Center at Cordera, LLC, the

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Smoke Deficiencies

Provide properly protected cooking facilities.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

A complaint survey, prompted by #CO2562737, #CO1939844, #CO1939845, #CO1939846 and Incident #2568959 was completed on 7/21/25 to 7/23/25. Five deficiencies were cited. Based 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.Findings include:I. Facility policy and procedureThe Self-administration of Medications policy, dated 3/19/24, was provided b.. Based 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.Findings include:I. Facility policy and procedureThe Analgesia policy and procedure, dated 2/1/18, was provided by the nursing home administrator (NHA) on 7/23/25 at 12:24 p.m. The policy read in pertinent part, “Nurses must follow pain parameters and enter pain scales for pain medicines. If a .. Based 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. III. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 7/17/25. According to the July 2025 CPO, diagnoses included chronic obstructive pulmonary disease.. Based 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.III. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on 8/29/24. According to the July 2025 CPO, diagnoses included dementia, Alzheimer’s disease and history of falling.The 5/30/25 MDS assessment revealed the resident had both sho.. Based 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. Findings include: I. Resident #14A. Resident status Resident #14, age 71, was admitted on 6/11/25. According to the July 2025 computerized physician orders (CPO), diagnoses included aftercare following surgery on the circulatory system, type 2 diabetes with diabetic kidney complication, end stage renal disease, dissection of the ascending aorta (tear in the lining of the aorta), encephalop..

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1.Fire Alarm Deficiency- Missed elevator detectors during the annual inspection - Need to update semi annual visual only language NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes.These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administra at the exit conference. The initial comments are informational only and are a representative of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is a three-story Type II (111) structure without a basement. The structure is protected by a National Fire Protection Association (NFPA) 13 automatic sprinkler system.This survey, conducted Sep 20, 2024 inspected the facility for compliance with Chapter 19, "Existing Health Care Occupancies," of the 2012 edition of NFPA 101-Life Safety Code, the 2012 edition of NFPA 99, Health Care Facilities Code, and other publications as referenced. The facility will meet these requirements when the following deficiencies are corrected.