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)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Routine
Deficiencies: 5
Date: Jul 23, 2025
Visit Reason
Routine inspection to assess compliance with regulatory requirements related to medication self-administration, resident rights, pain medication orders, accident prevention, and feeding tube care.
Findings
The facility failed to ensure clinical appropriateness and physician orders for self-administration of medications for three residents. It also failed to provide written notice of room changes for two residents, ensure pain medication orders included administration parameters for two residents, provide adequate supervision to prevent accidents related to wheelchair foot pedals for three residents, and ensure proper feeding tube care and accurate physician orders for two residents.
Deficiencies (5)
F554: The facility failed to ensure self-administration of medications was clinically appropriate and lacked physician orders for self-administration for Residents #3, #8, and #13.
F559: The facility failed to provide written notice of room changes to Residents #14 and #19 or their representatives.
F658: The facility failed to ensure physician orders for pain medications included parameters for administration based on pain levels for Residents #10 and #8.
F689: The facility failed to provide adequate supervision to ensure wheelchair foot pedals were in place when transporting Residents #20, #21, and #5, increasing fall risk.
F693: The facility failed to ensure residents with feeding tubes received appropriate treatment and services, including accurate physician orders and hydration per dietitian recommendations for Residents #8 and #3.
Report Facts
Residents in sample: 21
Residents reviewed for notifications: 5
Residents with feeding tubes reviewed: 4
Pain medication administration dates: 4
BIMS scores: 0
Water flush volume: 60
Water flush volume: 100
Weight lost: 9.4
Weight gained: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication self-administration and feeding tube medication administration for Residents #3 and #13 |
| RN #1 | Registered Nurse | Interviewed regarding medication administration and physician orders for Resident #8 |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding deficiencies in medication orders, room change notifications, accident prevention, and feeding tube care |
| Director of Rehabilitation | Director of Rehabilitation (DOR) | Interviewed regarding wheelchair pedal use and resident safety |
| Registered Dietitian | Registered Dietitian (RD) | Interviewed regarding nutritional assessments and feeding tube recommendations for Residents #3 and #8 |
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
Complaint Investigation
Deficiencies: 3
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 complaint investigation was substantiated. The facility failed to prevent falls for residents #30 and #5, failed to manage pain effectively for resident #1, and failed to maintain infection control practices including hand hygiene and enhanced barrier precautions.
Findings
The facility failed to provide adequate supervision and person-centered fall interventions for residents at high risk of falls, resulting in multiple falls with 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 (3)
F 0689: The facility failed to provide adequate supervision and person-centered fall interventions for two residents, resulting in multiple falls and a major injury.
F 0697: The facility failed to provide effective pain management for a resident with pressure ulcers, causing prolonged pain during wound care and daily activities.
F 0880: The facility failed to ensure housekeeping staff performed proper hand hygiene and disinfectant dwell times, and nursing staff did not follow enhanced barrier precautions during resident care.
Report Facts
Falls: 7
Repositioning: 49
Pain medication dosage: 325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Provided wound care to Resident #1 and was observed not offering pain relief during painful procedures. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding fall prevention interventions for Resident #5. |
| CNA #3 | Certified Nursing Assistant | Interviewed about rounds and fall risk awareness for Resident #5. |
| DOR | Director of Rehabilitation | Interviewed about fall risk and therapy interventions for Residents #5 and #30. |
| DON | Director of Nursing | Interviewed about fall prevention policies, pain management, and infection control practices. |
| HSKP #1 | Housekeeper | Observed not following proper hand hygiene and disinfectant dwell times. |
| RN #3 | Registered Nurse | Interviewed about pain management for Resident #1. |
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
Deficiencies: 6
Date: Apr 25, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, environment, food safety, fall prevention, pressure ulcer care, hospice services, and facility safety.
Findings
The facility was found deficient in multiple areas including environmental maintenance, pressure ulcer prevention, fall prevention interventions, food safety and hygiene, hospice communication and medication management, and water safety measures. Several residents were affected by these deficiencies, but harm was generally minimal or potential.
Deficiencies (6)
F 0584: The facility failed to maintain a sanitary, orderly, and comfortable environment in 17 of 44 resident rooms, including unclean walls and ventilation fans with dust accumulation affecting functionality.
F 0686: The facility failed to provide appropriate pressure ulcer care by not offloading Resident #9's bilateral heels while in bed, increasing risk of pressure ulcers.
F 0689: The facility failed to implement fall prevention interventions for Residents #197 and #198, including failure to keep beds in lowest position, absence of fall mats, and lack of yellow fall star indicators on doors.
F 0812: The facility failed to ensure food service staff practiced appropriate hand hygiene, reheated modified consistency foods to safe temperatures promptly, and maintained cutting boards free from deep scratches and stains.
F 0849: The facility failed to maintain effective communication and documentation with hospice providers for Residents #198 and #104, resulting in lack of documented hospice visits and failure to receive and administer hospice-ordered medication.
F 0921: The facility failed to ensure backflow prevention devices were installed on hoses in two maintenance closets, increasing risk of contamination to the main water supply.
Report Facts
Resident rooms affected: 17
Residents reviewed for pressure ulcers: 28
Residents reviewed for falls: 28
Residents reviewed for hospice care: 5
Modified food temperature: 163
Length of hose: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Interviewed regarding hospice communication for Resident #198 |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding medication orders for Resident #104 |
| Certified Nurse Aide #4 | CNA | Interviewed regarding fall prevention interventions for Residents #197 and #198 |
| Dietary Aide #1 | DA | Observed during food preparation and serving with hand hygiene deficiencies |
| Dietary Manager | DM | Interviewed regarding food safety and cutting board conditions |
| Director of Nursing | DON | Interviewed regarding fall prevention, hospice communication, and medication management |
| Housekeeping Supervisor | HKS | Interviewed regarding backflow prevention device installation |
| Hospice Clinical Director | HCD | Interviewed regarding hospice communication and documentation |
| Admissions Coordinator | ADM | Interviewed regarding hospice visit notes request |
Inspection Report
Routine
Deficiencies: 19
Date: Jan 20, 2022
Visit Reason
Routine state inspection of a nursing home facility to assess compliance with regulatory standards including resident care, medication administration, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including privacy during personal care, medication administration errors, discharge planning, assistance with activities of daily living, communication plans, activity programming, pharmaceutical services, pain management, dementia care, hospice coordination, infection control, and nursing competencies.
Deficiencies (19)
F 0583: Facility failed to ensure privacy during personal care for Resident #13, with blinds left open during care.
F 0658: Facility failed to follow professional standards in medication administration for Residents #13, #40, and #204 including missed medications and lack of physician orders for medication crushing.
F 0660: Facility failed to implement effective discharge planning for Resident #302, lacking communication about discharge goals and comprehensive interdisciplinary team involvement.
F 0676: Facility failed to provide necessary assistance with activities of daily living and communication for Resident #13, including failure to use hearing aids and communication tools.
F 0677: Facility failed to ensure Residents #10, #298, #13, and #40 received scheduled showers, timely meal assistance, and catheter care per care plans.
F 0679: Facility failed to provide ongoing activity programming meeting residents' interests and needs for Residents #10, #13, and #16.
F 0680: Facility failed to employ a qualified activities director to provide a comprehensive activities program.
F 0684: Facility failed to ensure Resident #10 received treatment and care per physician orders including excessive acetaminophen dosing and failure to monitor abnormal blood pressures.
F 0689: Facility failed to ensure adequate supervision and fall prevention interventions for Residents #298 and #299, including inaccurate fall risk assessment and lack of fall prevention measures.
F 0690: Facility failed to provide appropriate catheter care for Resident #147 including lack of physician order, failure to notify medical power of attorney, and lack of care plan and monitoring.
F 0695: Facility failed to provide safe and appropriate respiratory care for Residents #13, #16, and #296 including unclear oxygen titration orders and failure to date oxygen tubing.
F 0697: Facility failed to provide timely pain management for Resident #201, with late administration of pain medications and lack of non-pharmacological interventions.
F 0726: Facility failed to ensure nursing staff completed competencies prior to providing skilled services for three registered nurses.
F 0744: Facility failed to provide appropriate dementia care for Resident #32 including lack of person-centered approaches, inadequate staff training, and insufficient activity and social engagement.
F 0755: Facility failed to provide pharmaceutical services meeting residents' needs for Residents #40, #204, #32, and #10 including medication availability, timely administration, and monitoring.
F 0758: Facility failed to re-evaluate PRN psychotropic medications within 14 days, lacked duration orders, and failed to track hypnotic medication efficacy for Residents #13, #37, #40, and #152.
F 0842: Facility failed to accurately document events surrounding the death of Resident #47 including CPR efforts and timeline.
F 0849: Facility failed to ensure hospice services met professional standards for Resident #37 including lack of coordinated care, staff orientation, and care planning.
F 0880: Facility failed to maintain an infection control program including improper PPE use by staff and visitors, failure to offer resident hand hygiene before meals, inadequate hand hygiene by staff, failure to disinfect equipment between residents, and improper housekeeping cleaning practices.
Report Facts
Medication administration: 4
Medication administration: 22
Medication administration: 6
Medication administration: 20
Medication administration: 4
Medication administration: 23
Medication administration: 9
Falls: 3
Shower frequency: 1
Shower frequency: 2
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 |
| CNA #11 | Certified Nurse Aide | Observed failure to offer hearing aids and communication tools to Resident #13 |
| Activity Director | Activity Director | Reported lack of certification and limited activity programming |
| Pharmacist | Pharmacist | Reported medication review delays and recommendations for medication changes |
| Nursing Administrator | Nursing Administrator | Interviewed regarding multiple deficiencies including medication, infection control, and hospice coordination |
| Housekeeper Supervisor | Housekeeper Supervisor | Observed improper cleaning practices and lack of PPE training |
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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