Home / Colorado / Colorado Springs
104 Lois Ln, Colorado Springs, CO 80904 · El Paso County · (719) 635-2569
45 certified beds, about 43 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1984
CMS Care Compare ratings, data as of September 1, 2026 · CCN 065198 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on December 11, 2025, inspectors cited 1 health deficiency (the Colorado average is 8.7, the national average 9.2).
None of its 3 health citations since August 2022 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.04 hours per resident per day, against 3.72 across Colorado and 3.86 nationally. Registered nurses accounted for 0.81 of those hours.
56.1% of nursing staff left within the year CMS measured (Colorado average 47.1%).
CMS links it to Madison Creek Partners, an affiliated group of 13 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 3 health citations on file.
Inspectors wroteBased on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure dietary staff washed their hands and changed gloves appropriately; and,-Maintain the kitchen in a sanitary condition.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent the development and worsening of pressure injuries for one (#14) resident reviewed for pressure injuries out of 25 sample residents. Specifically, the facility failed to ensure interventions for Resident #14's pressure injury were consistently implemented.
Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#14 and #10) out of 19 sample residents were kept free from abuse. Specifically, the facility: -Failed to prevent a resident-to-resident altercation between Resident #15 and #10; -Failed to prevent a resident-to-resident altercation between Resident #15 and #14; -Failed to care plan and address the altercations involving Resident #15; and, -Failed to educate and train staff on triggers and the potential for Resident #15's aggression.
18 fire safety citations on file: 10 on December 11, 2025, 3 on November 30, 2023, 5 on August 17, 2022.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Colorado | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.04 | 3.72 | 3.86 |
| Registered nurses | 0.81 | 0.82 | 0.69 |
| All nursing staff on weekends | 2.65 | 3.29 | 3.42 |
| Nurse aides | 1.94 | ||
| Licensed practical nurses | 0.29 | ||
| Nursing staff turnover (share who left in a year) | 56.1% | 47.1% | 45.8% |
| Registered nurse turnover | 58.3% | 44.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 2.88 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.20 on weekdays and 2.65 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.3% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.88 in April to June 2025 to 3.04 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.04 | 0.81 | 3.20 | 2.65 | 2.3% | 0 of 90 | 43 |
| Oct to Dec 2025 | 2.97 | 0.84 | 3.15 | 2.52 | 3.0% | 0 of 92 | 43 |
| Jul to Sep 2025 | 2.91 | 0.79 | 3.07 | 2.50 | 3.8% | 0 of 92 | 44 |
| Apr to Jun 2025 | 2.88 | 0.72 | 3.06 | 2.42 | 5.2% | 0 of 91 | 44 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Colorado, Jan to Mar 2026 | 3.59 | 0.76 | 3.75 | 3.18 | 5.9% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Colorado, all employers | |||
| CNAs (nursing assistants) | $22.78 | $21.42 to $24.00 | 22,240 |
| LPNs and LVNs | $35.52 | $29.76 to $38.37 | 4,920 |
| Registered nurses | $48.20 | $40.67 to $52.37 | 54,490 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Colorado | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 8.5 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.6 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.3 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.9 | 3.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.7 | 1.6 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 8.7 | 13.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.2 | 3.4 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.7 | 20.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.8 | 20.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.3 | 12.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 1.4 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.5 | 1.7 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Gardens, the's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (51.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
51.4% this home
No different from the national rate
US median of homes 51.5% · Colorado: 39 better, 8 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 35 eligible stays.
9.5% this home
No different from the national rate
US median of homes 10.7% · Colorado: 3 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 40 eligible stays.
6.7% this home
No different from the national rate
US median of homes 7.1% · Colorado: 4 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 39 eligible stays.
63.0% this home
Median of homes: Colorado65.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 27 residents counted.
2.7% this home
Median of homes: Colorado0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 37 residents counted.
0.0% this home
Median of homes: Colorado0.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 37 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Colorado99.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 12 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: LOIS LANE OPERATIONS, LLC. CMS links this home to Madison Creek Partners, a group of 13 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Chief Joseph Trail, LLC | 5% or greater direct ownership interest | Organization | 100% | 03/02/2026 |
| Tippet, LLC | 5% or greater indirect ownership interest | Organization | 03/02/2026 | |
| White Canyon, LLC | 5% or greater indirect ownership interest | Organization | 03/02/2026 | |
| Clegg, Michael | 5% or greater indirect ownership interest | Individual | 03/02/2026 | |
| Clegg, Michael | Managing control - governing body | Individual | 06/26/2023 | |
| Ikerd, John | Managing control - governing body | Individual | 03/02/2026 | |
| Madison Creek Partners LLC | Operational/managerial control | Organization | 11/01/2013 | |
| Christensen, Covey | Operational/managerial control | Individual | 11/01/2013 | |
| Clegg, Michael | Operational/managerial control | Individual | 06/26/2023 | |
| Hopkins, Amber | Operational/managerial control | Individual | 12/01/2021 | |
| Ikerd, John | Operational/managerial control | Individual | 04/25/2022 | |
| Shepherd, David | Operational/managerial control | Individual | 12/19/2019 | |
| West, Dillon | Operational/managerial control | Individual | 05/13/2024 | |
| Madison Creek Partners LLC | Adp of the SNF | Organization | 03/25/2026 | |
| Christensen, Covey | Adp of the SNF | Individual | 11/01/2013 | |
| Clegg, Michael | Adp of the SNF | Individual | 06/26/2023 | |
| Hopkins, Amber | Adp of the SNF | Individual | 12/01/2021 | |
| Ikerd, John | Adp of the SNF | Individual | 04/25/2022 | |
| Shepherd, David | Adp of the SNF | Individual | 12/19/2019 | |
| West, Dillon | Adp of the SNF | Individual | 05/13/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Colorado. NursingHomeClear cannot take or act on complaints.