Sundance Skilled Nursing: Resident Drinks Drain Cleaner - CO
The chemical had already turned his lips and tongue blue.
The August incident at Sundance Skilled Nursing and Rehabilitation triggered an immediate jeopardy citation from federal inspectors, who found the facility had failed to protect residents from hazardous materials that could cause serious harm or death.
Resident #1 had consumed approximately 10 milliliters of the drain cleaner before CNA #1 discovered him in the hallway and took the bottle away. She immediately noticed the blue discoloration on his lips and tongue and alerted the charge nurse.
The facility's primary care physician reviewed the material safety data sheet for the product and contacted poison control. He estimated the amount consumed based on staff reports and how much remained in the bottle.
"If Resident #1 had ingested more drain cleaner he would have been in trouble, as it could have caused a hole through his esophagus or his stomach," the physician told inspectors.
The resident began experiencing abdominal pain and was transferred to the hospital "out of an abundance of caution," according to the physician, who said the resident appeared stable but required monitoring given the potential severity of chemical ingestion.
RN #2 contacted the resident's representative about the incident and hospital transfer. She told inspectors that all facility staff received re-education about hazardous items following the incident.
The discovery prompted an immediate facility-wide audit. Staff members searched the entire building, including all resident rooms, to identify and remove any hazardous items accessible to residents.
CNA #1 described the comprehensive response: "The facility had all staff check the facility, including all residents' rooms for hazardous items, including chemicals, following the incident."
The social services director participated in weekly rounds to check for hazardous items after the incident. She had received hazardous material training when hired and completed additional training both in-person and online following the drain cleaner incident.
"The training focused on the need to protect residents from hazardous items," the social services director told inspectors. "The extensive training post-incident for all staff helped to make the staff sensitive to the potential hazards that existed to residents."
The facility implemented both in-person and online training for all staff members. The education emphasized ensuring residents cannot access hazardous materials that could cause injury or death.
The physician said the facility conducted a performance improvement project related to the incident and addressed the underlying cause of the ingestion.
Federal inspectors classified the violation as immediate jeopardy, the most serious level of harm, indicating the facility's failure created a situation where residents faced the risk of serious injury, harm, impairment or death.
The inspection report does not specify how the drain cleaner became accessible to residents or detail the facility's storage practices for hazardous chemicals prior to the incident.
Drain cleaners typically contain caustic chemicals that can cause severe burns to the mouth, throat, esophagus and stomach. Even small amounts can cause significant tissue damage, particularly in elderly residents who may have increased vulnerability to chemical injuries.
The incident highlights ongoing challenges nursing homes face in balancing resident autonomy with safety requirements, particularly for residents with cognitive impairments who may not recognize dangerous substances.
Sundance Skilled Nursing and Rehabilitation must now demonstrate to federal regulators that it has implemented effective systems to prevent resident access to hazardous materials throughout the facility.
The resident's current condition following hospitalization was not detailed in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sundance Skilled Nursing and Rehabilitation from 2025-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SUNDANCE SKILLED NURSING AND REHABILITATION in COLORADO SPRINGS, CO was cited for violations during a health inspection on August 15, 2025.
The chemical had already turned his lips and tongue blue.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.