The Center at Cordera

In the surveyor’s words

From the most serious findings on record at The Center at Cordera, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jul 26, 2021

  Based on observations, record review and interviews, the facility failed to ensure for one (#1) of three residents reviewed for pressure injuries received care consistent with professional standards of practice. The facility failed to take steps to prevent a stage 4 facility acquired pressure injury on the coccyx for Resident #1 leading to hospitalization and surgery. Resident #1 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the facility identified the skin status to include redness to coccyx (a small triangular bone at the base of the spinal column). The resident did not have a pressure injury at the time of admission. Record review and interview revealed the facility failed to timely and adequately respond to skin breakdown. […]

• Actual harm, isolatedF689Aug 29, 2024

  Based on observations, record review and interviews, the facility failed to provide adequate supervision and assistance devices to prevent accidents for two (#30 and #5) of six residents reviewed for falls out of 28 sample residents. Resident #30, who was severely cognitively impaired and had a history of falls, was admitted to the facility on [DATE] after a fall at home which resulted in a left hip fracture requiring surgical repair. Upon the resident's admission, the facility initiated a fall care plan with generalized interventions that were implemented for all residents, including an intervention to ensure the resident's call light was within reach and a Call, don't fall sign was to be posted in the resident's room. […]

• Actual harm, isolatedF697Aug 29, 2024

  Based on observations, record review and interviews, the facility failed to provide effective pain management in accordance with professional standards for one (#1) of one resident out of 27 sample residents. Resident #1 was admitted on [DATE] with a diagnosis of intracerebral hemorrhage (stroke), type 2 diabetes, muscle weakness and adult failure to thrive. According to the 7/31/24 nursing comprehensive admission assessment for skin, Resident #1 had no skin issues. He often refused repositioning and to get out of bed due to pain. On 8/12/24 he developed pressure ulcers on his buttocks and coccyx. Additional medication was not ordered for wound care and all he was receiving for pain was Tylenol four times per day and a Lidocaine patch. […]

• No harm, potential for more than minimal, widespreadF726Apr 14, 2026

  Based on record review and interviews, the facility failed to ensure one of five nursing members were able to demonstrate skills and techniques necessary to care for residents' needs.Specifically, the facility failed to ensure licensed practice nurse (LPN) #1 was licensed in Colorado while working active shifts at the facility. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE]. I. Facility correctionA. Immediate actionThe human resources manager, while completing license verification checks on [DATE], identified LPN #1's expired multi-license nursing license. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2023

  Based on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; and, Cutting boards were free from deep scratches and stains. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. […]