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
Staffing
Hours and turnover
RN hours / resident day
1.27
Registered nurse staffing
LPN hours / resident day
1.03
Licensed practical nurse staffing
Aide hours / resident day
2.17
Nurse aide staffing
Weekend hours
4.00
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
19%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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