01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-11 | 1 | 2025-12-11 | 10 |
| Cycle 2 | 2023-11-30 | 1 | 2023-11-30 | 3 |
| Cycle 3 | 2022-08-17 | 1 | 2022-08-17 | 5 |
CMS CCN 0651982026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Gardens, The
104 Lois Ln · Colorado Springs, CO 80904 · El Paso County
Certified beds45CMS provider file
Recent citation rows21current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
21 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-11 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-12-282025-12-11 · FIREK0161Severity F · widespread; potential for more than minimal harm
Construction Deficiencies
Use approved construction type or materials.
Correction field: Deficient, Provider has plan of correction · 2026-06-152025-12-11 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2026-04-172025-12-11 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has plan of correction · 2026-06-152025-12-11 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2026-04-172025-12-11 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has plan of correction · 2026-06-152025-12-11 · FIREK0363Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2026-04-172025-12-11 · FIREK0372Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has plan of correction · 2026-06-152025-12-11 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has no plan of correction · 2026-06-152025-12-11 · FIREK0711Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Correction field: Deficient, Provider has date of correction · 2026-04-172025-12-11 · FIREK0927Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Correction field: Deficient, Provider has date of correction · 2026-04-172023-11-30 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2023-12-262023-11-30 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-01-112023-11-30 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-01-112023-11-30 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2024-01-112022-08-17 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2022-09-092022-08-17 · FIREK0325Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have properly installed hallway dispensers for alcohol-based hand rub.
Correction field: Deficient, Provider has date of correction · 2022-09-172022-08-17 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2022-09-172022-08-17 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2022-09-172022-08-17 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2022-09-142022-08-17 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2022-09-1403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHIEF JOSEPH TRAIL, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/02/2026
- TIPPET, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/02/2026
- WHITE CANYON, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/02/2026
- CLEGG, MICHAELIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/02/2026
- CLEGG, MICHAELIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/26/2023
- IKERD, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 03/02/2026
- MADISON CREEK PARTNERS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2013
- CHRISTENSEN, COVEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2013
- CLEGG, MICHAELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/26/2023
- HOPKINS, AMBERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2021
- IKERD, JOHNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/25/2022
- SHEPHERD, DAVIDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/19/2019
- WEST, DILLONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/13/2024
- MADISON CREEK PARTNERS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/25/2026
- CHRISTENSEN, COVEYIndividual · ADP OF THE SNFNOT APPLICABLE · since 11/01/2013
- CLEGG, MICHAELIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/26/2023
- HOPKINS, AMBERIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2021
- IKERD, JOHNIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/25/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.04per resident day
RN hours0.81per resident day
Weekend nurse hours2.65per resident day
Staff turnover56.1%CMS reported field
06 / LOCAL RECORDS
Open the Colorado Springs ledger →Other published facilities nearby
Advanced Health Care Of Colorado Springs34 beds · CMS overall 5/531 citation rowsBear Creek Senior Living45 beds · CMS overall 4/526 citation rowsBrookdale Skyline82 beds · CMS overall 5/546 citation rowsCenter At Centennial, The80 beds · CMS overall 5/537 citation rowsColonial Rehabilitation And Nursing, Llc80 beds · CMS overall 1/553 citation rowsFalcon Heights Rehabilitation And Nursing Llc107 beds · CMS overall 2/562 citation rowsFountain View Rehabilitation And Nursing Llc90 beds · CMS overall 3/525 citation rowsKiowa Hills Rehabilitation And Nursing, Llc83 beds · CMS overall 1/598 citation rows