Map showing the location of ROCK CANYON RESPIRATORY AND REHABILITATION CENTER in PUEBLO, Colorado
2515 PITMAN PL, PUEBLO, CO, 81004

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • ColoradoLowest tier among peers208 rated homes · average 3.1★
  • Pueblo CountyLowest tier among peers9 rated homes · average 3.3★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.7 vs CO avg
  • StaffingCan add or remove a star1★−2.1 vs CO avg
  • Quality measuresCan add or remove a star4★−0.2 vs CO avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 20% of peersCO avg2.7★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersCO avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 22% of peersCO avg4.2★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.05hrsAbove only 15% of peersCO avg3.73Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.56hrsAbove only 19% of peersCO avg0.83Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better53%Above only 44% of peersCO avg49%RN turnover47%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$89,938Above only 6% of peersCO avg$25,587Fines · denials3 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
43citations
9inspection dates
6actual harm (G–I)
1immediate jeopardy (J–L)
Dec 11, 2025most recent

Citations by monthDec 2022 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 11, 20251 citationCycle 1worst D · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 26, 2025
Jun 5, 20256 citationsCycle 1worst E · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jul 1, 2025
  2. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 1, 2025
  3. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 1, 2025
  4. F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 1, 2025
  5. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jul 1, 2025
  6. F688Provide 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 CareD · isolatedCorrected Jul 1, 2025
Apr 3, 20251 citationCycle 1worst G · actual harm$36,569
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected May 2, 2025
Jul 12, 20247 citationsCycle 2worst G · actual harm$30,729
  1. F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationF · widespreadCorrected Aug 9, 2024
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Aug 9, 2024
  3. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Aug 9, 2024
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Aug 9, 2024
  5. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Aug 9, 2024
  6. F693Ensure 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 CareF · widespreadCorrected Aug 9, 2024
  7. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Aug 9, 2024
Mar 21, 202410 citationsCycle 2worst E · no actual harm
  1. F584Honor 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 RightsE · patternCorrected Apr 12, 2024
  2. F622Not 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 RightsD · isolatedCorrected Apr 12, 2024
  3. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected Apr 12, 2024
  4. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Apr 12, 2024
  5. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Apr 12, 2024
  6. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Apr 12, 2024
  7. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Apr 12, 2024
  8. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 12, 2024
  9. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 12, 2024
  10. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Apr 12, 2024
Sep 11, 20236 citationsCycle 3worst G · actual harm
  1. F585Honor 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 RightsD · isolatedCorrected Oct 2, 2023
  2. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 2, 2023
  3. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Oct 2, 2023
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Oct 2, 2023
  5. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Oct 2, 2023
  6. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareG · isolatedCorrected Oct 2, 2023
Aug 10, 20235 citationsCycle 3worst F · no actual harm$22,640
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Sep 1, 2023
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Sep 1, 2023
  3. F725Provide 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 ServicesE · patternCorrected Sep 1, 2023
  4. F761Ensure 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 ServiceE · patternCorrected Sep 1, 2023
  5. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Sep 13, 2023
Apr 6, 20232 citationsCycle 3worst E · no actual harm
  1. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected May 5, 2023
  2. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 5, 2023
Dec 15, 20225 citationsCycle 3worst J · immediate jeopardy
  1. F742Provide 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 CareD · isolatedCorrected Jan 14, 2023
  2. F584Honor 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 RightsE · patternCorrected Jan 14, 2023
  3. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Jan 14, 2023
  4. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jan 14, 2023
  5. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareE · patternCorrected Jan 14, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.05hrsAbove only 15% of peers−0.68 vs CO avg
  • Registered nursesRN hours only0.56hrsAbove only 19% of peers−0.27 vs CO avg
  • Licensed practical nursesLPN hours0.75hrs
  • Nurse aidesCNA hours1.74hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.66hrs
  • Colorado average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better53%Above only 44% of peersCO avg 49%
  • RN turnoverRegistered nurses only47%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy151 certified beds · ~134 residents a day89%Above 69% of peersCO avg 79%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $89,938In fines
  • 3Fines
  • 0Payment denials
  • $25,587CO avg in fines
Above only 6% of peersFewer fines than 6% of rated homes in Colorado

Actions on record

  1. Apr 3, 2025Civil money penalty$36,569
  2. Jul 12, 2024Civil money penalty$30,729
  3. Aug 10, 2023Civil money penalty$22,640

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
The Ensign Group324 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Endura Healthcare LLC
Indirect owners (5%+)
  • The Ensign Group INC
Operational or managerial control
  • Mark Gardner
  • David Jorgensen
Corporate directors
  • Barry Port
Corporate officers
  • Soon Burnam
  • Chad Keetch

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 065100 · 2515 PITMAN PL, PUEBLO, CO, 81004.
  • Percentiles compare this facility with every rated nursing home in Colorado and Pueblo County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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