Cycle 1
Health 2024-08-29 · Fire 2024-08-29
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Colorado Springs, CO
Center At Cordera, LLC, The
4-star overall rating with 3-star inspections with $8,600 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
9208 Grand Cordera Pkwy, Colorado Springs, CO
(719) 522-2000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Veritas Management Group
Operator or chain grouping
Approved since
2015-02-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.31
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.95
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.41
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.96
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,472
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.58
Composite VBP score used to determine payment impact.
Payment multiplier
1.0036
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.4
Baseline 16.61% · Performance 18.93% · Measure score 5.4 · Achievement 5.4 · Improvement 0
Healthcare-associated infections
9.14
Baseline 5.70% · Performance 5.10% · Measure score 9.14 · Achievement 9.14 · Improvement 7.97
Total nurse turnover
3.29
Baseline 74.56% · Performance 55.71% · Measure score 3.29 · Achievement 1.95 · Improvement 3.29
Adjusted total nurse staffing
2
Baseline 4.07 hours · Performance 3.65 hours · Measure score 2 · Achievement 2 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.76% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 398 · Observed rate 6.53% · Lower 95% interval 6.45% |
| Discharge to community | 70.52% |
50.57%
19.9 pts better
|
Better than the National Rate · Eligible stays 393 · Observed rate 70.99% · Lower 95% interval 66.24% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 244 · Denominator 244 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 244 |
| Discharge self-care score | 74.76% |
53.69%
21.1 pts better
|
Numerator 154 · Denominator 206 |
| Discharge mobility score | 72.82% |
50.94%
21.9 pts better
|
Numerator 150 · Denominator 206 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 244 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.1% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 232 · Observed rate 3.02% · Lower 95% interval 2.87% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 74.51% |
42%
32.5 pts better
|
Numerator 152 · Denominator 204 |
| Discharge function score | 77.18% |
56.45%
20.7 pts better
|
Numerator 159 · Denominator 206 |
| Transfer of health information to provider | 98.17% |
95.95%
2.2 pts better
|
Numerator 161 · Denominator 164 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 72 · Denominator 75 |
| Resident COVID-19 vaccinations up to date | 6.71% |
25.2%
18.5 pts worse
|
Numerator 10 · Denominator 149 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.4%
3.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.0% |
7.4%
19.6 pts worse
|
11.4%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.0% |
| Percentage of long-stay residents who lose too much weight | 19.4% |
5.0%
14.4 pts worse
|
5.4%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
11.2%
0.7 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
14.6%
8.7 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 14.0% |
0.8%
13.2 pts worse
|
1.0%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.6% |
22.4%
14.2 pts worse
|
19.8%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.6% |
| Percentage of long-stay residents with pressure ulcers | 16.5% |
3.7%
12.8 pts worse
|
5.1%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
76.4%
23.2 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.8% · Q4 98.8% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
12.8%
1.9 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.1% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
75.6%
21 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.9% |
20.3%
1.4 pts better
|
23.9%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 18.9% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-25 · Fire 2023-04-25
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2022-01-20 · Fire 2022-01-20
19 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-27
F · Potential for more than minimal harm
2023-04-25
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-04-25
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-04-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-04-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-02
F · Potential for more than minimal harm
2023-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-04-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-04-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-04-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-25
F · Potential for more than minimal harm
2023-04-25
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-06-09
F · Potential for more than minimal harm
2023-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-26
F · Potential for more than minimal harm
2022-01-20
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-02-18
F · Potential for more than minimal harm
2022-01-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-02-18
F · Potential for more than minimal harm
2022-01-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-03-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-07-23
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-07-28
D · Potential for more than minimal harm
2025-07-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-07-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-14
D · Potential for more than minimal harm
2025-07-23
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-08-20
G · Actual harm
2024-08-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-16
G · Actual harm
2024-08-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-30
F · Potential for more than minimal harm
2023-04-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-25
E · Potential for more than minimal harm
2023-04-25
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-04-25
F849 · Administration Deficiencies
Health
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.
Corrected 2023-05-25
F · Potential for more than minimal harm
2022-01-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-18
E · Potential for more than minimal harm
2022-01-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-02-20
E · Potential for more than minimal harm
2022-01-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-02-20
E · Potential for more than minimal harm
2022-01-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-02-20
E · Potential for more than minimal harm
2022-01-20
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2022-02-20
E · Potential for more than minimal harm
2022-01-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-20
E · Potential for more than minimal harm
2022-01-20
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2022-02-20
E · Potential for more than minimal harm
2022-01-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-02-20
E · Potential for more than minimal harm
2022-01-20
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-02-20
E · Potential for more than minimal harm
2022-01-20
F849 · Administration Deficiencies
Health
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.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-02-20
Penalties and ownership
What sits behind the stars
$8,600
2024-08-29
Fine
Fine · fine $8,600
Fine
Ownership
Murdock, Monte
Operational/Managerial Control · Individual
Senkoff, Alexander
Operational/Managerial Control · Individual
Nearby options
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