Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 10
Date: Jul 16, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignity and engagement, inadequate investigation of abuse allegations, insufficient assistance with activities of daily living, lack of meaningful activities, improper use and monitoring of braces and splints, unsafe use of bed rails without proper assessment and consent, medication administration errors, inadequate hydration provision, improper food handling and sanitation practices, and failure to maintain an effective infection prevention and control program.
Deficiencies (10)
Failure to honor residents' rights to a dignified existence and promote quality of life through meaningful staff interaction.
Failure to thoroughly investigate allegations of abuse and resident-to-resident altercations.
Failure to provide appropriate care and assistance with activities of daily living, including safe transfers, communication, incontinence care, and repositioning.
Failure to provide meaningful activities and communication support in residents' native language.
Failure to ensure appropriate use, monitoring, and physician orders for braces and splints to maintain range of motion and prevent contractures.
Failure to assess residents for bed rail use, obtain informed consent, and ensure safe installation and maintenance.
Failure to ensure residents were free from significant medication errors, including failure to administer prescribed seizure medication and notify physician.
Failure to provide sufficient hydration consistent with resident needs and preferences.
Failure to procure, store, prepare, distribute, and serve food in accordance with professional standards, including improper hand hygiene and cross contamination during meal service.
Failure to provide and implement an effective infection prevention and control program, including inadequate cleaning of resident rooms, improper hand hygiene by housekeeping staff, improper linen and clothing transport, and failure to use appropriate PPE for residents on enhanced barrier precautions.
Report Facts
Residents sampled: 27
Observation period: 6
BIMS score: 3
BIMS score: 5
BIMS score: 6
BIMS score: 9
BIMS score: 4
BIMS score: 2
Medication dose: 5
Hydration volume: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in findings related to lack of interaction with residents, improper transfer techniques, and hydration assistance |
| LPN #3 | Licensed Practical Nurse | Named in findings related to abuse investigation, medication administration, brace monitoring, and infection control |
| Activity Director | Activity Director | Named in findings related to resident activities and communication support |
| Director of Rehabilitation | Director of Rehabilitation | Named in findings related to brace use and resident mobility |
| Housekeeper #1 | Housekeeper | Named in findings related to improper cleaning and hand hygiene |
| Laundry Aide | Laundry Aide | Named in findings related to improper linen transport and handling |
| Dietary Supervisor | Dietary Supervisor | Named in findings related to food handling and sanitation |
Inspection Report
Routine
Deficiencies: 10
Date: Jul 16, 2025
Visit Reason
Routine inspection of Liberty Heights nursing home to assess compliance with regulatory requirements related to resident rights, abuse investigations, activities of daily living, range of motion care, bed rail use, medication administration, hydration, food safety, and infection control.
Findings
The facility failed to ensure residents' rights to dignity and engagement, thorough abuse investigations, appropriate assistance with activities of daily living, proper use and monitoring of braces and splints, accurate assessments and consent for bed rail use, medication administration per physician orders, adequate hydration, sanitary food handling, and effective infection prevention and control practices.
Deficiencies (10)
F550: The facility failed to provide an environment of engagement and promote quality of life; staff did not interact meaningfully with residents during observations.
F0610: The facility failed to thoroughly investigate allegations of resident-to-resident altercations and injuries of unknown origin for two residents.
F0677: The facility failed to provide timely assistance with activities of daily living including safe transfers, communication in native language, incontinence care, repositioning, and eating assistance for two residents.
F0679: The facility failed to provide meaningful activities and a communication plan for two residents, including use of a digital translator and appropriate engagement.
F0688: The facility failed to ensure proper use, monitoring, and physician orders for braces and splints for two residents with limited range of motion.
F0700: The facility failed to assess, obtain informed consent, and document risks for bed rail use for three residents; bed rails were used without proper assessments or consent.
F0760: The facility failed to ensure one resident received seizure medication per physician orders; medication was unavailable and no notification was documented.
F0807: The facility failed to ensure two residents were offered and provided sufficient hydration to maintain hydration.
F0812: The facility failed to ensure food was stored, prepared, and served in a sanitary manner; staff failed to perform hand hygiene appropriately and cross contamination occurred during meal service.
F0880: The facility failed to maintain an infection control program; housekeeping staff failed to clean resident rooms hygienically, perform hand hygiene, transport linen and clothing properly, and staff failed to don appropriate PPE when providing care to residents on enhanced barrier precautions.
Report Facts
BIMS score: 6
BIMS score: 9
BIMS score: 2
BIMS score: 3
BIMS score: 8
Medication dose: 5
Hydration volume: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in findings related to lack of interaction with residents and improper transfer and incontinence care |
| LPN #3 | Licensed Practical Nurse | Named in findings related to abuse investigation, medication administration, and care plan reviews |
| Activity Director | Activity Director | Named in findings related to resident activities and communication |
| Housekeeper #1 | Housekeeper | Named in findings related to improper cleaning and hand hygiene |
| Director of Rehabilitation | Director of Rehabilitation | Named in findings related to brace and splint use and therapy assessments |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 13, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards following observations, record reviews, and interviews related to resident care and safety, including treatment of bruises and fall prevention.
Findings
The facility failed to ensure timely assessment, investigation, and notification regarding a resident's bruise, and failed to implement effective person-centered fall prevention interventions for two residents at high fall risk, resulting in multiple falls and injuries.
Deficiencies (2)
Failed to timely assess, investigate, notify physician, and implement interventions for a resident's bruise of unknown origin.
Failed to develop and implement person-centered care plans with effective interventions to reduce falls for two residents at high fall risk.
Report Facts
Bruise measurement: 8.5
Bruise measurement: 11
Fall risk score: 17
Fall risk score: 18
Fall incidents: 5
Fall incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified nurse aide #2 | Certified Nurse Aide | Interviewed regarding responsibility to notify nurse of resident condition changes |
| Licensed practical nurse #2 | Licensed Practical Nurse | Interviewed about responsibilities to complete assessments and report changes |
| Registered nurse #1 | Registered Nurse | Interviewed about assessment and notification duties for resident bruising |
| Director of Nursing | Director of Nursing | Interviewed about nurse responsibilities for change of condition assessments and notifications |
| Certified nurse aide #1 | Certified Nurse Aide | Interviewed about knowledge of fall risk interventions and documentation practices |
| Licensed practical nurse #1 | Licensed Practical Nurse | Interviewed about fall risk identification and intervention documentation |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about fall risk care plans, frequency of checks, and person-centered interventions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 13, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate treatment and care for residents, including failure to timely assess and intervene for bruising and failure to prevent falls for high-risk residents.
Complaint Details
The complaint investigation substantiated failures in care related to Resident #7's bruise and fall prevention for Residents #23 and #27. The facility did not timely assess or notify responsible parties about the bruise and did not implement individualized fall prevention interventions despite known risks.
Findings
The facility failed to ensure timely assessment, investigation, and notification for a resident with a bruise of unknown origin. Additionally, the facility failed to develop and implement person-centered care plans with effective interventions to reduce falls for two high fall-risk residents.
Deficiencies (2)
F684: The facility failed to timely assess, investigate, notify the physician, and implement interventions for a bruise of unknown origin on Resident #7's right arm.
F689: The facility failed to develop and implement person-centered care plans with effective interventions to reduce falls for Residents #23 and #27, despite their high fall risk and history of falls.
Report Facts
Residents reviewed: 24
Bruise size: 8.5
Bruise size: 11
Fall risk score: 17
Fall risk score: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #2 | Interviewed regarding responsibility to notify nurse of resident condition changes | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about responsibilities to complete assessments and report changes | |
| Registered Nurse (RN) #1 | Interviewed about assessment and notification duties for resident condition changes | |
| Director of Nursing (DON) | Interviewed about nurse responsibilities and documentation related to change of condition assessments | |
| Certified Nurse Aide (CNA) #1 | Interviewed about fall risk interventions and documentation practices | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about fall risk knowledge and documentation | |
| Nursing Home Administrator (NHA) | Interviewed about fall risk interventions and documentation policies |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 19, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and assistance to prevent falls, specifically concerning Resident #2 who experienced an avoidable fall with minor injury.
Complaint Details
The complaint investigation focused on Resident #2 who fell from bed on 11/30/19 resulting in a forehead laceration and hematoma. The fall occurred when a CNA left the room to get a Hoyer lift, leaving the resident unattended. The facility's post-fall investigation and interdisciplinary team review confirmed the fall and identified failures in supervision and staff training. Resident was on hospice care and had severe cognitive impairment.
Findings
The facility failed to ensure Resident #2 received adequate supervision during transfers, resulting in a fall with minor injury including a forehead laceration and hematoma. The facility also failed to provide two staff during mechanical lifts and adequate staff training post-fall to ensure safe transfers according to the care plan and policy.
Deficiencies (3)
Failed to ensure Resident #2 received adequate supervision to prevent an avoidable fall with minor injury.
Failed to provide two staff during the resident's transfer from bed to wheelchair.
Failed to provide adequate staff training after the resident's fall to ensure safe transfers according to care plan and policy.
Report Facts
Residents reviewed for falls: 23
Resident #2 Fall Risk Review total score: 9
Hematoma size: 1.9
Hematoma size: 0.5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 19, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall and the facility's failure to provide adequate supervision and assistance to prevent accidents.
Complaint Details
The complaint investigation focused on Resident #2 who fell on 11/30/19 resulting in a forehead laceration and bruising. The fall was unwitnessed but occurred when a CNA left the room to get a Hoyer lift. The resident was nonverbal, on hospice care, and required total assistance for transfers. The investigation found inadequate supervision and failure to follow care plan and policy.
Findings
The facility failed to ensure adequate supervision and assistance for Resident #2 during transfers, resulting in an avoidable fall with minor injury. The facility also failed to provide two staff during mechanical lifts and adequate staff training after the fall.
Deficiencies (1)
F 0689: The facility failed to ensure Resident #2 received adequate supervision to prevent an avoidable fall with minor injury. The facility did not provide two staff during the resident's transfer from bed to wheelchair and failed to provide adequate staff training after the fall.
Report Facts
Residents reviewed for falls: 23
Fall Risk Review total score: 9
Hematoma size (cm): 1.9
Hematoma size (cm): 0.5
Viewing
Loading inspection reports...
