The Center at Cordera

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for one (#40) of two residents reviewed for respiratory services out of 29 sample residents. Specifically, the facility failed to ensure there was a physician's order in place for Resident #40's bilevel positive airway pressure (BIPAP) machine and routine maintenance of the BiPAP.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications for two of two medication storage rooms and one of three medication carts. Specifically, the facility failed to:-Ensure expired medications were disposed of; -Ensure medications were contained in the original packaging; and,-Ensure the controlled medication box was permanently affixed in the medication storage room refrigerator.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards for four residents (#8, #2, #9 and #5) of eight out of 12 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician's orders for Resident #8, #2, #9 and #5.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure self-administration of medications was clinically appropriate for three (#3, #8 and #13) of three residents out of 21 sample residents. Specifically, the facility failed to: -Ensure Resident #3, Resident #8 and Resident #13 were assessed for the appropriateness and safety of self-administration of medications;-Ensure there was a physician order for self-administration of medications; and,-Ensure there was a physician order for medications at the bedside for Resident #8 and Resident #13.

Inspectors wroteBased on record review and interviews, the facility failed to provide written notice of room changes for two (#14 and #19) of five residents reviewed for notifications out of 21 sample residents. Specifically, the facility failed to ensure Resident #14 and Resident #19 received written notice of a room change.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure services provided to residents met professional standards of quality for two (#10 and #8 ) of one resident out of 21 sample residents. Specifically, the facility failed to ensure physician's orders for pain medications included parameters for when to administer specific pain medications for Resident #10 and Resident #8.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide adequate supervision during the use of assistive devices to keep residents free from safety hazards for three (#20, #21, and #5) of the six residents out of 21 sample residents. Specifically, the facility failed to ensure Resident #20, Resident #21, and Resident #5's foot pedals were in place on their wheelchairs when staff were transporting the residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for two (#8 and #3) of the four residents reviewed with a feeding tube out of 23 sample residents. Specifically, the facility failed to ensure:-Resident #8's physician's orders were complete and accurate, with the correct route, and orders were followed; and,-Resident #3 received adequate hydration per the registered dietitian's (RD) recommendations.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. On 8/27/24 Resident #1 was observed to be in severe pain during wound care of his buttocks and coccyx wounds. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections on one of five hallways. Specifically, the facility failed to: -Ensure the housekeeping staff completed proper hand hygiene when cleaning resident rooms and followed the appropriate guidelines for disinfectant solution; and, -Ensure the nursing staff followed enhanced barrier precautions (EBP) appropriately during resident care.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on hoses in two maintenance closets, increasing the risk of contamination to the facility's main water supply.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 17 of 44 resident rooms in four hallways. Specifically, the facility failed to ensure walls, and ventilation fans were cleaned and properly maintained.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring for one (#9) of two residents reviewed out of 28 sample residents. Specifically, the facility failed to ensure Resident #9's bilateral heels were offloaded while in bed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement interventions to reduce hazards and risks for falls for two (#198 and #197) residents out of five residents reviewed for falls out of 28 sample residents. Specifically, the facility failed to ensure Resident #197 and #198 were provided the interventions available to prevent repeated falls and staff were aware of person-centered interventions.

Inspectors wroteBased on observation, record review and interviews the facility failed to maintain communication with the hospice provider, including how the communication would be documented between the facility and the provider for two (#198 and #104) of two residents reviewed for hospice care services out of five residents reviewed for hospicare care out of 28 sample residents. Specifically, the facility failed to: -Demonstrate documentation of a collaboration of care between the facility and the hospice provider for Resident #198; and, -Ensure medication orders from the hospice provider were received and administered for Resident #104.