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

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.44

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.98

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

1.82

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.24

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.42

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

2.72

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.25

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.22

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.47

CMS adjusted RN staffing hours

Adjusted total hours

3.42

CMS adjusted total nurse staffing hours

Case-mix index

1.30

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

63%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,717

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

15.61

Composite VBP score used to determine payment impact.

Payment multiplier

0.9815

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.53% · Performance 21.82% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

4.41

Baseline 6.35% · Performance 6.52% · Measure score 4.41 · Achievement 4.41 · Improvement 0

Total nurse turnover

Baseline 62.50% · Performance 71.23% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

1.84

Baseline 3.81 hours · Performance 3.6 hours · Measure score 1.84 · Achievement 1.84 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.49%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 113 · Observed rate 10.62% · Lower 95% interval 7.72%
Discharge to community	39.28%	50.57% 11.3 pts worse	Worse than the National Rate · Eligible stays 94 · Observed rate 30.85% · Lower 95% interval 30.21%
Medicare spending per beneficiary	1.2	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 57 · Denominator 57
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 57
Discharge self-care score	39.53%	53.69% 14.2 pts worse	Numerator 17 · Denominator 43
Discharge mobility score	37.21%	50.94% 13.7 pts worse	Numerator 16 · Denominator 43
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 57 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.52%	7.12% 0.6 pts better	No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.36%
Staff COVID-19 vaccination coverage	2.99%	8.2% 5.2 pts worse	Numerator 4 · Denominator 134
Staff flu vaccination coverage	26.6%	42% 15.4 pts worse	Numerator 54 · Denominator 203
Discharge function score	46.51%	56.45% 9.9 pts worse	Numerator 20 · Denominator 43
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	21.43%	25.2% 3.8 pts worse	Numerator 6 · Denominator 28

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 · Adjusted 2.2 · Observed 2.6 · Expected 2.2 · Used in QM five-star
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 · Adjusted 2.3 · Observed 2.3 · Expected 1.7 · Used in QM five-star
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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 · 4Q avg 88.2%
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 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
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 · Q1 8.9% · Q2 7.1% · Q3 9.3% · Q4 11.1% · 4Q avg 9.1%
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 · Q1 2.4% · Q2 0.0% · Q3 3.0% · Q4 11.9% · 4Q avg 4.6%
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 · Q1 8.9% · Q2 5.4% · Q3 5.4% · Q4 4.7% · 4Q avg 6.2%
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 · Q1 6.5% · Q2 3.6% · Q3 3.7% · Q4 8.6% · 4Q avg 5.8% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · 4Q avg 18.3% · Used in QM five-star
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 · Q1 8.9% · Q2 27.0% · Q3 32.4% · Q4 25.0% · 4Q avg 22.6% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
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 · Q1 23.2% · Q2 36.4% · Q3 13.4% · Q4 24.8% · 4Q avg 24.5%
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 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 6.2% · 4Q avg 2.8% · Used in QM five-star
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 · Q1 100.0% · Q2 98.6% · Q3 98.4% · Q4 100.0% · 4Q avg 99.2%
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 · Adjusted 18.6% · Observed 21.9% · Expected 13.1% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 4.3% · 4Q avg 1.8% · Used in QM five-star
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 · 4Q avg 94.2%
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 · Adjusted 13.7% · Observed 15.6% · Expected 27.1% · Used in QM five-star

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