LIBERTY HEIGHTS
Address
12205 GUNSTOCK DRIVE
COLORADO SPRINGS, CO 80921
(719) 481-9494
Nursing Home Ratings
Health Inspections | |
Quality Measures | |
Nursing Staff | |
R.N. Staff Only | |
Overall Rating |
Percent of Beds Occupied
Number of Residents and Certified Beds
- Residents: 28
- Certified Beds: 42
This Facility Accepts
- Medicare
Operational Details
- Operated By For Profit - Corporation
- Offers Both Resident and Family Counseling Services
- Part of a Continuing Care Retirement Community (CCRC)
- This Facility is Not Part of a Chain or Franchise
Resident Services
The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Liberty Heights. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.
Resident Services | Resident Conditions | Percent of Service Days |
Ultra-High Rehabilitation
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
ADL Index Range: 11-16 | 12.5% |
ADL Index Range: 6-10 | 37.7% |
ADL Index Range: 0-5 | 8.3% |
Total Percent: | 58.4% |
Very High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 11.7% |
ADL Index Range: 6-10 | 16.7% |
ADL Index Range: 0-5 | 0.08% |
Total Percent: | 28.5% |
High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 1.5% |
ADL Index Range: 6-10 | 6.6% |
ADL Index Range: 0-5 | 1.2% |
Total Percent: | 9.3% |
Medium Rehabilitation
- Five days any combination of three rehabilitation disciplines
ADL Index Range: 6-10 | 0.3% |
ADL Index Range: 0-5 | 2.1% |
Total Percent: | 2.4% |
Special Care High
- Comatose
- Septicemia
- Diabetes with daily injections and a change of order two or more days
- Quadriplegia with ADL score greater or equal to 5
- Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath when lying flat
- Fever with pneumonia, or vomiting, or weight loss, or feeding tube
- Parenteral/IV feedings
- Respiratory therapy for 7 days
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 11-14 - No Signs of depression | 0.08% |
Total Percent: | 0.08% |
Special Care Low
- Cerebral palsy, multiple sclerosis, or Parkinson's disease with ADL score greater or equal to 5
- Respiratory failure and oxygen therapy while a resident
- Feeding tube where calories >= 51% or calories are in the range of 26-50% and fluid >= 501 mL)
- Ulcers: 2 or more stage II or 1 or more stage III or IV pressure ulcers
- Ulcers: 2 or more venous or arterial ulcers
- Ulcers: 1 stage II pressure ulcer and 1 venous or arterial ulcer with 2 or more skin care treatments
- Foot infection/diabetic foot ulcer/open lesions of foot with treatment
- Radiation therapy while a resident
- Dialysis while a resident
- Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 15-16 - No Signs of depression | 0.5% |
ADL Index Range: 6-10 - Signs of depression | 0.2% |
Total Percent: | 0.8% |
Clinically Complex
- Pneumonia, hemiplegia with ADL score >=5
- Surgical wounds or open lesions with treatment
- Burns
- Chemotherapy while a resident
- Oxygen therapy while a resident
- IV medications or transfusions while a resident
- Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1
ADL Index Range: 6-10 - No Signs of depression | 0.08% |
ADL Index Range: 2-5 - No Signs of depression | 0.2% |
Total Percent: | 0.2% |
Reduced Physical Function
- Urinary and/or bowel training program
- Passive and/or active range of motion (ROM)
- Amputation/prosthesis training
- Dressing or grooming training
- Eating or swallowing training
- Transfer training
- Splint or brace assistance
- Bed mobility and/or walking training
- Communication training
ADL Index Range: 0-1 - Less restorative nursing | 0.3% |
Total Percent: | 0.3% |
Rating Details For Liberty Heights
Nursing Staff -
The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.
Nursing Hours Per Resident Per Day | Reported | Expected |
Registered Nurse (RN) Hours | 1 Hour and 54 Minutes | 1 Hour and 31 Minutes |
Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 42 Minutes | 44 Minutes |
Certified Nursing Assistant (CNA) Hours | 2 Hours and 38 Minutes | 2 Hours and 23 Minutes |
Total Licensed Nurse Hours | 2 Hours and 36 Minutes | 2 Hours and 14 Minutes |
Total Nurse Hours | 5 Hours and 14 Minutes | 4 Hours and 37 Minutes |
Quality of Care -
Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Colorado are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.
This Facility | Colorado Average |
Long-Term Stay Preventive Actions
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 88% |
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 87% |
Long-Term Stay Deficiencies
Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 14% | 9% |
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 18% | 9% |
Percent of Long-Stay Residents Who Lose Too Much Weight | 5% | 8% |
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 42% | 48% |
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 14% | 7% |
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | 4% | 3% |
Percent of Long-Stay Residents Who Are More Depressed or Anxious | 22% | 16% |
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 16% | 11% |
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 11% | 15% |
Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 1% | 4% |
Percent of Long-Stay Residents Who Were Physically Restrained | 1% | 4% |
Short-Term Stay Preventive Actions
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 79% |
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 81% |
Short-Term Stay Deficiencies
Percent of Short-Stay Residents Who Have Delirium | 1% | 3% |
Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 12% | 23% |
Percent of Short-Stay Residents Who Have Pressure Sores | 7% | 9% |
Health Inspection Details -
All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 03/07/2011.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Administration
Keep Accurate and Appropriate Medical Records.
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Keep Accurate and Appropriate Medical Records.
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Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Have a Program to Keep Infection from Spreading.
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Mistreatment
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
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Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
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1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
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Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
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1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
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Nutrition and Dietary
Store, Cook, and Give out Food in a Safe and Clean Way.
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Store, Cook, and Give out Food in a Safe and Clean Way.
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Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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Properly Mark Drugs and Other Similar Products.
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Properly Mark Drugs and Other Similar Products.
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1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes.
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Quality Care
Give Professional Services That Meet a Professional Standard of Quality.
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Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Provide Activities to Meet the Needs of Each Resident.
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Give Professional Services That Follow Each Resident's Written Care Plan.
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Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion.
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Make Sure That Each Resident's Nutritional Needs Were Met.
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Resident Assessment
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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Electronically Record and Report Resident Status Assessments in a Timely Manner As Required in Order to Monitor Resident Health and Progress.
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Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them.
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Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan.
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Resident Rights
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
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Keep Each Resident's Personal and Medical Records Private and Confidential.
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Listen to the Resident or Family Groups or Act on Their Complaints or Suggestions.
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Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
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Make Sure Each Resident Has the Right to Choose Activities, Schedules and Health Care According to His or Her Interests, Assessment, and Plan of Care.
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Fire Safety
Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Liberty Heights had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 01/20/2011.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Automatic Sprinkler Systems
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Building Construction
Approved Construction Type or Materials.
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Corridor Walls and Doors
Corridor and Hallway Doors That Block Smoke.
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Corridor and Hallway Doors That Block Smoke.
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Electrical
Weekly Inspections and Monthly Testing of Generators.
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Weekly Inspections and Monthly Testing of Generators.
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Properly Installed Electrical Wiring and Equipment.
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Fire Alarm Systems
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
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Furnishings and Decorations
Exits That Are Free from Obstructions and Can Be Used at All Times.
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Illumination and Emergency Power
Emergency Lighting That Can Last at Least 1 1/2 Hours.
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Medical Gases and Anesthetizing Areas
Proper Fire Barriers, Ventilation and Signs for the Transport of Oxygen.
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