Cycle 1
Health 2024-07-18 · Fire 2024-07-18
13 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Pueblo, CO
Pueblo Heights Nursing and Rehabilitation
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1601 Constitution Rd, Pueblo, CO
(719) 562-7200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Care Center
Operator or chain grouping
Approved since
1982-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,591
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9923
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
5.54
Baseline 7.11% · Performance 6.18% · Measure score 5.54 · Achievement 5.54 · Improvement 3.89
Total nurse turnover
5.44
Baseline 54.10% · Performance 41.43% · Measure score 5.44 · Achievement 5.44 · Improvement 3.83
Adjusted total nurse staffing
0.83
Baseline 3.22 hours · Performance 3.31 hours · Measure score 0.83 · Achievement 0.83 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.21% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 2.22% · Lower 95% interval 6.22% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 0% |
95.27%
95.3 pts worse
|
Numerator 0 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 23.81% |
53.69%
29.9 pts worse
|
Numerator 5 · Denominator 21 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 6 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 2.89% |
| Staff COVID-19 vaccination coverage | 12.75% |
8.2%
4.6 pts better
|
Numerator 13 · Denominator 102 |
| Staff flu vaccination coverage | 60.74% |
42%
18.7 pts better
|
Numerator 99 · Denominator 163 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 9 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
93.5%
1 pts better
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 98.6% · Q3 92.6% · Q4 90.1% · 4Q avg 94.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.4%
1.7 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.7% · Q3 1.5% · Q4 1.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.7% |
7.4%
0.3 pts worse
|
11.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 14.1% · Q4 8.8% · 4Q avg 7.7% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
5.0%
1.6 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 9.5% · Q3 1.6% · Q4 3.2% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
11.2%
1.1 pts worse
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 11.8% · Q3 9.1% · Q4 12.5% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
20.6%
0.5 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 22.7% · Q3 20.5% · Q4 19.1% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.4% |
15.2%
2.8 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 14.3% · Q3 18.2% · Q4 8.4% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
14.6%
0.3 pts better
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 15.9% · Q3 15.9% · Q4 10.0% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.8%
0.4 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.6% |
22.4%
5.8 pts better
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 12.9% · Q3 16.2% · Q4 11.3% · 4Q avg 16.6% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
3.7%
1.4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.0% · Q3 0.0% · Q4 1.5% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.4% |
76.4%
29 pts worse
|
81.7%
34.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.5% · Q2 53.8% · Q3 30.0% · Q4 29.8% · 4Q avg 47.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
12.8%
1.5 pts better
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 11.1% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.5% |
75.6%
6.9 pts better
|
79.7%
2.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.2% |
20.3%
10.1 pts better
|
23.9%
13.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 11.1% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-16 · Fire 2023-02-16
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-11-04 · Fire 2021-11-04
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-31
F · Potential for more than minimal harm
2024-07-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-02
F · Potential for more than minimal harm
2024-07-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-02
F · Potential for more than minimal harm
2023-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-29
F · Potential for more than minimal harm
2023-02-16
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2023-03-22
F · Potential for more than minimal harm
2021-11-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-06
F · Potential for more than minimal harm
2021-11-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-15
F · Potential for more than minimal harm
2021-11-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-12-06
F · Potential for more than minimal harm
2021-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-13
E · Potential for more than minimal harm
2021-11-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-11-30
E · Potential for more than minimal harm
2021-11-04
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-12-07
E · Potential for more than minimal harm
2021-11-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-07-18
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-07-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-07
E · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-05
F · Potential for more than minimal harm
2023-02-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-02-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-02-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-02-16
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-02-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-02-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-31
E · Potential for more than minimal harm
2021-11-04
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-12-08
D · Potential for more than minimal harm
2021-11-04
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2021-12-08
D · Potential for more than minimal harm
2021-11-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-08
D · Potential for more than minimal harm
2021-11-04
F742 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2021-12-08
D · Potential for more than minimal harm
2021-11-04
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-12-08
Penalties and ownership
What sits behind the stars
Ownership
Christensen, Covey
Operational/Managerial Control · Individual
Clegg, Michael
Operational/Managerial Control · Individual
Constitution Operations LLC
5% Or Greater Mortgage Interest · Organization
Hopkins, Amber
Operational/Managerial Control · Individual
Sanders, Mark
Operational/Managerial Control · Individual
Shepherd, David
Operational/Managerial Control · Individual
Nearby options
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#2
University Park Care Center
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4-star overall rating with 3-star inspections with $22,653 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Sharmar Village Senior Care Community
Pueblo, CO
3-star overall rating with 2-star inspections with $72,840 in total fines with 11 recent health deficiencies
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