Gardens, the
104 Lois Ln, Colorado Springs, CO 80904
Gardens, the is a nursing home in Colorado Springs, Colorado. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (719) 635-2569
- Last standard health inspection
- December 11, 2025 (11 months ago)
- Certified beds
- 45
- Residents per day, on average
- 42.9
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Lois Lane Operations, LLC
- Chain
- Madison Creek Partners
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Colorado average (3 vs 25).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of March 25, 2026
Fire safety citation
CMS removed citation K0741 from the fire safety inspection on December 11, 2025.
1 citation
Health inspection on December 11, 2025
CMS lists this as a standard inspection.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 28, 2025.
10 citations
Fire safety inspection on December 11, 2025
CMS lists this as a standard inspection.
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on June 15, 2026.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on April 17, 2026.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 15, 2026.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 17, 2026.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 15, 2026.
CMS has cited this home for K0353 2 times since 2022.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 17, 2026.
CMS has cited this home for K0363 2 times since 2023.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on June 15, 2026.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on June 15, 2026.
CMS has cited this home for K0521 2 times since 2022.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on April 17, 2026.
Citation K0927. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
CMS lists it as corrected on April 17, 2026.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
1 citation
Health inspection on November 30, 2023
CMS lists this as a standard inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on December 26, 2023.
3 citations
Fire safety inspection on November 30, 2023
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on January 11, 2024.
CMS has cited this home for K0345 2 times since 2022.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 11, 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on January 11, 2024.
1 citation
Health inspection on August 17, 2022
CMS lists this as a standard inspection.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on September 9, 2022.
5 citations
Fire safety inspection on August 17, 2022
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on September 17, 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 17, 2022.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on September 14, 2022.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on September 14, 2022.
Citation K0325. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed hallway dispensers for alcohol-based hand rub.
CMS lists it as corrected on September 17, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CHIEF JOSEPH TRAIL, LLC5% or greater direct ownership interest · 100% · since 03/02/2026
- TIPPET, LLC5% or greater indirect ownership interest · no percentage provided · since 03/02/2026
- WHITE CANYON, LLC5% or greater indirect ownership interest · no percentage provided · since 03/02/2026
- CLEGG, MICHAEL5% or greater indirect ownership interest · no percentage provided · since 03/02/2026
- MADISON CREEK PARTNERS LLCOperational/managerial control · not applicable · since 11/01/2013
- CHRISTENSEN, COVEYOperational/managerial control · not applicable · since 11/01/2013
- CLEGG, MICHAELOperational/managerial control · not applicable · since 06/26/2023
- HOPKINS, AMBEROperational/managerial control · not applicable · since 12/01/2021
- IKERD, JOHNOperational/managerial control · not applicable · since 04/25/2022
- SHEPHERD, DAVIDOperational/managerial control · not applicable · since 12/19/2019
- WEST, DILLONOperational/managerial control · not applicable · since 05/13/2024
Questions
When was Gardens, the last inspected?
CMS lists December 11, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Gardens, the have?
CMS lists 3 health citations since August 17, 2022. CMS also calls these deficiencies.
Has Gardens, the been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Gardens, the?
Its CMS overall star rating is 5 of 5.
Is Gardens, the a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.
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- Life Care Center of Colorado Springs