Sundance Skilled Nursing and Rehabilitation
2612 W Cucharras St, Colorado Springs, CO 80904 · El Paso County · 68 certified beds · avg 60 residents/day · certified since Feb 12, 1981
Part of chain: MADISON CREEK PARTNERS (13 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Aug 15, 2025 · 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 (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.
All citations in the current public record (27)
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 |
|---|---|---|
| Feb 26, 2026 | 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. |
| Feb 26, 2026 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 26, 2026 | 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. |
| Feb 26, 2026 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 26, 2026 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Feb 26, 2026 | D · Potential for 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. |
| Feb 26, 2026 | D · Potential for 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. |
| Feb 26, 2026 | D · Potential for 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. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Feb 26, 2026 | 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. |
| Feb 26, 2026 | D · Potential for harm, one-off | 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. |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not have enough fresh-air ventilation, whether through windows, mechanical systems, or both. |
| Aug 15, 2025 | ▲ J · Immediate jeopardy, 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 |
| Feb 27, 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. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint |
| Oct 5, 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 |
| Oct 5, 2023 | D · Potential for 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 |
| Oct 5, 2023 | D · Potential for 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 |
| Nov 17, 2022 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Nov 17, 2022 | 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. |
| Nov 17, 2022 | D · Potential for 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. |
| Nov 17, 2022 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (1 → 17).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 4 | 0 | E |
| 2023 | 4 | 0 | D |
| 2024 | 1 | 0 | D |
| 2025 | 1 | 1 | J ▲ |
| 2026 | 17 | 0 | E |
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)
1 fine totaling $14,901.
| Date | Type | Amount / length |
|---|---|---|
| Aug 15, 2025 | Fine | $14,901 |
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) | 3.97 | 3.89 | 3.95 | top 37% in Colorado; top 41% in the U.S. |
| Registered Nurse hours | 1.24 | 0.86 | 0.69 | top 14% in Colorado; top 9% in the U.S. |
| Weekend total nurse staffing | 3.43 | 3.44 | 3.50 | top 43% in Colorado; top 46% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.69 | 0.61 | 0.48 | top 31% in Colorado; top 16% in the U.S. |
| Total nursing staff turnover (%) | 42.9 | 47.1 | 45.8 | top 36% in Colorado; top 44% in the U.S. |
| RN turnover (%) | 25.0 | 44.6 | 42.9 | top 14% in Colorado; top 20% 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 3.11, RN 0.97, weekend 2.68. Staffing rating: 4/5.
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: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Chief Joseph Trail, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/02/2026 |
| Clegg, Michael | Individual | 5% or Greater Indirect Ownership Interest | — | 03/02/2026 |
| Tippet, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/02/2026 |
| White Canyon, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/02/2026 |
| Christensen, Covey | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2013 |
| Christensen, Covey | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2013 |
| Clegg, Michael | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/26/2023 |
| Clegg, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/26/2023 |
| Clegg, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 06/26/2023 |
| Hopkins, Amber | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2021 |
| Hopkins, Amber | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2021 |
| Ikerd, John | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/02/2026 |
| Ikerd, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/25/2022 |
| Ikerd, John | Individual | ADP of the SNF | NOT APPLICABLE | 04/25/2022 |
| Madison Creek Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/01/2013 |
| Madison Creek Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2013 |
| Shepherd, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/19/2019 |
| Shepherd, David | Individual | ADP of the SNF | NOT APPLICABLE | 12/19/2019 |
| Terrazas, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2022 |
| Terrazas, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "How do you train staff to treat residents with dignity, and how do you protect residents' personal belongings?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "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 |
|---|---|---|---|---|---|
| Bear Creek Senior Living | 0.9 mi | Colorado Springs, CO | ★★★★☆ | 4/5 | |
| Gardens, the | 0.9 mi | Colorado Springs, CO | ★★★★★ | 5/5 | |
| Brookdale Skyline | 1.1 mi | Colorado Springs, CO | ★★★★★ | 3/5 | |
| Kiowa Hills Rehabilitation and Nursing, LLC | 1.8 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | |
| The Healthcare Resort of Colorado Springs | 2.0 mi | Colorado Springs, CO | ★★★☆☆ | 2/5 | |
| Springs Village Care Center | 2.6 mi | Colorado Springs, CO | ★★☆☆☆ | 2/5 | |
| Center at Centennial, the | 2.7 mi | Colorado Springs, CO | ★★★★★ | 4/5 | |
| Medallion Post Acute Rehabilitation | 3.9 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | |
| Colonial Rehabilitation and Nursing, LLC | 4.2 mi | Colorado Springs, CO | ★☆☆☆☆ | 2/5 | abuse |
| Pikes Peak Post Acute | 4.6 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | abuse |
| Sunny Vista Living Center | 4.8 mi | Colorado Springs, CO | ★★★☆☆ | 3/5 | |
| Mountain View Post Acute | 4.9 mi | Colorado Springs, CO | ★★☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 065152.