Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Center At Cordera during CMS and state inspections, most recent first.
The facility failed to ensure that all nursing staff held appropriate, active licensure when providing care. An LPN was initially hired with a valid multistate license originating from Texas that allowed practice in Colorado, but that license later expired and the LPN continued to work three shifts without valid authorization to practice in Colorado. The HR manager, who was responsible for monthly license verification for all nurses and for preventing unlicensed staff from working, did not complete or document timely verification after the expiration date, allowing the LPN to work while improperly licensed.
Multiple residents with COPD and other respiratory conditions received oxygen therapy that was not titrated or documented in accordance with physician orders and professional standards. Several residents were observed on higher oxygen flow rates than their hospital discharge baselines, despite consistently high SpO2 readings and orders to titrate within a 1–5 LPM range to maintain saturations ≥ 88%. Staff interviews showed that RNs and an LPN relied on broad standing orders, did not consistently titrate oxygen down when saturations were above target, and often did not know or communicate residents’ baseline oxygen needs. The DON reported that nurses could adjust oxygen within the ordered range without notifying providers, while a NP stated that any change in titration should be reported, and training materials lacked specific instruction on when and how to titrate oxygen or notify providers of changes.
Three residents were found to have medications at their bedside and were self-administering or receiving assistance with medications without required clinical assessments or physician orders. Nursing staff did not document evaluations for self-administration, and care plans did not address the safety or appropriateness of this practice. Staff interviews confirmed the absence of necessary orders and assessments.
Two residents with complex medical conditions were moved to different rooms without receiving written notice of the room change, as required. Although family members were verbally informed by phone and assisted with the moves, there was no documentation of written notification in the records. Staff interviews confirmed the absence of a policy for written notification of room changes.
The facility did not ensure that physician orders for PRN pain medications included specific pain level parameters for two residents, resulting in nurses using their own judgment to decide which pain medication to administer. This led to both opioid and non-opioid medications being given without clear guidance, contrary to facility policy requiring pain parameters and documentation.
Three residents with significant fall risk were transported in wheelchairs without foot pedals attached, resulting in their feet dangling or dragging on the floor. Despite care plans identifying them as high fall risk, interventions did not specify the use of foot pedals during transport, and staff failed to consistently implement this safety measure.
Two residents with feeding tubes did not receive appropriate care due to incomplete and inaccurate physician orders and failure to follow RD hydration recommendations. One resident, who was NPO, had medications ordered orally instead of via PEG tube, and staff administered medications without clear orders. Another resident did not receive the increased water flushes recommended by the RD, and staff failed to document or measure water given during medication administration.
Two residents in a LTC facility experienced multiple falls due to inadequate supervision and lack of person-centered fall interventions. One resident, with severe cognitive impairments, fell twice within 13 days, resulting in a refractured hip. Another resident with Parkinson's disease and a history of falls experienced seven falls due to insufficient fall prevention measures and staff awareness. The facility's generalized fall prevention policy was not effectively implemented, leading to repeated falls and injuries.
A resident with multiple health issues, including a stroke and diabetes, developed pressure ulcers and experienced severe pain due to inadequate pain management. The facility failed to provide effective interventions beyond Tylenol and Lidocaine patches, and staff did not adequately monitor or address the resident's pain. Observations and interviews revealed that the resident frequently expressed pain, especially during wound care and repositioning, but additional pain management strategies were not implemented.
The facility failed to maintain a sanitary environment, as housekeeping staff did not perform proper hand hygiene or follow disinfectant guidelines, and nursing staff did not adhere to enhanced barrier precautions (EBP) during resident care. Observations showed a housekeeper not washing hands between glove changes and not allowing disinfectant to dwell for the required time. Additionally, a CNA and a staffing coordinator did not wear gowns while assisting residents on EBP, despite available supplies and signage.
Unlicensed LPN Worked Shifts Due to Lapse in License Verification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and maintained appropriate licensure and competencies to provide care to residents. Record review showed that one LPN was hired and worked under a valid multistate nursing license originating from Texas, which authorized practice in Colorado. That multistate license expired on a specific date, yet the LPN continued to work three shifts at the facility after the expiration. Timecard (punch) records documented that the LPN worked evening and day shifts on three separate occasions following the expiration of the multistate license. Interviews and documentation revealed that the human resources manager was responsible for conducting monthly license verification checks for all nurses, including as-needed staff, and for ensuring that nurses without valid licenses did not work. The NHA reported that the human resources manager did not verify the LPN’s license after a certain date and that this verification “fell through the cracks.” It was also identified that the human resources manager had not been printing and retaining license verification documentation to demonstrate that checks were being completed. As a result of these inactions, the LPN worked active shifts in Colorado without a valid multistate license authorizing practice in that state.
Failure to Titrate and Document Oxygen Therapy per Orders and Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care, specifically oxygen therapy, in accordance with professional standards and physician orders for multiple residents. For several residents with respiratory diagnoses, including COPD, acute respiratory failure with hypoxia, and chronic respiratory failure with hypoxia, oxygen was administered at higher flow rates than their documented baseline or hospital discharge levels, without documented clinical need or titration based on SpO2 readings. Oxygen was treated as a standing range order (1–5 LPM with a goal SpO2 ≥ 88%), but staff did not consistently titrate down when saturations were well above the target range, and there was no documentation supporting the need for increased flow. One resident with acute respiratory failure, asthma, and obstructive sleep apnea was discharged from the hospital and admitted on 1 LPM of oxygen, with initial SpO2 readings of 92–95%. However, the MAR showed the resident on 3 LPM starting the day after admission, and surveyors observed the resident repeatedly on 4 LPM. There was no documentation that the resident’s oxygen saturation had dropped below the ordered threshold to justify increasing the flow. The resident reported not understanding how staff determined his oxygen needs and did not know his flow rate. An agency RN caring for this resident stated she was not informed of his baseline oxygen needs, did not receive updated report sheets, and believed that because the order allowed 1–5 LPM, she did not need to titrate down or notify the provider when the resident’s SpO2 was 97% on 4.5 LPM. Another resident with interstitial pulmonary disease and chronic respiratory failure with hypoxia was observed on 4 LPM via nasal cannula, despite a hospital discharge summary indicating a baseline of 3 LPM. The resident confirmed her baseline was 3 LPM. The CPO contained the same 1–5 LPM titration order to maintain SpO2 ≥ 88%, and staff reported that a NP had reduced the oxygen because the saturation was good and baseline was 3 LPM, yet the resident was still observed on 4 LPM. For two additional residents with COPD and continuous oxygen orders of 1–5 LPM with titration to maintain SpO2 ≥ 88%, EMR review showed their oxygen saturations remained above 93% over extended periods, but there was no documentation that oxygen was titrated down or omitted when within range. One RN believed the resident was on 2.5 LPM when the resident was actually on 3.5 LPM, and an LPN acknowledged not knowing the exact liter flow for a resident on oxygen and not notifying providers when changing flow within the ordered range. Across these cases, staff interviews revealed inconsistent understanding and implementation of oxygen titration. Multiple nurses and the DON acknowledged that oxygen is a medication requiring an order, but described relying on broad standing orders (1–5 LPM) and nursing judgment without routinely notifying providers when changing flow rates, as long as they stayed within the range. The DON stated that nurses were expected to document changes in oxygen flow in the vital signs log and did not need to notify providers unless the flow exceeded 5 LPM, while one NP stated that the standard protocol was for nursing staff to notify the provider of any change in oxygen titration and to wean residents off oxygen as soon as possible. Training records provided showed education on initiating oxygen and changing tubing, but did not include guidance on when to notify providers of changes in oxygenation or how to titrate oxygen appropriately within ordered parameters.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that self-administration of medications was clinically appropriate for three residents. Specifically, the nursing staff did not complete required assessments to determine if these residents were capable and safe to self-administer their medications. In each case, there was no documentation of a self-administration evaluation assessment in the electronic medical record, and the residents' care plans did not address the safety or appropriateness of keeping medications at the bedside. For one resident with chronic obstructive pulmonary disease and respiratory failure, an albuterol inhaler was observed at the bedside on multiple occasions, but there was no physician's order allowing the resident to self-administer the medication or to keep it at the bedside. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had eye drops at the bedside that were administered by a representative without a physician's order or assessment for self-administration. A third resident, cognitively intact but with significant physical limitations, kept Rolaids at the bedside and self-administered them without an order or assessment. Staff interviews confirmed that the required physician's orders and assessments for self-administration were missing for all three residents. Nursing staff acknowledged the lack of documentation and orders, and the director of nursing confirmed that residents with medications at the bedside should be evaluated for cognitive ability and clinical appropriateness, which had not been done in these cases.
Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to provide written notice of room changes to two residents out of a sample of five reviewed for notifications. For one resident with multiple complex diagnoses, including aftercare following circulatory surgery, type 2 diabetes with kidney complications, end stage renal disease, and encephalopathy, the record showed that a message was left for the resident's son and a friend was contacted regarding the room change. However, there was no documentation in the electronic medical record that written notice of the room change was provided to the resident or their representative. Similarly, another resident with diagnoses such as a displaced femur fracture, subluxation of the cervical vertebrae, Alzheimer's disease, and dementia was moved to a different room after the family was notified by phone and assisted with the move. Despite verbal communication, there was no evidence in the record that written notification of the room change was given to the resident or their representative. Staff interviews confirmed that the facility did not have a policy for resident room changes and that notifications were typically made by phone, without written documentation.
Failure to Specify Pain Medication Parameters in Physician Orders
Penalty
Summary
The facility failed to ensure that services provided to residents met professional standards of quality by not including specific pain level parameters in physician orders for PRN pain medications for two residents. For one resident with a fractured wrist, hypertension, and diabetes, the physician's orders for oxycodone and acetaminophen did not specify which medication to administer based on the resident's reported pain level. As a result, the resident received oxycodone for moderate pain levels when acetaminophen could have been administered first, contrary to the facility's analgesia policy that requires nurses to follow pain parameters and document pain scales for pain medications. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had physician orders for both morphine and oxycodone for pain management. However, these orders also lacked specific pain level parameters to guide the administration of each medication. Medication administration records showed that both medications were given for similar pain levels without clear guidance from the orders. Staff interviews confirmed that nurses relied on their own judgment rather than specific physician instructions, and that pain parameters were not consistently added to pain medication orders.
Failure to Ensure Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The facility failed to provide adequate supervision and ensure the use of assistive devices to prevent accident hazards for three residents who were identified as high fall risks. Observations revealed that these residents were transported in their wheelchairs without foot pedals attached, resulting in their feet dangling or dragging on the floor during movement. This occurred on multiple occasions and involved both nursing and non-nursing staff members pushing the residents without the required safety equipment in place. Resident records indicated that all three individuals had significant medical histories, including recent fractures, muscle weakness, dementia, and a history of falls. Their care plans and fall risk assessments identified them as high risk for falls and included various interventions, but none specified the need to ensure foot pedals were attached to their wheelchairs during transport. This omission left a gap in their fall prevention strategies. Interviews with facility leadership confirmed that staff were expected to use foot pedals when transporting residents in wheelchairs. The DON and DOR both acknowledged the importance of this practice for resident safety, with the DOR specifically noting the risk of residents falling forward if their feet were left dangling or dragging. Despite these expectations, the deficiency persisted due to the lack of specific interventions in care plans and failure of staff to consistently implement safety measures during resident transport.
Failure to Ensure Accurate Feeding Tube Orders and Adequate Hydration
Penalty
Summary
The facility failed to ensure that residents with feeding tubes received appropriate treatment and services, as evidenced by incomplete and inaccurate physician orders and failure to follow registered dietitian (RD) recommendations. For one resident with a PEG tube who was severely cognitively impaired and at risk for aspiration, physician orders were not updated to reflect the correct route of medication administration. Despite the resident being designated as NPO (nothing by mouth), some medications were still ordered to be given orally, and staff administered medications via the PEG tube without clear, accurate orders specifying this route. The director of nursing acknowledged that the orders were not accurate and that it was the responsibility of the nurse entering the orders to ensure their completeness and correctness. Another resident with a feeding tube, who was alert and oriented, experienced inadequate hydration due to the facility's failure to update physician orders in accordance with the RD's recommendations. The RD had assessed that the resident's fluid needs were not being met and recommended an increase in water flushes before and after feedings. However, the physician's orders were not updated to reflect this recommendation, and the medication administration record did not document that the additional hydration was provided. Additionally, a nurse administered an unmeasured amount of water during medication administration, and the electronic medical record lacked specific instructions for water flush amounts during this process. These deficiencies were identified through observations, record reviews, and staff and resident interviews, which revealed that the facility did not ensure physician orders were complete, accurate, and followed, nor did it ensure that residents received adequate hydration as recommended by the RD. The failures involved both the accuracy of medication administration routes and the provision of sufficient hydration for residents with feeding tubes.
Inadequate Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and person-centered fall interventions for two residents, leading to multiple falls and injuries. Resident #30, who was severely cognitively impaired, was admitted after a fall at home that resulted in a hip fracture. Despite her cognitive impairments, the facility implemented generalized fall interventions, such as ensuring the call light was within reach and posting a 'Call, don't fall' sign, which were not suitable for her condition. The facility did not assess her ability to use the call light or understand the sign, nor did they educate staff on her increased need for supervision. As a result, Resident #30 experienced two falls within 13 days, with the second fall causing a refracture of her left hip. Resident #5, diagnosed with Parkinson's disease and a history of falls, also suffered from inadequate fall prevention measures. The facility failed to implement timely, person-centered interventions and did not ensure staff were aware of his increased fall risk. Between his admission and mid-August, Resident #5 experienced seven falls. Despite his intact cognition, the facility did not assess his ability to use the call light effectively, given his history of traumatic brain injuries. The care plans for Resident #5 lacked specificity in terms of how often he should be checked on, and staff interviews revealed a lack of awareness regarding his fall risk and necessary interventions. The facility's fall prevention policy, which included interventions such as routine toileting schedules, low beds, and frequent rounding, was not effectively implemented for these residents. Staff interviews indicated a lack of awareness and training regarding specific fall prevention strategies for high-risk residents. The Director of Nursing acknowledged that all residents were considered at risk for falls, but the facility did not differentiate levels of risk or tailor interventions accordingly. This lack of individualized care planning and staff education contributed to the repeated falls and injuries experienced by Residents #30 and #5.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident who was admitted with a diagnosis of intracerebral hemorrhage, type 2 diabetes, muscle weakness, and adult failure to thrive. Upon admission, the resident had no skin issues but was at risk for developing pressure ulcers. Despite this, the resident developed pressure ulcers on the buttocks and coccyx, and the facility did not order additional medication for wound care. The resident was only receiving Tylenol four times per day and a Lidocaine patch, which were insufficient to manage the severe pain experienced during wound care and daily activities. Observations and interviews revealed that the resident frequently expressed severe pain, especially during wound care and repositioning. The resident was often in pain when moved, and staff did not offer any additional pain interventions during these times. The resident's pain was not adequately addressed, as evidenced by the lack of non-pharmacological interventions such as ice packs or heat packs, which were not documented in the resident's electronic medical record. Furthermore, the effectiveness of the administered Tylenol was not monitored, and the resident was repositioned infrequently, contrary to the facility's policy. Staff interviews indicated a lack of awareness and action regarding the resident's pain management needs. Certified nurse aides reported the resident's pain to nurses, but there was no evidence of follow-up or additional pain management strategies being implemented. The director of nursing acknowledged the resident's risk for pressure ulcers and pain but was unsure if the current pain management regimen was effective. This lack of effective pain management contributed to the resident's prolonged suffering and inadequate care.
Infection Control Deficiencies in Housekeeping and Nursing Practices
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of communicable diseases and infections, particularly on one of its hallways. Observations revealed that housekeeping staff did not adhere to proper hand hygiene protocols. Specifically, a housekeeper was seen cleaning multiple resident rooms without performing hand hygiene between glove changes. Additionally, the housekeeper did not follow the manufacturer's recommended dwell time for the disinfectant solution, which was supposed to be ten minutes, but was instead wiped off immediately after application. Furthermore, the nursing staff did not comply with enhanced barrier precautions (EBP) during resident care. Observations showed that a certified nursing assistant (CNA) and a staffing coordinator (SC) failed to wear gowns while assisting residents who were on EBP due to having indwelling medical devices. Despite the presence of signs and carts stocked with gowns and gloves outside the residents' rooms, the staff members only donned gloves and neglected to use gowns during high-contact activities such as transferring residents and handling catheter drainage bags. Interviews with the housekeeping director and the director of nursing confirmed the discrepancies between the observed practices and the facility's policies. The housekeeping director acknowledged the incorrect dwell time used by the housekeeper, while the director of nursing reiterated the importance of following EBP, including the use of gowns and gloves during high-contact activities with residents who have medical devices or chronic wounds.
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What surveyors actually found near you
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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 Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Liberty Heights | 4.4 mi | ★★★★★ | 3 | 1 |
| Pikes Peak Post Acute | 7.2 mi | ★★★★★ | 2 | 0 |
| Colonial Rehabilitation And Nursing, Llc | 7.2 mi | ★★★★★ | 3 | 0 |
| Mount St Francis Nursing Center | 8.1 mi | ★★★★★ | 0 | 0 |
| Center At Centennial, The | 8.5 mi | ★★★★★ | 0 | 0 |
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