Rock Canyon Respiratory and Rehabilitation Center
2515 Pitman Pl, Pueblo, CO 81004 · Pueblo County · 151 certified beds · avg 135 residents/day · certified since Mar 24, 1968
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Dec 15, 2022 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 14, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 3, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 2, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 12, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 9, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 12, 2024 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 9, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 11, 2023 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 2, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 11, 2023 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 2, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 11, 2023 · F-0695 · triggered by a complaint
The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Why it matters: Mistakes in breathing care can quickly become life-threatening for residents who depend on oxygen or equipment.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 2, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (41)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 5, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. · from a complaint |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · from a complaint |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 3, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 12, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 12, 2024 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Jul 12, 2024 | F · Potential for harm, facility-wide | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jul 12, 2024 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · from a complaint |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 12, 2024 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Jul 12, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 21, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Mar 21, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 21, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 21, 2024 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 11, 2023 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 11, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Sep 11, 2023 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Sep 11, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Sep 11, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Sep 11, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Aug 10, 2023 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Aug 10, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Aug 10, 2023 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Aug 10, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Aug 10, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 15, 2022 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Dec 15, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Dec 15, 2022 | E · Potential for harm, repeated | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Dec 15, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 15, 2022 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (10 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 5 | 1 | J ▲ |
| 2023 | 11 | 3 | G ▲ |
| 2024 | 17 | 2 | G ▲ |
| 2025 | 8 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $67,298.
| Date | Type | Amount / length |
|---|---|---|
| Apr 3, 2025 | Fine | $36,569 |
| Jul 12, 2024 | Fine | $30,729 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.40 | 3.89 | 3.95 | bottom 2% in Colorado; bottom 3% in the U.S. |
| Registered Nurse hours | 0.44 | 0.86 | 0.69 | bottom 5% in Colorado; bottom 29% in the U.S. |
| Weekend total nurse staffing | 2.11 | 3.44 | 3.50 | bottom 2% in Colorado; bottom 3% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.35 | 0.61 | 0.48 | bottom 17% in Colorado; bottom 43% in the U.S. |
| Total nursing staff turnover (%) | 49.1 | 47.1 | 45.8 | bottom 43% in Colorado; bottom 39% in the U.S. |
| RN turnover (%) | 47.4 | 44.6 | 42.9 | bottom 42% in Colorado; bottom 40% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.80, RN 0.52, weekend 2.47. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burnam, Soon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/09/2024 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Gardner, Mark | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2023 |
| Gardner, Mark | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2023 |
| Gardner, Mark | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2023 |
| Jorgensen, David | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/31/2023 |
| Jorgensen, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2015 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2022 |
| Kettle Creek Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Port, Barry | Individual | Corporate Director | NOT APPLICABLE | 01/01/2022 |
| Reddy, Vikas | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/29/2020 |
| Reddy, Vikas | Individual | ADP of the SNF | NOT APPLICABLE | 06/28/2025 |
| Standard Bearer Healthcare Op LP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Atlas Post Acute | 0.2 mi | Pueblo, CO | ★★★☆☆ | 4/5 | |
| Lakeshore Post Acute and Rehabilitation Center | 1.3 mi | Pueblo, CO | ★★★★☆ | 3/5 | |
| Life Care Center of Pueblo | 1.8 mi | Pueblo, CO | ★★★★☆ | 3/5 | |
| High Plains Post Acute LLC | 2.1 mi | Pueblo, CO | ★★☆☆☆ | 2/5 | |
| Vista Ridge Care and Rehabilitation | 4.0 mi | Pueblo, CO | ★★★☆☆ | 3/5 | |
| Pueblo Heights Nursing and Rehabilitation | 4.7 mi | Pueblo, CO | ★★☆☆☆ | 2/5 | |
| Center at Park West LLC, the | 5.1 mi | Pueblo, CO | ★★☆☆☆ | 2/5 | |
| University Park Care Center | 5.5 mi | Pueblo, CO | ★★★★☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065100.