Sundance Skilled Nursing And Rehabilitation
Colorado Springs, El Paso County, Colorado · CCN 065152 · For-profit (LLC) · part of Madison Creek Partners (13 facilities, chain average 3.2 stars)
CMS rates Sundance Skilled Nursing And Rehabilitation 2 of 5 overall as of August 2026. 68 certified beds, 60 residents a day on average. 27 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $14,901.
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 | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 4 / — of 5 |
Staffing
| Total nurse staffing | 3.10849 hours per resident per day |
|---|---|
| Registered nurses | 0.96944 hours per resident per day |
| Weekend total | 2.6839 hours per resident per day |
| Nursing staff turnover | 42.9% (registered nurses 25%) |
| Administrators who left | 0 |
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.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-02-26 | 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 2026-03-28 |
| 2026-02-26 | 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 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | 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 2026-03-28 |
| 2026-02-26 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · tag F0921 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · tag F0557 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · tag F0565 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · tag F0806 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | 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 2026-03-28 |
| 2026-02-26 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2026-02-26 | Have enough outside ventilation via a window or mechanical ventilation, or both. Environmental Deficiencies · tag F0923 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-28 |
| 2025-08-15 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 |
J Immediate jeopardy to resident health or safety; isolated | Past Non-Compliance |
| 2024-02-27 | 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 2024-03-22 |
| 2023-10-05 complaint survey |
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Resident Rights Deficiencies · tag F0573 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-01 |
| 2023-10-05 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 2023-11-13 |
| 2023-10-05 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-01 |
| 2023-10-05 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 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-13 |
| 2022-11-17 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · tag F0565 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-12-23 |
| 2022-11-17 | 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 2022-12-23 |
| 2022-11-17 | 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 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-12-27 |
| 2022-11-17 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-01-18 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-08-15 | Fine | $14,901 |
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.
| Name | Role | Share | Since |
|---|---|---|---|
| Chief Joseph Trail, LLC Organization | 5% or greater direct ownership interest | 100% | 2026-03-02 |
| Tippet, LLC Organization | 5% or greater indirect ownership interest | — | 2026-03-02 |
| White Canyon, LLC Organization | 5% or greater indirect ownership interest | — | 2026-03-02 |
| Madison Creek Partners LLC Organization | adp of the snf | — | 2013-11-01 |
| Madison Creek Partners LLC Organization | operational/managerial control | — | 2013-11-01 |
| Clegg, Michael Individual | 5% or greater indirect ownership interest | — | 2026-03-02 |
| Christensen, Covey Individual | adp of the snf | — | 2013-11-01 |
| Clegg, Michael Individual | adp of the snf | — | 2023-06-26 |
| Hopkins, Amber Individual | adp of the snf | — | 2021-12-01 |
| Ikerd, John Individual | adp of the snf | — | 2022-04-25 |
| Shepherd, David Individual | adp of the snf | — | 2019-12-19 |
| Terrazas, Lisa Individual | adp of the snf | — | 2022-05-01 |
| Clegg, Michael Individual | managing control - governing body | — | 2023-06-26 |
| Ikerd, John Individual | managing control - governing body | — | 2026-03-02 |
| Christensen, Covey Individual | operational/managerial control | — | 2013-11-01 |
| Clegg, Michael Individual | operational/managerial control | — | 2023-06-26 |
| Hopkins, Amber Individual | operational/managerial control | — | 2021-12-01 |
| Ikerd, John Individual | operational/managerial control | — | 2022-04-25 |
| Shepherd, David Individual | operational/managerial control | — | 2019-12-19 |
| Terrazas, Lisa Individual | operational/managerial control | — | 2022-05-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Sundance Skilled Nursing And Rehabilitation.
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 El Paso County.