Sundance Skilled Nursing And Rehabilitation

Sundance Skilled Nursing And Rehabilitation was recognized and ceritified in 1981 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Sundance Skilled Nursing And Rehabilitation which is located in 2612 West Cucharras Street Colorado Springs, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Sundance Skilled Nursing And Rehabilitation is being offered ceritified services and products in Colorado.
Address:   2612 West Cucharras Street
       Colorado Springs, CO 80904

Phone:   (719) 632-7474

County: El Paso
Federal Provider Number: 065152
Participates in: Medicare And Medicaid
Certified Date: Thursday, February 12, 1981 (44 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: Cucharras Operations, Llc
Ownership Type: For Profit - Corporation
Provider Changed Ownership in Last 12 Months: Yes



TypeNameRole Description
OrganizationMadison Partners Inc5% Or More Ownership Interest
PersonLawrence WesterOperational/managerial Control

Provider Resides in Hospital: No
Number of Federally Certified Beds: 68
Number of Residents in Federally Certified Beds: 58 (86% occupied)
Continuing Care Retirement Community: No
Special Focus Facility: No
With a Resident and Family Council: Both
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Tuesday, August 26, 2014
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Thursday, September 18, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, August 26, 2014
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Tuesday, September 30, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, August 26, 2014
Survey Type: Fire Safety
Deficiency: K0130 (Other fire safety features required by fire safety codes.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, September 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, August 26, 2014
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Monday, September 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0311 (Make sure that residents receive treatments/services to maintain or improve their ability to care fo)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0221 (Keep each resident free from physical restraints, unless needed for medical treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, August 6, 2014
Survey Type: Health
Deficiency: F0242 (Ensure residents have the right to have a choice over activities, their schedules, and health care a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, September 17, 2013
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 27, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, September 17, 2013
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 27, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, September 17, 2013
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 27, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, September 17, 2013
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 29, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, September 17, 2013
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, October 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, September 17, 2013
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 27, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0257 (Maintain comfortable and safe temperature levels.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0311 (Make sure that residents receive treatments/services to maintain or improve their ability to care fo)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0318 (Ensure that residents with limited range of motion receive appropriate treatment and services to inc)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0412 (Provide or obtain dental services for each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 22, 2013
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, September 20, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 2, 2012
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, December 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 2, 2012
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, December 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 2, 2012
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, December 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, October 2, 2012
Survey Type: Fire Safety
Deficiency: K0034 (Exit stairways and towers that are smoke proof.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 20, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 10, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, September 29, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 10, 2012
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, September 29, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 10, 2012
Survey Type: Health
Deficiency: F0252 (Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal be)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, September 29, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, September 10, 2012
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, September 29, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Number of Facility Reported Incidents: 0
Number of Substantiated Complaints: 8
Number of Fines: 0
Number of Payment Denials: 0
Total Number of Penalties: 0
Total Amount of Fines in Dollars: USD 0
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This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (3 out of 5 stars)
Quality Rating (4 out of 5 stars)
Staffing Rating (4 out of 5 stars)
RN Staffing Rating (5 out of 5 stars)
Overall Rating (4 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
5%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
4%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
9%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
1%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
16%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
4%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
5%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
20%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
90%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
92%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
5%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
7%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
17%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
48%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
78%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
2%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
82%
84%

N/A
Data not available.

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Sundance Skilled Nursing And Rehabilitation [Federal No:065152] near 2612 West Cucharras Street, Colorado Springs CO

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