CMS PUBLIC RECORD · AUGUST 2026 RELEASERECORDS ARE ONE INPUT—NOT A PLACEMENT RECOMMENDATION
NURSING HOMELEDGERINSPECTIONS · OWNERSHIP · PENALTIES
CMS CCN 0651522026-08-01 PROCESSING DATE

NURSING HOME PUBLIC RECORD

Sundance Skilled Nursing And Rehabilitation

2612 W Cucharras St · Colorado Springs, CO 80904 · El Paso County

CMS OVERALL RATING★★☆☆☆2/5CMS field—not our score or recommendation
Certified beds68CMS provider file
Recent citation rows48current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.

The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.

01 / INSPECTION LEDGER

Survey cycles in this release

CycleHealth dateHealth deficienciesFire dateFire deficiencies
Cycle 12026-02-26182026-02-264
Cycle 22024-02-2712024-02-279
Cycle 32022-11-1782022-11-178
02 / CITATION DETAIL

48 rows in the current release

1 rows carry G–L scope/severity codes; 1 carry J–L. 10 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.

2026-02-26 · HEALTHF0557Severity D · isolated; potential for more than minimal harm

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0565Severity D · isolated; potential for more than minimal harm

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0584Severity E · pattern; potential for more than minimal harm

Resident Rights Deficiencies

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.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0679Severity D · isolated; potential for more than minimal harm

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0684Severity D · isolated; potential for more than minimal harm

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0686Severity D · isolated; potential for more than minimal harm

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0689Severity E · pattern; potential for more than minimal harm

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0695Severity D · isolated; potential for more than minimal harm

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0697Severity D · isolated; potential for more than minimal harm

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0761Severity E · pattern; potential for more than minimal harm

Pharmacy Service Deficiencies

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.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0791Severity D · isolated; potential for more than minimal harm

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0804Severity E · pattern; potential for more than minimal harm

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0806Severity D · isolated; potential for more than minimal harm

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0880Severity D · isolated; potential for more than minimal harm

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0919Severity D · isolated; potential for more than minimal harm

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0921Severity E · pattern; potential for more than minimal harm

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · HEALTHF0923Severity D · isolated; potential for more than minimal harm

Environmental Deficiencies

Have enough outside ventilation via a window or mechanical ventilation, or both.

Correction field: Deficient, Provider has date of correction · 2026-03-28
2026-02-26 · FIREK0161Severity F · widespread; potential for more than minimal harm

Construction Deficiencies

Use approved construction type or materials.

Correction field: Deficient, Provider has plan of correction · 2026-08-15
2026-02-26 · FIREK0324Severity E · pattern; potential for more than minimal harm

Smoke Deficiencies

Provide properly protected cooking facilities.

Correction field: Deficient, Provider has plan of correction · 2026-04-25
2026-02-26 · FIREK0353Severity F · widespread; potential for more than minimal harm

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Correction field: Deficient, Provider has plan of correction · 2026-04-25
2026-02-26 · FIREK0751Severity E · pattern; potential for more than minimal harm

Miscellaneous Deficiencies

Have restrictions on the use of flammable curtains.

Correction field: Deficient, Provider has plan of correction · 2026-08-15
2025-08-15 · HEALTHF0689Severity J · isolated immediate jeopardy

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Correction field: Past Non-Compliance · complaint
2024-02-27 · HEALTHF0880Severity D · isolated; potential for more than minimal harm

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Correction field: Deficient, Provider has date of correction · 2024-03-22
2024-02-27 · FIREK0345Severity F · widespread; potential for more than minimal harm

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Correction field: Deficient, Provider has date of correction · 2024-04-28
03 / ENFORCEMENT FILE

Penalties reported by CMS

Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.

DateTypeFine amountPayment-denial days
2025-08-15Fine$14,9010
04 / OWNERSHIP DISCLOSURES

Who appears in the CMS file

  • CHIEF JOSEPH TRAIL, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
    100% · since 03/02/2026
  • TIPPET, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
    NO PERCENTAGE PROVIDED · since 03/02/2026
  • WHITE CANYON, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
    NO PERCENTAGE PROVIDED · since 03/02/2026
  • CLEGG, MICHAELIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
    NO PERCENTAGE PROVIDED · since 03/02/2026
  • CLEGG, MICHAELIndividual · MANAGING CONTROL - GOVERNING BODY
    NOT APPLICABLE · since 06/26/2023
  • IKERD, JOHNIndividual · MANAGING CONTROL - GOVERNING BODY
    NOT APPLICABLE · since 03/02/2026
  • MADISON CREEK PARTNERS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 11/01/2013
  • CHRISTENSEN, COVEYIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 11/01/2013
  • CLEGG, MICHAELIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 06/26/2023
  • HOPKINS, AMBERIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 12/01/2021
  • IKERD, JOHNIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 04/25/2022
  • SHEPHERD, DAVIDIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 12/19/2019
  • TERRAZAS, LISAIndividual · OPERATIONAL/MANAGERIAL CONTROL
    NOT APPLICABLE · since 05/01/2022
  • MADISON CREEK PARTNERS LLCOrganization · ADP OF THE SNF
    NOT APPLICABLE · since 11/01/2013
  • CHRISTENSEN, COVEYIndividual · ADP OF THE SNF
    NOT APPLICABLE · since 11/01/2013
  • CLEGG, MICHAELIndividual · ADP OF THE SNF
    NOT APPLICABLE · since 06/26/2023
  • HOPKINS, AMBERIndividual · ADP OF THE SNF
    NOT APPLICABLE · since 12/01/2021
  • IKERD, JOHNIndividual · ADP OF THE SNF
    NOT APPLICABLE · since 04/25/2022

Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.

05 / CMS STAFFING FIELDS

Reported hours and turnover

Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.

Total nurse hours3.11per resident day
RN hours0.97per resident day
Weekend nurse hours2.68per resident day
Staff turnover42.9%CMS reported field
BEFORE A CARE DECISION

Verify the current record and visit in person.

Use this ledger to frame questions—not to choose care on its own. Recheck Medicare Care Compare, contact the state survey agency and long-term care ombudsman, and ask the facility about anything you find.