Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Liberty Heights during CMS and state inspections, most recent first.
A resident with significant spinal and bone conditions, who was cognitively intact and experienced chronic pain, reported that a CNA told him he "stunk" and needed a bath and was rough while turning him during a bed bath, causing visible pain and tears. Facility records showed the resident was at risk for pain and had documented sharp, stabbing pain with positioning and increased pain after the bed bath. The facility’s investigation confirmed that the CNA made the disrespectful comment, completed the bed bath despite the resident’s pain before getting a nurse, and that the resident felt the care should have been more gentle, constituting a failure to treat the resident with dignity and respect.
A resident with CHF, COPD, emphysema, and acute/chronic respiratory failure had an order and care plan for continuous O2 at 6 LPM via nasal cannula for hypoxia. During a dinner meal, the resident’s representative found the resident in the dining room appearing anxious and cyanotic, and discovered the portable O2 tank was turned off. The representative turned the tank on to a high flow, after which the cyanosis resolved, and later informed a CNA and a nurse. When the nurse assessed the resident, the O2 was already on and the saturation was 92%, and the nurse documented the resident was at baseline. The record contained no assessment at the time of the incident in the dining room and no documentation that the physician was notified of the lack of O2 during the meal, despite staff being responsible for ensuring portable O2 was on and at the ordered flow rate.
A resident with Barrett’s esophagus, Zenker’s diverticulum, dysphagia, GERD, and dementia was discharged from the hospital on an SLP-recommended IDDSI level 6 (soft and bite-sized) dysphagia diet, but the facility failed to transcribe the ordered diet into the medical record, incorrectly documented a regular texture diet on the baseline care plan, and did not complete the required diet communication form to dietary. As a result, the resident was served regular texture meals, including pork loin and sausage, and later an egg salad sandwich on whole bread with crust and potato chips, which did not meet level 6 criteria. The resident’s condition worsened with coughing, painful swallowing, and breathing difficulty, and hospital evaluation revealed a bleeding Zenker’s diverticulum with impacted food requiring surgical removal. Staff interviews confirmed that established admission and diet communication processes were not followed and that dietary staff misjudged the appropriateness of the foods served for a dysphagia diet.
The facility did not obtain food from approved sources or ensure that food was stored, prepared, distributed, and served according to professional standards.
Surveyors identified multiple failures in infection prevention and control, including improper hand hygiene and cleaning practices by housekeeping staff, uncovered transport of clean and soiled linens and clothing, and failure of staff to use required PPE during direct care of a resident with a stage 2 pressure ulcer on EBP. Staff interviews revealed inconsistent understanding and implementation of infection control protocols.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not properly assess or document the use of bed rails for three residents, failed to attempt less restrictive alternatives, and did not obtain or document informed consent or review of risks and benefits with the residents or their representatives. Staff interviews revealed a lack of awareness regarding the risks and responsibilities associated with bed rail use, and some bed rails were installed without prior physician orders or proper care plan documentation.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Two residents with significant cognitive and physical impairments were not provided with meaningful activities or engagement, as required by their care plans. One resident, with severe dementia and a language barrier, was left sitting in front of a silent television with minimal staff interaction and was not consistently offered activities or communication in her native language. Another resident, with moderate cognitive impairment and a history of stroke and epilepsy, was observed sitting idle in a common area without access to activities or reading materials, despite documented preferences for reading and religious engagement. Staff interviews and record reviews confirmed that activity care plans were not consistently implemented for these residents.
Two residents with limited ROM and contractures did not receive appropriate treatment and services, including lack of clear physician orders, inconsistent application and monitoring of braces and splints, and missing documentation of adaptive equipment use. Staff were unclear about responsibilities, and care plans were not updated to reflect necessary interventions or monitor their effectiveness.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
The facility did not consistently provide drinks in accordance with resident needs and preferences, resulting in insufficient hydration for residents.
Failure to Provide Dignified and Gentle Personal Care During Bed Bath
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with dignity and respect during personal care provided by a CNA. The facility’s own policy on promoting and maintaining resident dignity requires staff to treat each resident with respect, recognize individuality, respond to requests in a timely manner, explain care and procedures before initiating activities, and speak respectfully to residents. Despite this policy, the facility’s investigation determined that a CNA told a resident that he “stunk” and “really needed a shower,” which the facility substantiated as a failure to treat the resident with dignity. The resident involved was an older adult with diagnoses including methicillin staphylococcus aureus infection, spinal stenosis, discitis, osteomyelitis, and osteoporosis. An MDS assessment showed he was cognitively intact, required substantial to maximal assistance with bathing, and experienced pain. His care plan identified a risk for pain related to discitis and osteomyelitis, with interventions to identify, monitor, and limit causes of pain. On the day of the incident, progress notes documented that he reported increased pain not alleviated with non-pharmacological interventions, and later that he had sharp, stabbing pain with positioning and increased pain after a bed bath. During the bed bath in question, the resident reported that the CNA was rough when turning him side to side, that he experienced pain, and that he had tears in his eyes during the care. The facility’s investigation confirmed that the resident experienced pain during the bed bath and that the CNA completed the care before obtaining a nurse, despite the resident’s pain and visible distress. The resident later clarified that he did not believe the CNA was physically abusive or intended to hurt him, but maintained that her approach and handling were problematic and that she should have been more careful and gentle. The NHA and DON acknowledged the incident and confirmed that the CNA’s comment about the resident’s odor and the manner of care during the bed bath did not meet the standard of treating the resident with dignity and respect.
Failure to Provide Ordered Continuous Oxygen During Mealtime
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who required continuous oxygen therapy received oxygen according to the physician’s orders during a mealtime in the dining room. The resident had an active physician order for continuous oxygen at 6 LPM via nasal cannula due to hypoxia, with instructions to notify the provider if oxygen saturation fell below 90%. The resident’s care plan documented oxygen therapy related to CHF, ineffective gas exchange, COPD, emphysema, and acute and chronic respiratory failure, and included an intervention to provide oxygen via nasal cannula at 6 LPM. Despite these orders and care plan interventions, the resident was in the dining room without the ordered oxygen being delivered. On the date of the incident, the resident’s representative arrived during the dinner meal and observed the resident appearing anxious and cyanotic in the lips and fingers. Upon checking the portable oxygen tank, the representative found that it was turned off, even though it should have been set at 6 LPM. The representative then turned the portable oxygen tank on to the highest flow, after which the resident’s cyanosis resolved over approximately 10 minutes. The representative reported to a CNA and a nurse that the resident’s portable oxygen had not been on when he arrived. When the nurse came to assess the resident, the oxygen tank was already on, and the nurse reported that the resident was at her baseline and that her oxygen saturation was 92%. The resident’s representative told the nurse that the oxygen saturation was normal because he had already turned the oxygen on to a high flow before the nurse assessed the resident. The representative also expressed concern that the resident had been sitting in the dining room with difficulty breathing and cyanosis without staff noticing. Review of the resident’s electronic medical record did not show an assessment at the time of the incident in the dining room; instead, the nurse waited until after the mealtime was over to assess the resident. Documentation also did not show that the physician was notified of the lack of oxygen during the mealtime. The facility’s internal investigation concluded that the resident had been transported to the dining room with a full portable oxygen tank that may not have been turned on, and interviews with leadership confirmed that both nurses and CNAs were responsible for checking portable oxygen concentrators to ensure they were turned on and set to the ordered liter flow rate.
Failure to Provide Physician-Ordered Dysphagia Diet Texture Resulting in Harm
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received food in the correct texture as ordered by the physician. The resident was admitted with multiple significant diagnoses, including Barrett’s esophagus, Zenker’s diverticulum, dysphagia, GERD, dementia, and a recent history of pneumonia and acute respiratory failure. Hospital records prior to admission documented ongoing oral and suspected pharyngeal dysphagia with overt signs of laryngeal penetration and aspiration on thin liquids and regular solids, and the hospital SLP recommended a dysphagia level 6 (soft and bite-sized) diet with thin liquids, along with specific swallowing precautions. The hospital discharge summary documented that the resident was discharged on a dysphagia diet due to dysphagia being the discharging diagnosis. Upon admission, the facility did not transcribe the physician-ordered dysphagia level 6 diet into the resident’s medical record and did not complete or transmit the required diet form from nursing to dietary. The baseline care plan instead documented a regular texture diet with thin liquids and instructions for the resident to eat two bites and then drink water, which conflicted with the hospital discharge documentation and SLP recommendations. There was no physician order for diet texture in the facility record, indicating the ordered dysphagia diet was not entered. The DON later confirmed that the admitting nurse did not verify and transcribe the diet order and that the nursing department did not complete the diet form needed to communicate the diet to dietary. As a result of these omissions, the resident was served regular texture meals rather than the ordered dysphagia level 6 soft and bite-sized diet. The dietary manager reported that, from admission until after breakfast the following day, the resident received regular texture meals, including pork loin for dinner and eggs with sausage links for breakfast, with the meat only cut up but not altered to a soft, fork-depressible consistency. After the diet order was eventually communicated to dietary, the resident was still served an egg salad sandwich on whole bread with crust and a bag of potato chips for dinner, which did not meet IDDSI level 6 criteria and was not considered appropriate for the resident based on the hospital records and SLP interview. The resident’s representative observed the resident consuming this boxed meal and later reported that the resident appeared to have worsened, with coughing, pain on swallowing, and difficulty breathing, leading to transfer back to the hospital, where an upper GI endoscopy revealed a bleeding Zenker’s diverticulum with a large opening and impacted food requiring surgical removal. Staff interviews further described the breakdown in processes that led to the deficiency. The RD explained that the usual process required nursing to complete a diet form for new admissions and provide it to dietary so the diet could be entered into the tray ticket system, but this was not done for this resident. The dietary manager confirmed that no formal diet form was received, that a text message thread used on the admission day was not a formal communication system, and that she assumed certain items, such as an egg salad sandwich and thin potato chips, were dysphagia-appropriate. The SLP clarified that dysphagia level 6 soft and bite-sized foods must be chopped into 1.5 cm pieces, be soft enough to be fully flattened with a fork, and that regular texture meats, whole bread with crust, and potato chips were not appropriate for this resident given his diagnoses and swallowing difficulties. The DON acknowledged that the facility did not follow its established admission and diet communication processes and confirmed that the resident should have been provided a dysphagia level 6 soft and bite-sized diet upon admission but instead received regular texture meals and later an inappropriate sandwich and chips.
Removal Plan
- The facility conducted an audit to identify other residents who may be receiving the incorrect diet texture by reviewing physician orders and dietary tickets; no other issues were identified.
- The DON or designee provided education to all nursing and dining staff on therapeutic (mechanically altered) diets, the admission process for diet order transcription to the medical record, communication of diet to the dietary department, and accurate documentation in the baseline care plan; staff will not be permitted to work until trained.
- The SLP provided education to dietary staff on therapeutic (mechanically altered) diet textures per IDDSI guidelines; education will continue until all dietary staff have been educated prior to working.
- The DON provided education to nursing staff on how to read the resident's tray card and properly identify correct altered textured diets; education will continue until all staff are sufficiently trained.
- All new staff will receive the same training prior to working in the kitchen or serving residents food, snacks, or beverages.
- The DON reviewed all identified residents with altered diet texture care plans and updated them to reflect each resident's specific dietary interventions and needs.
Failure to Follow Approved Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. No additional details regarding specific residents, staff, or events are provided in the report.
Infection Control Program Deficiencies: Housekeeping, Linen Handling, and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in housekeeping, linen handling, and the use of personal protective equipment (PPE) for residents requiring enhanced barrier precautions (EBP). Housekeeping staff did not consistently perform hand hygiene before donning gloves, between glove changes, or after removing gloves. Cleaning procedures were not followed as required, with staff cleaning from dirty to clean areas, using the same cleaning materials for different surfaces, and failing to clean high-touch areas such as call lights, bed controls, and door handles. These actions were observed during the cleaning of multiple resident rooms, and staff interviews revealed a lack of awareness regarding proper hand hygiene and cleaning protocols. Linen and resident clothing were not transported in a hygienic manner. Staff were observed moving both clean and soiled linens and personal clothing items on uncovered carts through resident areas, contrary to facility policy and CDC guidelines. Soiled linens were sometimes handled without being bagged or covered, and clean linens were delivered to resident rooms without protective coverings, increasing the risk of environmental contamination. Staff interviews confirmed that linens should be covered during transport, but this was not consistently practiced. The facility also failed to ensure that staff donned appropriate PPE when providing direct care to residents who should be on EBP. For a resident with a stage 2 pressure ulcer, staff did not wear gowns and gloves during high-contact care activities such as transfers and toileting assistance, and PPE was not made available at the resident’s room. Interviews with staff indicated inconsistent understanding and implementation of EBP requirements, with some staff relying on signage or verbal instructions rather than established protocols. These failures were directly observed during care activities involving the resident requiring EBP.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or events involved.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that proper assessments and informed consent procedures were followed prior to the use of bed rails (enabler bars) for three residents. Specifically, the facility did not assess these residents for safety risks, did not attempt less restrictive alternatives before installing bed rails, and did not document that the risks and benefits were reviewed with the residents or their representatives. In addition, informed consent for the use of bed rails was not obtained or documented for these residents. For one resident with severe cognitive impairment and multiple diagnoses including cerebral infarction, vascular dementia, and a history of falls, bed rails were observed in use despite the care plan and MDS assessment not reflecting their use. The enabler review was only completed during the survey and did not document alternative interventions attempted, the risks of using the bed rails, or whether these risks were explained to the resident or representative. Staff interviews revealed a lack of awareness regarding the risks associated with bed rails and uncertainty about who was responsible for obtaining informed consent. Two other residents, one with moderate cognitive impairment and hemiplegia, and another with severe cognitive impairment and dementia, also had bed rails in use without prior physician orders, proper documentation in their care plans, or evidence of informed consent. In both cases, the enabler reviews were completed during the survey and failed to document alternative interventions or the risks of bed rail use. Staff interviews indicated confusion about the assessment process, the need for consent, and the safety checks required for bed rails, with some staff unaware of potential safety concerns such as gaps between the bed rail and mattress.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide a program of meaningful activities designed to support the physical, mental, and psychosocial well-being of two residents. For one resident with severe cognitive impairment, Alzheimer’s disease, and dementia, observations over multiple days revealed she was repeatedly left sitting in front of a television with the sound off, with little to no staff interaction or engagement in meaningful activities. Despite her care plan indicating preferences for group and independent activities, and the use of a baby doll and communication in her native language, staff did not consistently offer her these interventions. She was not routinely invited to group activities, and staff rarely used available translation tools to communicate with her in Japanese, as outlined in her care plan. Staff interviews confirmed a lack of awareness and implementation of her activity and communication needs. Another resident, who was moderately cognitively impaired and had diagnoses including cerebral infarction, epilepsy, and diabetes, was also observed sitting in a common area without access to meaningful activities. The television was not turned on, and staff did not engage him in conversation or offer activities while he was present in the common area. His care plan indicated interests in reading, religious activities, and spending time outside, but there was no evidence that these preferences were being met. His representative noted he was an avid reader and active in his faith, but had not seen reading materials or opportunities for faith-based activities provided to him. Record reviews and staff interviews further revealed gaps in the implementation of activity care plans for both residents. Activity participation logs were incomplete or missing, and staff were not consistently inviting or assisting residents to attend activities aligned with their preferences. Communication between the activities department and nursing staff was lacking, resulting in missed opportunities to provide individualized and meaningful engagement for residents with significant cognitive and physical limitations.
Failure to Provide Appropriate ROM and Contracture Management
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) and contracture management for two residents with limited ROM. For one resident with a history of cerebral infarction, hemiplegia, and limited mobility, there was a lack of clear physician orders specifying the schedule, duration, and responsible staff for donning and doffing a left hand brace. Observations showed the resident was not consistently wearing the brace, and staff interviews revealed uncertainty about who should apply the brace and when. The care plan only referenced the brace in the context of skin integrity, and there was no documentation of skin monitoring under the brace prior to the survey. Occupational therapy notes indicated the need for the brace, but the facility did not have corresponding physician orders or consistent documentation of its application and monitoring. For another resident with severe cognitive impairment, dementia, and a left hand contracture, the facility failed to follow physician orders for contracture management. The resident was observed without the prescribed adaptive equipment, such as a two-handled cup, and there was no care plan intervention for the use of a carrot splint for the contracture. Staff interviews confirmed that the resident often refused the splint, but there was no documentation of splint application or refusals in the medical record. The physician's order for the splint lacked specific parameters, and the care plan did not address the use or effectiveness of the splint or the resident's refusals. Additionally, the facility's documentation systems, including the medication and treatment administration records and CNA task documentation, did not reflect the application of splints or adaptive equipment as ordered. Staff were unclear about the frequency and responsibility for applying the splints, and the care plans were not updated to include these interventions or to monitor their effectiveness. These deficiencies resulted in a lack of appropriate treatment and services for residents with limited ROM and contractures, as required by facility policy and physician orders.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to ensure that each resident received drinks consistent with their needs and preferences, and did not provide sufficient fluids to maintain proper hydration. This deficiency was identified through observations and review of facility practices, which showed that residents were not consistently offered or provided with adequate fluids according to their individual hydration requirements and stated preferences.
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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) |
|---|---|---|---|---|
| The Center At Cordera | 4.4 mi | ★★★★★ | 2 | 0 |
| Mount St Francis Nursing Center | 6.4 mi | ★★★★★ | 0 | 0 |
| Center At Centennial, The | 9.1 mi | ★★★★★ | 0 | 0 |
| Colonial Rehabilitation And Nursing, Llc | 9.3 mi | ★★★★★ | 3 | 0 |
| Pikes Peak Post Acute | 9.5 mi | ★★★★★ | 2 | 0 |
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