administration and hydration for two residents.
Deficiencies (5)
Failed to ensure self-administration of medications was clinically appropriate and lacked physician orders for self-administration for Residents #3, #8, and #13.
Failed to provide written notice of room changes for Residents #14 and #19.
Failed to ensure physician's orders for pain medications included parameters for administration based on pain levels for Residents #10 and #8.
Failed to provide adequate supervision to prevent accidents by ensuring wheelchair foot pedals were in place for Residents #20, #21, and #5.
Failed to ensure feeding tube medications and hydration were administered correctly and physician orders were accurate for Residents #8 and #3.
Report Facts
Residents in sample: 21
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 2
Pain medication doses: 4
Pain medication doses: 5
BIMS score: 0
BIMS score: 0
BIMS score: 15
BIMS score: 8
Weight loss: 9.4
Weight gain: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Identified medication on bedside table and confirmed lack of physician orders for self-administration for Resident #3 and Resident #13; administered medications via feeding tube for Resident #3 |
| RN #1 | Registered Nurse | Administered eye drops and confirmed lack of physician orders for Resident #8 |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding deficiencies in medication orders, room change notifications, pain medication parameters, wheelchair safety, and feeding tube care |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding pain medication administration for Resident #10 |
| Director of Rehabilitation | Director of Rehabilitation (DOR) | Interviewed regarding wheelchair foot pedal safety and therapy practices |
| Registered Dietitian | Registered Dietitian (RD) | Interviewed regarding feeding tube assessments and recommendations for Residents #3 and #8 |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 29, 2024
Visit Reason
The inspection was conducted due to complaints regarding inadequate supervision to prevent falls, ineffective pain management, and failure to maintain infection control standards at the nursing home.
Complaint Details
The investigation was complaint-driven based on allegations of inadequate fall prevention, pain management, and infection control practices. The complaint was substantiated with findings of actual harm to residents due to falls and pain mismanagement.
Findings
The facility failed to provide adequate supervision and person-centered fall interventions for residents at high risk of falls, resulting in multiple falls and injuries. The facility also failed to provide effective pain management for a resident with pressure ulcers and did not ensure proper infection prevention and control practices, including hand hygiene and enhanced barrier precautions.
Deficiencies (4)
Failure to provide adequate supervision and person-centered fall interventions for residents #30 and #5, resulting in multiple falls and injuries.
Failure to provide effective pain management for Resident #1 with pressure ulcers, resulting in prolonged pain.
Failure to ensure housekeeping staff performed proper hand hygiene and followed disinfectant dwell time guidelines.
Failure to ensure nursing staff followed enhanced barrier precautions appropriately during resident care for residents with wounds and indwelling devices.
Report Facts
Falls sustained by Resident #5: 7
Falls sustained by Resident #30: 2
Repositioning frequency: 49
BIMS score: 2
BIMS score: 14
Medication doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Reported Resident #30's fall and care observations |
| DOR | Director of Rehabilitation | Interviewed regarding Resident #30 and Resident #5 fall risks and interventions |
| LPN #2 | Licensed Practical Nurse | Interviewed about fall prevention knowledge for Resident #5 |
| CNA #3 | Certified Nursing Assistant | Interviewed about awareness of Resident #5's fall risk |
| LPN #1 | Licensed Practical Nurse | Interviewed about fall prevention approaches for Resident #5 |
| RN #2 | Registered Nurse | Provided wound care to Resident #1 and described pain management |
| CNA #4 | Certified Nursing Assistant | Assisted Resident #1 with care and feeding, reported pain |
| CNA #5 | Certified Nursing Assistant | Assisted Resident #1 with feeding and care, reported pain |
| RN #3 | Registered Nurse | Interviewed about pain management for Resident #1 |
| DON | Director of Nursing | Interviewed about fall prevention, pain management, and infection control policies |
| HSKP #1 | Housekeeper | Observed not following hand hygiene and disinfectant dwell time protocols |
| HSKD | Housekeeping Director | Interviewed about disinfectant dwell time and hand hygiene |
| SC | Staffing Coordinator | Observed assisting resident on enhanced barrier precautions without gown |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care, environment, food service, fall prevention, pressure ulcer care, hospice services, and facility maintenance.
Findings
The facility was found deficient in maintaining a sanitary and comfortable environment, providing appropriate pressure ulcer care, implementing fall prevention interventions, ensuring safe food handling and preparation, maintaining communication with hospice providers, and ensuring a safe physical environment with proper backflow prevention devices.
Deficiencies (6)
Failed to maintain a sanitary, orderly, and comfortable environment in 17 of 44 resident rooms, including unclean walls and ventilation fans.
Failed to provide necessary treatment and services to prevent pressure ulcers for one resident by not offloading bilateral heels while in bed.
Failed to implement interventions to reduce hazards and risks for falls for two residents, including failure to keep beds in lowest position, use fall mats, and place fall risk indicators.
Failed to ensure food was stored, prepared, and served under sanitary conditions, including improper hand hygiene by food service staff, inadequate reheating of modified consistency foods, and use of cutting boards with deep scratches and stains.
Failed to maintain communication with hospice providers, including lack of documentation of collaboration and failure to ensure medication orders from hospice were received and administered.
Failed to ensure backflow prevention devices were installed on hoses in two maintenance closets, increasing risk of contamination to the facility's main water supply.
Report Facts
Resident rooms affected: 17
Residents reviewed for pressure ulcers: 28
Residents reviewed for falls: 28
Dates of hospice visit notes requested: 19
Temperature readings: 118
Temperature readings: 163
Length of hose: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding hospice communication binder for Resident #198 |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding medication order for Resident #104 |
| Director of Nursing | Director of Nursing | Interviewed regarding fall prevention, hospice communication, and medication orders |
| Dietary Aide #1 | Dietary Aide | Observed during food preparation and serving with improper hand hygiene |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and cutting boards |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding backflow prevention devices in maintenance closets |
Inspection Report
Routine
Deficiencies: 14
Date: Jan 20, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with professional standards, medication administration, discharge planning, activities, pain management, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during personal care, medication administration errors including missed and late medications, inadequate discharge planning, insufficient assistance with activities of daily living, lack of effective activity programming, failure to ensure nursing competencies, inadequate dementia care, pharmaceutical service deficiencies, failure to provide appropriate hospice coordination, incomplete documentation of resident death, and infection control lapses including improper PPE use and equipment sanitation.
Deficiencies (14)
Facility failed to ensure privacy during personal care for Resident #13.
Failed to notify provider of missed or late medications and failed to obtain physician crush medication order for Resident #13.
Failed to implement effective discharge planning for Resident #302 including communication and comprehensive plan development.
Failed to provide necessary assistance with activities of daily living for Residents #10, #298, #13, and #40 including showering, meal assistance, and catheter care.
Failed to provide ongoing activity programming to meet residents' interests and needs for Residents #13, #16, and #10.
Failed to employ a qualified activities director to provide a program of activities for residents requiring activity and recreational support.
Failed to ensure appropriate treatment and care for Resident #10 including excessive acetaminophen dosing and failure to monitor blood pressure outside baseline.
Failed to ensure supervision and assistive devices to prevent falls for Residents #298 and #299 including inaccurate fall assessments and lack of fall prevention interventions.
Failed to provide appropriate respiratory care including unclear oxygen titration orders and undated oxygen tubing for Residents #13, #16, and #296.
Failed to provide timely pain management for Resident #201 including late administration of pain medications and lack of non-pharmacological interventions.
Failed to safeguard resident-identifiable information and maintain accurate medical records documenting the events surrounding the death of Resident #47.
Failed to ensure hospice services met professional standards including lack of interdisciplinary team collaboration, hospice aide orientation, and coordinated care plan for Resident #37.
Failed to provide and implement an infection prevention and control program including improper PPE use by staff and visitors, failure to offer hand hygiene before meals, inadequate handwashing, failure to disinfect equipment between residents, and improper use of cleaning chemicals.
Failed to ensure as needed (PRN) psychotropic medications were re-evaluated by a physician within 14 days, lacked duration for PRN orders, failed to follow pharmacy recommendations to discontinue PRN medications, and failed to track hours of sleep for hypnotic use for Residents #13, #37, #40, and #152.
Report Facts
Medication administration frequency: 4
Medication administration frequency: 22
Medication administration frequency: 6
Medication administration frequency: 20
Medication administration frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Confirmed excessive acetaminophen dosing for Resident #10 and failure to notify physician |
| RN #1 | Registered Nurse | Observed late pain medication administration for Resident #201 and confirmed oxygen tubing needs weekly change |
| CNA #11 | Certified Nurse Aide | Observed failing to offer hearing aids and communication tools to Resident #13 |
| Nursing Home Administrator | Administrator | Provided facility policies and interviewed regarding multiple deficiencies including activities director qualifications and hospice coordination |
| Pharmacist | Pharmacist | Reviewed medication orders and identified missed medication issues and excessive dosing |
| Activity Director | Activity Director | Interviewed regarding lack of qualified activities program and limited activities offered |
| Housekeeper Supervisor | Housekeeper Supervisor | Interviewed regarding cleaning procedures and disinfectant use |
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