Liberty Heights

In the surveyor’s words

From the most serious findings on record at Liberty Heights, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Jan 7, 2026

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of three sample residents received food prepared in a form designed to meet individual needs.The facility failed to ensure Resident #1 was served the correct diet texture as ordered by the physician. Resident #1, who was diagnosed with Barrett's esophagus (a condition where the tissue lining the esophagus changes to resemble intestinal lining), Zenker's diverticulum (a pouch that forms at the top of the esophagus, in the throat, due to a weak spot where the throat muscles and esophagus meet, often caused by the upper esophageal muscle not relaxing properly during swallowing, leading to trapped food), difficulty swallowing, regurgitation, bad breath, risk of aspiration, dysphagia (difficulty… […]

• No harm, potential for more than minimal, widespreadF812Jul 16, 2025

  Based on observations, record review and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen.Specifically, the facility failed to ensure employees performed hand hygiene appropriately during meal service and avoided cross contamination. Findings include:I. Professional referenceThe Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the… […]

• No harm, potential for more than minimal, widespreadF880Jul 16, 2025

  Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections.Specifically, the facility failed to:-Ensure resident rooms were cleaned in hygienic manner;-Ensure housekeeping staff performed hand hygiene appropriately during room cleaning;-Ensure linen and resident clothing were transported in hygienic manner;-Ensure dirty linen was transported appropriately; and, Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who should be on enhanced barrier precautions (EBP).Findings include: I. Housekeeping failures A. […]

• No harm, potential for more than minimal, patternF550Jul 16, 2025

  Based on observations and interviews, the facility failed to ensure residents had the right to a dignified existence.Specifically, the facility failed to provide an environment of engagement and promote quality of life for residents.Findings include:I. Facility policy and procedureThe Quality of Life: Dignity policy and procedure, reviewed on 2/23/24, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. It revealed in pertinent part, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining or enhancing his or her self-esteem and self-worth. […]

• No harm, potential for more than minimal, patternF700Jul 16, 2025

  Based on observations, record review and interviews, the facility failed to ensure accurate assessments and informed risks were in place for three (#18, #3 and #7) of five residents with bed rails out of 27 sample residents.Specifically, the facility failed to:-Ensure Resident #18, Resident #3 and Resident #7 were assessed for the use of bed rails and less restrictive alternatives were attempted prior to use; and,-Ensure the risks of bed rails were explained to and informed consent for use was obtained from Resident #18, Resident #3 and Resident #7.Findings include: I. Facility policy and procedure The Use of an Enabler policy, reviewed 5/21/25, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. […]