Cycle 1
Health 2025-12-11 · Fire 2025-12-11
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Colorado Springs, CO
Gardens, The
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
104 Lois Ln, Colorado Springs, CO
(719) 635-2569
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Madison Creek Partners
Operator or chain grouping
Approved since
1984-10-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.30
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.91
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.50
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.02
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,794
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9888
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.50
Performance 19.35% · Measure score 4.50 · Achievement 4.50 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.70
Performance 6.73% · Measure score 3.70 · Achievement 3.70 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.30
Baseline 2.75 hours · Performance 3.60 hours · Measure score 2.30 · Achievement 1.85 · Improvement 2.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.47% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 2.5% · Lower 95% interval 5.45% |
| Discharge to community | 51.4% |
50.57%
0.8 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 42.86% · Lower 95% interval 37.32% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 38 · Denominator 38 |
| Falls with major injury | 5.26% |
0.77%
4.5 pts worse
|
Numerator 2 · Denominator 38 |
| Discharge self-care score | 37.5% |
53.69%
16.2 pts worse
|
Numerator 12 · Denominator 32 |
| Discharge mobility score | 28.13% |
50.94%
22.8 pts worse
|
Numerator 9 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.63% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 38 · Adjusted rate 3.06% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 5.13% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 63 |
| Staff flu vaccination coverage | 39.42% |
42%
2.6 pts worse
|
Numerator 41 · Denominator 104 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 16 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.81% |
25.2%
1.4 pts worse
|
Numerator 5 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
1.7
2 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.4%
2.1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
7.4%
7.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.1% |
5.0%
5.1 pts worse
|
5.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 11.1% · Q3 8.1% · Q4 7.5% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
11.2%
3.2 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.3% · Q3 8.1% · Q4 7.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
20.6%
10.5 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 10.3% · Q3 6.5% · Q4 10.0% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.8% |
15.2%
0.4 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 36.5% · Q4 0.0% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
14.6%
1.8 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 19.4% · Q3 13.5% · Q4 10.0% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.5%
0.2 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
22.4%
4 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 18.6% · Q3 12.7% · Q4 14.5% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
76.4%
23.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
12.8%
5.8 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.9% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.8% |
1.5%
6.3 pts worse
|
1.6%
6.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
75.6%
9.6 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
20.3%
1.3 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 20.7% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-08-17 · Fire 2022-08-17
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-11
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-19
F · Potential for more than minimal harm
2025-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-12-31
F · Potential for more than minimal harm
2025-12-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2026-02-13
F · Potential for more than minimal harm
2023-11-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-11-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-11
F · Potential for more than minimal harm
2022-08-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-17
F · Potential for more than minimal harm
2022-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-17
F · Potential for more than minimal harm
2022-08-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-14
E · Potential for more than minimal harm
2022-08-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-14
D · Potential for more than minimal harm
2022-08-17
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-09-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-28
D · Potential for more than minimal harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-26
D · Potential for more than minimal harm
2022-08-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-09-09
Penalties and ownership
What sits behind the stars
Ownership
Christensen, Covey
5% Or Greater Indirect Ownership Interest · Individual
Madison Partners Inc
5% Or Greater Direct Ownership Interest · Organization
Christensen, Covey
Operational/Managerial Control · Individual
Christensen, Covey
Corporate Officer · Individual
Clegg, Michael
Operational/Managerial Control · Individual
Madison Partners Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Sundance Skilled Nursing And Rehabilitation
Colorado Springs, CO
5-star overall rating with 4-star inspections with $50,063 in total fines with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Bear Creek Senior Living
Colorado Springs, CO
4-star overall rating with 4-star inspections with $6,614 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Healthcare Resort Of Colorado Springs, The
Colorado Springs, CO
3-star overall rating with 2-star inspections with $79,098 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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