Nursing Care Index

Rock Canyon Respiratory And Rehabilitation Center

Pueblo, Pueblo County, Colorado · CCN 065100 · For-profit (LLC) · part of The Ensign Group (342 facilities, chain average 3.2 stars)

CMS rates Rock Canyon Respiratory And Rehabilitation Center 1 of 5 overall as of August 2026. 151 certified beds, 135 residents a day on average. 41 citations on record from the current inspection cycles, 1 at immediate jeopardy; 2 fines totalling $67,298.

On record

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★☆☆☆☆ 1 of 5
Health inspections★★☆☆☆ 2 of 5
Staffing★☆☆☆☆ 1 of 5
Quality measures★★★★☆ 4 of 5
Quality: long-stay / short-stay5 / 4 of 5

Staffing

Total nurse staffing2.80046 hours per resident per day
Registered nurses0.51929 hours per resident per day
Weekend total2.46923 hours per resident per day
Nursing staff turnover49.1% (registered nurses 47.4%)
Administrators who left0

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.

SurveyFindingSeverityStatus
2025-12-11
complaint survey
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
2025-12-26
2025-06-05
complaint survey
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
2025-07-01
2025-06-05
complaint survey
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
2025-07-01
2025-06-05
complaint survey
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0605
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-01
2025-06-05
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-01
2025-06-05
complaint survey
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.
Quality of Life and Care Deficiencies · tag F0688
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-01
2025-06-05
complaint survey
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
2025-07-01
2025-04-03
complaint survey
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
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-05-02
2024-07-12
complaint survey
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
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-08-09
2024-07-12
complaint survey
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-08-09
2024-07-12
complaint survey
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.
Quality of Life and Care Deficiencies · tag F0693
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-08-09
2024-07-12
complaint survey
Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · tag F0865
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-08-09
2024-07-12
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-09
2024-07-12
complaint survey
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · tag F0919
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-09
2024-07-12
complaint survey
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
2024-08-09
2024-03-21 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
2024-04-12
2024-03-21 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
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-12
2024-03-21 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-12
2024-03-21
complaint survey
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · tag F0919
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-04-12
2024-03-21
complaint survey
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
2024-04-12
2024-03-21 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.
Resident Rights Deficiencies · tag F0622
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-12
2024-03-21 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · tag F0744
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-12
2024-03-21 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-12
2024-03-21 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
2024-04-12
2024-03-21 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-12
2023-09-11
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-10-02
2023-09-11
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-10-02
2023-09-11
complaint survey
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-10-02
2023-09-11
complaint survey
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Resident Rights Deficiencies · tag F0585
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-02
2023-09-11
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-02
2023-09-11
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-10-02
2023-08-10
complaint survey
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Environmental Deficiencies · tag F0925
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-09-13
2023-08-10
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-09-01
2023-08-10
complaint survey
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-09-01
2023-08-10
complaint survey
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
2023-09-01
2023-08-10
complaint survey
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
2023-09-01
2022-12-15 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
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2023-01-14
2022-12-15 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
2023-01-14
2022-12-15 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · tag F0744
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-01-14
2022-12-15 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-01-14
2022-12-15 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
2023-01-14

Fines and payment denials

DatePenaltyAmount
2025-04-03Fine$36,569
2024-07-12Fine$30,729

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.

NameRoleShareSince
Ensign Services Inc.
Organization
adp of the snf2022-01-01
Kettle Creek Health Holdings LLC
Organization
adp of the snf2022-01-01
Standard Bearer Healthcare Op Lp
Organization
adp of the snf2022-01-01
The Ensign Group Inc.
Organization
adp of the snf2022-01-01
Gardner, Mark
Individual
adp of the snf2023-06-01
Reddy, Vikas
Individual
adp of the snf2025-06-28
Port, Barry
Individual
corporate director2022-01-01
Burnam, Soon
Individual
corporate officer2024-09-09
Keetch, Chad
Individual
corporate officer2022-01-01
Burnam, Soon
Individual
managing control - governing body2024-09-09
Gardner, Mark
Individual
managing control - governing body2023-06-01
Jorgensen, David
Individual
managing control - governing body2023-05-31
Reddy, Vikas
Individual
managing control - governing body2020-07-29
Gardner, Mark
Individual
operational/managerial control2023-06-01
Jorgensen, David
Individual
operational/managerial control2015-01-01

What changed

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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.