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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G4 | H· | I· |
| Potential harm | D22 | E6 | F21 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Mar 4, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Aug 29, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Apr 18, 2024 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Apr 18, 2024 | Health | Health Complaint, Health Standard | 7 | Actual harm | — | Open → |
| Nov 13, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 29, 2022 | Fire safety | Fire Safety Standard | 5 | Potential harm | — | Open → |
| Dec 29, 2022 | Health | Health Standard | 3 | Potential harm | — | Open → |
| Sep 16, 2021 | Fire safety | Fire Safety Standard | 12 | Potential harm | — | Open → |
| Sep 16, 2021 | Health | Health Standard | 9 | Actual harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Apr 18, 2024 | Civil money penalty (fine) | $10,033 | — | 065235|Fine|115855 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G4 | H· | I· |
| Potential harm | D22 | E6 | F21 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Mar 4, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 28, 2025 | Complaint |
| Aug 29, 2024 | F-0584 | 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 · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Sep 18, 2024 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
13 facilities in 2 states. CMS chain ID 328.
Chain average overall rating (CMS): 3.2
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Chief Joseph Trail, LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Mar 2, 2026 |
| Tippet, LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 2, 2026 |
| White Canyon, LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 2, 2026 |
| Michael Clegg | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 2, 2026 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Chief Joseph Trail, LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Mar 2, 2026 |
| Tippet, LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 2, 2026 |
| White Canyon, LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 2, 2026 |
| Michael Clegg | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Sundance Skilled Nursing and Rehabilitation 2612 W Cucharras St, Colorado Springs, CO 80904 CCN 065152 | 68 | Feb 26, 2026 | 481 IJ | $15k | |
| Pueblo Heights Nursing and Rehabilitation 1601 Constitution Rd, Pueblo, CO 81001 CCN 065169 | 120 |
Coordinates as published by CMS.
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 065235 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 065235 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Complaint |
| Aug 29, 2024 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 16, 2024 | Complaint |
| Aug 29, 2024 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 18, 2024 | Complaint |
| Apr 18, 2024 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Past non-compliance Apr 2, 2024 |
| Apr 18, 2024 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 1, 2024 |
| Apr 18, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jul 9, 2024 |
| Apr 18, 2024 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 1, 2024 |
| Apr 18, 2024 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 20, 2024 |
| Apr 18, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 1, 2024 |
| Apr 18, 2024 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 1, 2024 |
| Apr 18, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 1, 2024 |
| Apr 18, 2024 | K-0522 | Have an externally vented heating system. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 2, 2024 |
| Apr 18, 2024 | K-0751 | Have restrictions on the use of flammable curtains. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 8, 2024 |
| Apr 18, 2024 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 5, 2024 |
| Apr 18, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 29, 2024 |
| Apr 18, 2024 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Aug 1, 2024 |
| Apr 18, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 10, 2024 |
| Apr 18, 2024 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 10, 2024 | Complaint |
| Apr 18, 2024 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 10, 2024 |
| Apr 18, 2024 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected May 10, 2024 |
| Apr 18, 2024 | F-0761 | 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 · Medication management | D · Potential harm Isolated | Corrected May 10, 2024 |
| Apr 18, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected May 10, 2024 |
| Nov 13, 2023 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Dec 25, 2023 | Complaint |
| Dec 29, 2022 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 3, 2023 |
| Dec 29, 2022 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 14, 2023 |
| Dec 29, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 3, 2023 |
| Dec 29, 2022 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 3, 2023 |
| Dec 29, 2022 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 16, 2023 |
| Dec 29, 2022 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Feb 11, 2023 |
| Dec 29, 2022 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Feb 11, 2023 |
| Dec 29, 2022 | F-0886 | Perform COVID19 testing on residents and staff. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Feb 11, 2023 |
| Sep 16, 2021 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | G · Actual harm Isolated | Corrected Oct 11, 2021 |
| Sep 16, 2021 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Oct 11, 2021 |
| Sep 16, 2021 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Oct 11, 2021 |
| Sep 16, 2021 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Oct 11, 2021 |
| Sep 16, 2021 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 14, 2021 |
| Sep 16, 2021 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 14, 2021 |
| Sep 16, 2021 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 14, 2021 |
| Sep 16, 2021 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 15, 2021 |
| Sep 16, 2021 | K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 19, 2021 |
| Sep 16, 2021 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 19, 2021 |
| Sep 16, 2021 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 14, 2021 |
| Sep 16, 2021 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 19, 2021 |
| Sep 16, 2021 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 19, 2021 |
| Sep 16, 2021 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 19, 2021 |
| Sep 16, 2021 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 14, 2021 |
| Sep 16, 2021 | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 11, 2021 |
| Sep 16, 2021 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 11, 2021 |
| Sep 16, 2021 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 11, 2021 |
| Sep 16, 2021 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Past non-compliance Aug 2, 2021 |
| Sep 16, 2021 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 11, 2021 |
| Sep 16, 2021 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Oct 11, 2021 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.82 (case-mix index 1.05).
| Mar 2, 2026 |
| Michael Clegg | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jun 26, 2023 |
| John Ikerd | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Mar 2, 2026 |
| Madison Creek Partners LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2016 |
| Covey Christensen | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jul 1, 2016 |
| Michael Clegg | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 26, 2023 |
| Cameron Cook | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 27, 2025 |
| Amber Hopkins | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 1, 2021 |
| John Ikerd | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 25, 2022 |
| David Shepherd | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 1, 2022 |
| Madison Creek Partners LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 30, 2026 |
| Covey Christensen | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2016 |
| Michael Clegg | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jun 26, 2023 |
| Cameron Cook | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 27, 2025 |
| Amber Hopkins | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Dec 1, 2021 |
| John Ikerd | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 25, 2022 |
| David Shepherd | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jun 1, 2022 |
| Apr 14, 2026 |
391 IJ |
| $20k |
| The Gardens 104 Lois Ln, Colorado Springs, CO 80904 CCN 065198 | 45 | Dec 11, 2025 | 215 open | — |
| Glenwood Springs Healthcare 2305 Blake Ave, Glenwood Springs, CO 81601 CCN 065244 | 54 | Apr 21, 2026 | 582 harm | — |
| Paonia Care and Rehabilitation Center 1625 Meadowbrook Blvd, Paonia, CO 81428 CCN 065251Abuse icon | 60 | Jul 14, 2026 | 691 IJ5 harm4 open | $33k |
| Silver Heights Skilled Nursing and Rehabilitation 4001 Home St, Castle Rock, CO 80108 CCN 065285 | 91 | Apr 3, 2025 | 58 | — |
| Lakewood Villa 1625 Simms St, Lakewood, CO 80215 CCN 065408 | 57 | Jul 7, 2025 | 421 IJ4 harm | $17k |