01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-07-18 | 14 | 2024-07-18 | 4 |
| Cycle 2 | 2023-02-16 | 7 | 2023-02-16 | 2 |
| Cycle 3 | 2021-11-04 | 5 | 2021-11-04 | 7 |
CMS CCN 0651692026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Pueblo Heights Nursing And Rehabilitation
1601 Constitution Rd · Pueblo, CO 81001 · Pueblo County
Certified beds120CMS provider file
Recent citation rows39current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
39 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-14 · HEALTHF0740Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Correction field: Deficient, Provider has date of correction · 2026-05-08 · complaint2024-07-18 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-08-052024-07-18 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-08-012024-07-18 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2024-08-092024-07-18 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-08-012024-07-18 · HEALTHF0676Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Correction field: Deficient, Provider has date of correction · 2024-08-062024-07-18 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2024-08-052024-07-18 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-08-062024-07-18 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-08-062024-07-18 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-08-012024-07-18 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2024-08-052024-07-18 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2024-08-072024-07-18 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-08-052024-07-18 · HEALTHF0921Severity F · widespread; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2024-08-072024-07-18 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2024-07-312024-07-18 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-08-122024-07-18 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-08-022024-07-18 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-08-022023-02-16 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2023-04-282023-02-16 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2023-04-282023-02-16 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-04-282023-02-16 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2023-05-042023-02-16 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-04-282023-02-16 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2023-03-3103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-04-14 | Fine | $7,425 | 0 |
| 2026-04-14 | Fine | $23,282 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MADISON CREEK PARTNERS LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 07/11/2025
- CHRISTENSEN, COVEYIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 07/11/2025
- CONSTITUTION OPERATIONS LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 07/11/2025
- CHRISTENSEN, COVEYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/11/2025
- CHRISTENSEN, COVEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/11/2025
- CLEGG, MICHAELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/11/2025
- HOPKINS, AMBERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/11/2025
- SANDERS, MARKIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/11/2025
- SHEPHERD, DAVIDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/11/2025
- CONSTITUTION OPERATIONS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- CHRISTENSEN, COVEYIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- CLEGG, MICHAELIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- HOPKINS, AMBERIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- SANDERS, MARKIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- SHEPHERD, DAVIDIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.88per resident day
RN hours0.60per resident day
Weekend nurse hours2.66per resident day
Staff turnover55.6%CMS reported field
06 / LOCAL RECORDS
Open the Pueblo ledger →Other published facilities nearby
Atlas Post Acute146 beds · CMS overall 3/552 citation rowsCenter At Park West Llc, The80 beds · CMS overall 2/534 citation rowsHigh Plains Post Acute Llc59 beds · CMS overall 2/535 citation rowsLakeshore Post Acute And Rehabilitation Center106 beds · CMS overall 4/570 citation rowsLife Care Center Of Pueblo187 beds · CMS overall 4/554 citation rowsRock Canyon Respiratory And Rehabilitation Center151 beds · CMS overall 1/548 citation rowsUniversity Park Care Center180 beds · CMS overall 4/543 citation rowsVista Ridge Care And Rehabilitation90 beds · CMS overall 3/554 citation rows