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
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing
LPN hours / resident day
0.30
Licensed practical nurse staffing
Aide hours / resident day
1.82
Nurse aide staffing
Weekend hours
2.50
Weekend nurse staffing
RN turnover
70%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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