Cycle 1
Health 2025-07-16 · Fire 2025-07-16
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Colorado Springs, CO
Liberty Heights
3-star overall rating with 2-star inspections with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
12205 Gunstock Dr, Colorado Springs, CO
(719) 481-9494
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Senior Lifestyle
Operator or chain grouping
Approved since
1992-10-15
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
2 facilities
Chain averages 4 overall / 3 health / 5 staffing / 4 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
1.27
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.47
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.30
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.00
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.28
CMS adjusted RN staffing hours
Adjusted total hours
4.51
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
19%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,897
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9952
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.71
Baseline 19.99% · Performance 20.64% · Measure score 1.71 · Achievement 1.71 · Improvement 0
Healthcare-associated infections
4.74
Baseline 6.03% · Performance 6.42% · Measure score 4.74 · Achievement 4.74 · Improvement 0
Total nurse turnover
6.09
Baseline 60.87% · Performance 38.78% · Measure score 6.09 · Achievement 6.09 · Improvement 5.63
Adjusted total nurse staffing
4.35
Baseline 4.07 hours · Performance 4.31 hours · Measure score 4.35 · Achievement 4.35 · Improvement 0.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 227 · Observed rate 6.61% · Lower 95% interval 7.22% |
| Discharge to community | 69.33% |
50.57%
18.8 pts better
|
Better than the National Rate · Eligible stays 224 · Observed rate 69.64% · Lower 95% interval 64.48% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 91.33% |
95.27%
3.9 pts worse
|
Numerator 137 · Denominator 150 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 150 |
| Discharge self-care score | 64.66% |
53.69%
11 pts better
|
Numerator 75 · Denominator 116 |
| Discharge mobility score | 59.48% |
50.94%
8.5 pts better
|
Numerator 69 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 6% |
2.29%
3.7 pts worse
|
Numerator 9 · Denominator 150 · Adjusted rate 7.34% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 156 · Observed rate 4.49% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 58.33% |
42%
16.3 pts better
|
Numerator 77 · Denominator 132 |
| Discharge function score | 64.66% |
56.45%
8.2 pts better
|
Numerator 75 · Denominator 116 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 62 · Denominator 62 |
| Transfer of health information to patient | 98.65% |
96.28%
2.4 pts better
|
Numerator 73 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 2.82% |
25.2%
22.4 pts worse
|
Numerator 2 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.7
1.7 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
93.5%
5.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.9% |
94.7%
5.8 pts worse
|
95.5%
6.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.4%
2.3 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
7.4%
6.2 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.2% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.0%
1.7 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.3% |
11.2%
7.9 pts better
|
19.6%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
20.6%
13.8 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 34.1% |
15.2%
18.9 pts worse
|
16.3%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
14.6%
1.9 pts better
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.8%
About the same
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 0.8% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.8% |
22.4%
15.4 pts worse
|
19.8%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.6% · Q3 17.4% · Q4 38.6% · 4Q avg 37.8% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
3.7%
2.4 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 11.8% · Q3 0.0% · Q4 2.9% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
76.4%
18.8 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 94.1% · Q3 95.7% · Q4 94.8% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
12.8%
1.8 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 13.5% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 2.8% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.1% |
75.6%
10.5 pts better
|
79.7%
6.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
20.3%
0.6 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 19.0% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-13 · Fire 2023-09-13
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2019-12-19 · Fire 2019-12-19
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-21
F · Potential for more than minimal harm
2025-07-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-21
F · Potential for more than minimal harm
2025-07-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-21
F · Potential for more than minimal harm
2025-07-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-11-05
F · Potential for more than minimal harm
2025-07-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-09-21
F · Potential for more than minimal harm
2025-07-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-21
D · Potential for more than minimal harm
2025-07-16
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2025-09-21
D · Potential for more than minimal harm
2025-07-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-21
D · Potential for more than minimal harm
2025-07-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-21
F · Potential for more than minimal harm
2023-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-09-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-09-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-09-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-09-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-09-13
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-11-14
F · Potential for more than minimal harm
2019-12-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-27
F · Potential for more than minimal harm
2019-12-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-30
F · Potential for more than minimal harm
2019-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-05
E · Potential for more than minimal harm
2019-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-14
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-07
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2026-01-26
F · Potential for more than minimal harm
2025-07-16
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 2025-08-15
F · Potential for more than minimal harm
2025-07-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-07-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-07-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-16
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 2025-08-15
D · Potential for more than minimal harm
2025-07-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-16
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-08-15
D · Potential for more than minimal harm
2023-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-09-13
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 2023-11-13
D · Potential for more than minimal harm
2019-12-19
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 2020-01-21
Penalties and ownership
What sits behind the stars
Ownership
Ccrc Ops Mb1-T LLC
5% Or Greater Direct Ownership Interest · Organization
Baker, Dana
Corporate Officer · Individual
Blackrock, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Cummings, Christian
Corporate Officer · Individual
Fry, Brian
Corporate Officer · Individual
J.p. Morgan Investment Management, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Minuhin, Tammy
Contracted Managing Employee · Individual
Sl Liberty Heights LLC
Operational/Managerial Control · Organization
Smith, Michael
Corporate Officer · Individual
State Street Corporation
5% Or Greater Indirect Ownership Interest · Organization
Vanguard Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Ventas Ms, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ventas Ssl, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Ventas, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Vtr Shi Trs, LLC
5% Or Greater Indirect Ownership Interest · Organization
Vtr Shi Venture, LLC
5% Or Greater Indirect Ownership Interest · Organization
Wood, Brian
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Center At Cordera, LLC, The
Colorado Springs, CO
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
#2
Mount St Francis Nursing Center
Colorado Springs, CO
2-star overall rating with 2-star inspections with abuse icon flag with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Center At Centennial, The
Colorado Springs, CO
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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