Colorado Springs, CO

Medallion Post Acute Rehabilitation

1-star overall rating with 1-star inspections with $86,723 in total fines with 16 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle

1719 E Bijou St, Colorado Springs, CO

(719) 381-4963

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

1970-09-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.44

Registered nurse staffing

LPN hours / resident day

0.98

Licensed practical nurse staffing

Aide hours / resident day

1.82

Nurse aide staffing

Weekend hours

2.72

Weekend nurse staffing

RN turnover

60%

Annual RN turnover

Total nurse turnover

63%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.2	1.3 0.9 pts worse	1.9 0.3 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	2.3	1.7 0.6 pts worse	1.8 0.5 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	88.2%	94.7% 6.5 pts worse	95.5% 7.3 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	0.5%	3.4% 2.9 pts better	3.3% 2.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	9.1%	7.4% 1.7 pts worse	11.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	4.6%	5.0% 0.4 pts better	5.4% 0.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.2%	11.2% 5 pts better	19.6% 13.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	5.8%	20.6% 14.8 pts better	16.7% 10.9 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	18.3%	15.2% 3.1 pts worse	16.3% 2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	22.6%	14.6% 8 pts worse	14.9% 7.7 pts worse	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	0.6%	1.5% 0.9 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.5%	22.4% 2.1 pts worse	19.8% 4.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	2.8%	3.7% 0.9 pts better	5.1% 2.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.2%	76.4% 22.8 pts better	81.7% 17.5 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	18.6%	12.8% 5.8 pts worse	12.0% 6.6 pts worse	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	1.8%	1.5% 0.3 pts worse	1.6% 0.2 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.2%	75.6% 18.6 pts better	79.7% 14.5 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	13.7%	20.3% 6.6 pts better	23.9% 10.2 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-15 · Fire 2024-08-15

16 health deficiencies

Top issue: Resident Rights (6 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2023-02-16 · Fire 2023-02-16

5 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2021-10-21 · Fire 2021-10-21

4 health deficiencies

Top issue: Resident Rights (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-08-15

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2024-10-15

F · Potential for more than minimal harm 2024-08-15

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-10-15

F · Potential for more than minimal harm 2024-08-15

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-10-15

F · Potential for more than minimal harm 2024-08-15

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-10-15

F · Potential for more than minimal harm 2024-08-15

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2024-10-15

F · Potential for more than minimal harm 2024-08-15

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-10-15

F · Potential for more than minimal harm 2024-08-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-15

F · Potential for more than minimal harm 2024-08-15

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-10-15

F · Potential for more than minimal harm 2024-08-15

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-10-15

E · Potential for more than minimal harm 2024-08-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-10-15

E · Potential for more than minimal harm 2024-08-15

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-10-15

E · Potential for more than minimal harm 2024-08-15

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-10-15

F · Potential for more than minimal harm 2023-02-16

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-05-14

F · Potential for more than minimal harm 2023-02-16

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-05-14

F · Potential for more than minimal harm 2023-02-16

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-05-15

E · Potential for more than minimal harm 2023-02-16

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-05-14

D · Potential for more than minimal harm 2023-02-16

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-05-14

D · Potential for more than minimal harm 2023-02-16

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-05-14

F · Potential for more than minimal harm 2021-10-21

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2021-11-30

F · Potential for more than minimal harm 2021-10-21

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2021-11-27

E · Potential for more than minimal harm 2021-10-21

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2021-12-15

D · Potential for more than minimal harm 2021-10-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-12-05

Inspection history

Recent health citations

G · Actual harm 2025-04-22

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-05-14

J · Immediate jeopardy 2025-02-13

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-02-04

G · Actual harm 2024-08-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-09-12

E · Potential for more than minimal harm 2024-08-15

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-09-12

E · Potential for more than minimal harm 2024-08-15

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-09-12

E · Potential for more than minimal harm 2024-08-15

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-09-12

E · Potential for more than minimal harm 2024-08-15

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-09-12

E · Potential for more than minimal harm 2024-08-15

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-09-12