Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

LIBERTY HEIGHTS

COLORADO SPRINGS, CO · 42 certified beds · Last Life Safety survey July 16, 2025

CMS Certification Number 065305 · first certified October 1992

Ownership

Operated by SENIOR LIFESTYLE · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

22
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
6
Tags cited more than once
Across separate surveys
16
Inspection & testing records
Of the citations on file

Position within CO

22 citations — more than 66% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 9 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens December 2026 — about 3 months from now. This facility’s last Life Safety survey was July 2025. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.

This facility22CO median16National median11
Citations on file over three years, compared
MeasureCitations
This facility22
Median facility in CO16
Median facility nationally11

Survey history

Citations at each Life Safety survey
42019-1292023-0992025-07
Citations at each Life Safety survey
Survey dateCitations
December 19, 20194
September 13, 20239
July 16, 20259

Most-cited tags

Most-cited tags at this facility
K-09183K-03453K-03632K-03532K-09142K-09232K-03721K-07121
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.32025-07-16
K-0345Have approved installation, maintenance and testing program for fire alarm systems.32025-07-16
K-0363Install corridor and hallway doors that block smoke.22025-07-16
K-0353Inspect, test, and maintain automatic sprinkler systems.22025-07-16
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.22025-07-16
K-0923Have proper medical gas storage and administration areas.22025-07-16
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.12023-09-13
K-0712Have simulated fire drills held at unexpected times.12019-12-19

What the citations cover

Citations by CMS category
  • Gas, Vacuum, and Electrical Systems Deficiencies 9
  • Smoke Deficiencies 9
  • Egress Deficiencies 2
  • Services Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Gas, Vacuum, and Electrical Systems Deficiencies9
Smoke Deficiencies9
Egress Deficiencies2
Services Deficiencies1
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

July 16, 2025 — 9 citations

Citations issued on July 16, 2025
TagWhat the surveyor checksStatus
K-0221Provide rooms that can be unlocked from inside without a key.Deficient, Provider has date of correction (September 21, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has plan of correction (September 21, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has plan of correction (September 21, 2025)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (September 21, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (September 21, 2025)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (November 5, 2025)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (September 21, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (September 21, 2025)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (September 21, 2025)

September 13, 2023 — 9 citations

Citations issued on September 13, 2023
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (November 14, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (November 14, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (November 14, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (November 14, 2023)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (November 14, 2023)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (November 14, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (November 14, 2023)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (November 14, 2023)
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.Deficient, Provider has date of correction (November 14, 2023)

December 19, 2019 — 4 citations

Citations issued on December 19, 2019
TagWhat the surveyor checksStatus
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (January 27, 2020)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (January 14, 2020)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (January 30, 2020)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (February 5, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.