Rock Canyon Respiratory and Rehabilitation Center
2515 Pitman Pl · Pueblo, CO · 81004 · 7195640550
151 certified beds For profit - Limited Liability company Chain: The Ensign Group Part of a CCRC
Why this verdict
- Carries CMS’s abuse warning icon.
- Federal penalties on record: $67,298 in fines in the last 24 months.
- 6 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$67,298 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
Total nurse staffing below 3.0 hours per resident-day
2.99 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 2.99 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.53 | 0.55–0.75 |
| Weekend hours / resident-day | 2.66 | ≈ weekday level |
| Nursing turnover / year | 50% | median 45% |
| Fines (3-yr window) | 3 · $89,938 |
Inspection citations (41 in the current record)
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Potential for harm · D December 11, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 26, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 5, 2025 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected July 1, 2025 · Resident Rights
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Potential for harm · D June 5, 2025 · found via complaint
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected July 1, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 5, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected July 1, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 5, 2025 · found via complaint
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected July 1, 2025 · Quality of Life and Care
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Potential for harm · D June 5, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected July 1, 2025 · Pharmacy Service
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Potential for harm · E June 5, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected July 1, 2025 · Infection Control
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Actual harm · G April 3, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G July 12, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 9, 2024 · Quality of Life and Care
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Actual harm · G July 12, 2024 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected August 9, 2024 · Quality of Life and Care
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Potential for harm · D July 12, 2024 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected August 9, 2024 · Resident Rights
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Potential for harm · E July 12, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected August 9, 2024 · Quality of Life and Care
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Potential for harm · F July 12, 2024 · found via complaint
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected August 9, 2024 · Quality of Life and Care
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Potential for harm · F July 12, 2024 · found via complaint
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected August 9, 2024 · Administration
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Potential for harm · E July 12, 2024 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected August 9, 2024 · Environmental
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Potential for harm · E March 21, 2024
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 April 12, 2024 · Resident Rights
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Potential for harm · D March 21, 2024
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected April 12, 2024 · Resident Rights
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Potential for harm · D March 21, 2024
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected April 12, 2024 · Quality of Life and Care
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Potential for harm · D March 21, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected April 12, 2024 · Pharmacy Service
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Potential for harm · D March 21, 2024
Ensure that residents are free from significant medication errors.
Corrected April 12, 2024 · Pharmacy Service
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Potential for harm · E March 21, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 12, 2024 · Nutrition and Dietary
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Potential for harm · E March 21, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected April 12, 2024 · Resident Assessment and Care Planning
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Potential for harm · D March 21, 2024
Provide and implement an infection prevention and control program.
Corrected April 12, 2024 · Infection Control
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Potential for harm · D March 21, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 12, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E March 21, 2024 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected April 12, 2024 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 3, 2025 | Fine | $36,569 |
| July 12, 2024 | Fine | $30,729 |
| August 10, 2023 | Fine | $22,640 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 065100 · certified since March 24, 1968. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.