Sundance Skilled Nursing: Resident Drank Chemical - CO
The nursing assistant, identified in federal inspection records as CNA #1, was the one who spotted it. She realized what had happened only after seeing the discoloration on the resident's mouth. She pulled the bottle away from him, then notified the charge nurse.
Federal inspectors who investigated the incident classified it as immediate jeopardy, the most serious category of harm available under the inspection system, reserved for situations where a facility's failures have placed residents at serious risk of injury or death.
The charge nurse and the resident's primary care physician evaluated him after CNA #1 raised the alarm. The inspection report does not describe what the chemical was, how it got within the resident's reach, or what medical treatment followed.
What the report does describe is what the facility did next. Staff were sent through every room in the building to search for hazardous items. Every resident's room was checked. Then came the training, both in-person sessions and online modules, for all staff, focused on keeping hazardous materials away from residents.
The social services director told inspectors she had received hazardous material training when she was first hired, and then completed it again, both in person and online, after the incident involving Resident #1. She said the post-incident training helped make staff more aware of the dangers that existed inside the building. She was also assigned to weekly rounds specifically to check for hazardous items.
The inspection, conducted as a complaint investigation, was completed on August 15, 2025. Inspectors noted that the harm was classified as affecting a small number of residents.
None of that changes what the record shows: a resident drank something that turned his lips and tongue blue, and the person responsible for his care did not notice until it was already happening.
The inspection report does not say how the chemical got into the room, who brought it in, or whether it was left there accidentally. It does not say how long the bottle had been within the resident's reach before he drank from it. It does not name the chemical or describe the severity of the resident's reaction beyond what CNA #1 observed in the moment.
What it records is the sequence. A resident reached a hazardous substance. He drank some of it. A nursing assistant saw his lips and tongue had changed color. She took the bottle away. She told the charge nurse.
The facility responded with searches and training. The social services director described the effort as extensive. She said it made staff sensitive to hazards they had not been adequately protecting residents from before.
Resident #1 is identified in the report only by that designation. His age, his diagnosis, his condition before or after the incident, and whether he was able to communicate what had happened to him, none of that appears in the inspection record. What appears is a single physical detail, reported secondhand, by the person who finally noticed: his lips and tongue were blue.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 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 nursing assistant, identified in federal inspection records as CNA #1, was the one who spotted it.
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.