C

LIBERTY HEIGHTS

12205 GUNSTOCK DR, COLORADO SPRINGS, CO 80921
Score: 66 / 100

Liberty Heights is an average performer in CMS ratings, earning a C grade with a score of 66/100. Located in Colorado Springs, Colorado, the facility meets baseline standards across most quality metrics.

Staffing levels at Liberty Heights exceed national averages, with 4.47 total nursing hours per resident per day — compared to the national average of 3.8 hours. RN coverage of 1.27 hours per resident per day also exceeds the national average of 0.7 hours.

Recent CMS inspections identified 14 deficiencies at Liberty Heights, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs..

Score Breakdown

Overall CMS Rating 24 / 40 pts
3 ★ CMS rating
Health Inspections 10 / 25 pts
2 ★ inspection rating
Staffing 20 / 20 pts
5 ★ staffing rating
Quality Measures 12 / 15 pts
4 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 4.47 3.8 Above Average
Registered Nurses (RN) 1.27 0.7 Above Average
Licensed Practical Nurses (LPN) 1.03 0.7 Above Average
Certified Nursing Assistants (CNA) 2.17 2.4 Average
Weekend Total Nursing 4.00 3.8 Average
Weekend RN Hours 0.80 0.7 Above Average

🔍 Inspection & Deficiency History

14
Total Deficiencies
Jan 6, 2026
Most Recent Inspection
🟠 13 Moderate 🔴 1 Serious
View recent deficiencies (5 shown)
  • Tag 0805 Severity J
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    Jan 6, 2026 · Nutrition and Dietary Deficiencies
  • Tag 0812 Severity F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Jul 15, 2025 · Nutrition and Dietary Deficiencies
  • Tag 0880 Severity F
    Provide and implement an infection prevention and control program.
    Jul 15, 2025 · Infection Control Deficiencies
  • Tag 0550 Severity E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    Jul 15, 2025 · Resident Rights Deficiencies
  • Tag 0700 Severity E
    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
    Jul 15, 2025 · Quality of Life and Care Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 6.1% 4.5% Worse
Falls with major injury 1.1% 3.0% Better
On antipsychotic medication 6.8% 14.5% Better
Urinary tract infections 0.0% 2.5% Better
ADL decline (daily activities) 12.7% 14.0% Average
Excessive weight loss 6.7% 7.5% Better
New/worsened incontinence 37.8% 45.0% Better

How This Grade Was Calculated

This facility's grade of C is based on a score of 66 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 3★ → 24 pts (max 40)
  • Health Inspection Rating: 2★ → 10 pts (max 25)
  • Staffing Rating: 5★ → 20 pts (max 20)
  • Quality Measures Rating: 4★ → 12 pts (max 15)

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
For profit - Limited Liability company
Certified Beds
42
Provider Type
Medicare
Resident Council
No
Family Council
No
Sprinkler System
Yes
Last Inspection
Jul 15, 2025
Deficiencies (Cycle 1)
11