Pueblo Heights Nursing And Rehabilitation
Pueblo, Pueblo County, Colorado · CCN 065169 · For-profit (Individual) · part of Madison Creek Partners (13 facilities, chain average 3.2 stars)
CMS rates Pueblo Heights Nursing And Rehabilitation 2 of 5 overall as of August 2026. 120 certified beds, 90 residents a day on average. 26 citations on record from the current inspection cycles, 1 at immediate jeopardy; 2 fines totalling $30,707.
On record
- No health inspection in more than two years, by CMS’s own flag.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 4 / 3 of 5 |
Staffing
| Total nurse staffing | 2.87563 hours per resident per day |
|---|---|
| Registered nurses | 0.60253 hours per resident per day |
| Weekend total | 2.65916 hours per resident per day |
| Nursing staff turnover | 55.6% (registered nurses 46.2%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-04-14 complaint survey |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · tag F0740 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2026-05-08 |
| 2024-07-18 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · tag F0921 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-08-07 |
| 2024-07-18 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-18 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-07 |
| 2024-07-18 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-05 |
| 2024-07-18 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-05 |
| 2024-07-18 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-01 |
| 2024-07-18 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-09 |
| 2024-07-18 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-01 |
| 2024-07-18 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-18 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-05 |
| 2024-07-18 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-06 |
| 2024-07-18 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-01 |
| 2024-07-18 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-05 |
| 2023-02-16 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-04-28 |
| 2023-02-16 | 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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-04-28 |
| 2023-02-16 | 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-05-04 |
| 2023-02-16 | Perform COVID19 testing on residents and staff. Infection Control Deficiencies · tag F0886 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-03-31 |
| 2023-02-16 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-28 |
| 2023-02-16 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-04-28 |
| 2023-02-16 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-31 |
| 2021-11-04 | 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-12-08 |
| 2021-11-04 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · tag F0561 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-08 |
| 2021-11-04 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-08 |
| 2021-11-04 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Quality of Life and Care Deficiencies · tag F0742 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-08 |
| 2021-11-04 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-08 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2026-04-14 | Fine | $23,282 |
| 2026-04-14 | Fine | $7,425 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Constitution Operations LLC Organization | 5% or greater mortgage interest | — | 2025-07-11 |
| Constitution Operations LLC Organization | adp of the snf | — | 2025-07-11 |
| Madison Creek Partners LLC Organization | direct ownership interest | — | 2025-07-11 |
| Christensen, Covey Individual | adp of the snf | — | 2025-07-11 |
| Clegg, Michael Individual | adp of the snf | — | 2025-07-11 |
| Hopkins, Amber Individual | adp of the snf | — | 2025-07-11 |
| Sanders, Mark Individual | adp of the snf | — | 2025-07-11 |
| Shepherd, David Individual | adp of the snf | — | 2025-07-11 |
| Christensen, Covey Individual | indirect ownership interest | — | 2025-07-11 |
| Christensen, Covey Individual | managing control - governing body | — | 2025-07-11 |
| Christensen, Covey Individual | operational/managerial control | — | 2025-07-11 |
| Clegg, Michael Individual | operational/managerial control | — | 2025-07-11 |
| Hopkins, Amber Individual | operational/managerial control | — | 2025-07-11 |
| Sanders, Mark Individual | operational/managerial control | — | 2025-07-11 |
| Shepherd, David Individual | operational/managerial control | — | 2025-07-11 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Pueblo Heights Nursing And Rehabilitation.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Pueblo County.