Federal inspection record · CMS data as of October 1, 2026
Sundance Skilled Nursing And Rehabilitation
2612 W Cucharras St, Colorado Springs, CO · (719) 632-7474
- Certified beds
- 68
- Residents per day
- 58
- Ownership
- For-Profit
- Chain
- Madison Creek Partners
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 12, 1981
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Colorado.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Colorado homes
Sundance Skilled Nursing And Rehabilitation carries 76 inspection points. That is fewer than 38% of Colorado's 208 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Colorado: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–22 pts
- 4★ 22–44 pts
- 3★ 44–70.75 pts
- 2★ 70.75–104 pts
- 1★ over 104 pts
Bars show every rated home in Colorado by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
27 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care11E
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide activities to meet all resident's needs.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
Provide or obtain dental services for each resident.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Resident Rights5E
- E
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.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- D
Honor the resident's right to organize and participate in resident/family groups in the facility.
- D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Pharmacy Service3E
- E
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.
- E
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.
- D
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.
Environmental3E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
- D
Have enough outside ventilation via a window or mechanical ventilation, or both.
Nutrition and Dietary2E
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Infection Control2D
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Inspection history
2026-02-26
17 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2024-02-27
2 health deficiencies · 9 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
2022-11-17
8 health deficiencies · 8 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 5 min of nursing staff time a day, 55 min of it from a registered nurse.
This home
3 h 5 min
Colorado average
3 h 42 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 44% of nursing staff and 27% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$14,901 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-08-15 | Fine | $14,901 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts worse | 2.1 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.2 pts worse | 1.9 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.4 pts better | 94.8% | 93.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3.2 pts better | 96.9% | 93.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.2 pts better | 2.2% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms8.8 pts better | 0.0% | 8.8% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.2 pts worse | 8.0% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication1.7 pts better | 9.9% | 11.6% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication7.5 pts worse | 27.4% | 19.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened5.5 pts better | 6.2% | 11.7% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased5.6 pts better | 7.2% | 12.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.5 pts better | 0.0% | 0.5% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence13.1 pts better | 7.5% | 20.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.1 pts better | 2.3% | 3.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine24.4 pts worse | 52.6% | 77.0% | 82.3% |
·
Who owns and runs it
20 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Chief Joseph Trail, LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 8 facilities |
| Christensen, Covey | Operational/Managerial Control · Individual | 0% | 16 facilities |
| Christensen, Covey | Adp Of The SNF · Individual | 0% | 16 facilities |
| Clegg, Michael | 5% Or Greater Indirect Ownership Interest · Individual | 0% | 12 facilities |
| Clegg, Michael | Managing Control - Governing Body · Individual | 0% | 12 facilities |
| Clegg, Michael | Operational/Managerial Control · Individual | 0% | 12 facilities |
| Clegg, Michael | Adp Of The SNF · Individual | 0% | 12 facilities |
| Hopkins, Amber | Operational/Managerial Control · Individual | 0% | 12 facilities |
| Hopkins, Amber | Adp Of The SNF · Individual | 0% | 12 facilities |
| Ikerd, John | Managing Control - Governing Body · Individual | 0% | 11 facilities |
| Ikerd, John | Operational/Managerial Control · Individual | 0% | 11 facilities |
| Ikerd, John | Adp Of The SNF · Individual | 0% | 11 facilities |
| Madison Creek Partners LLC | Operational/Managerial Control · Organization | 0% | 13 facilities |
| Madison Creek Partners LLC | Adp Of The SNF · Organization | 0% | 13 facilities |
| Shepherd, David | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Shepherd, David | Adp Of The SNF · Individual | 0% | 9 facilities |
| Terrazas, Lisa | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Terrazas, Lisa | Adp Of The SNF · Individual | 0% | 1 facilities |
| Tippet, LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 8 facilities |
| White Canyon, LLC | 5% Or Greater Indirect Ownership Interest · Organization | 0% | 8 facilities |
·
Fire safety
21 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke9F
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Install corridor and hallway doors that block smoke.
- E
Inspect, test, and maintain automatic sprinkler systems.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
Miscellaneous4F
- E
Have restrictions on the use of flammable curtains.
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems4F
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Ensure proper usage of power strips and extension cords.
Services2F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E
Have properly installed electrical wiring and gas equipment.
Construction1F
- F
Use approved construction type or materials.
Egress1D
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
·
Other homes nearby
-
Bear Creek Senior Living
Colorado Springs, CO
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 33 min
- Fines
- $6,614
-
Gardens, The
Colorado Springs, CO · Madison Creek Partners
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h
- Fines
- $0
-
Brookdale Skyline
Colorado Springs, CO · Brookdale Senior Living
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 7 min
- Fines
- $9,110