Medallion Post Acute Rehabilitation
1719 E Bijou St, Colorado Springs, CO 80909 · El Paso County · 60 certified beds · avg 58 residents/day · certified since Sep 21, 1970
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Feb 13, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 4, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Apr 11, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 22, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 14, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 15, 2024 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 12, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 16, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 10, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 21, 2021 · F-0550
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Why it matters: Being treated without dignity harms a resident's self-worth, mental health, and overall quality of life.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 12, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 21, 2021 · F-0585
The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Why it matters: Residents may stay silent about real problems out of fear, or complain and see nothing change.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 12, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (26)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 16, 2026 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Apr 22, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 13, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 15, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 11, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 16, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 16, 2023 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Feb 16, 2023 | B · Minimal risk, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Oct 21, 2021 | ▲ G · Actual harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Oct 21, 2021 | ▲ G · Actual harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Oct 21, 2021 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Oct 21, 2021 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 15).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 4 | 2 | G ▲ |
| 2023 | 3 | 1 | G ▲ |
| 2024 | 16 | 2 | J ▲ |
| 2025 | 2 | 2 | J ▲ |
| 2026 | 1 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $86,723.
| Date | Type | Amount / length |
|---|---|---|
| Apr 22, 2025 | Fine | $24,382 |
| Feb 13, 2025 | Fine | $12,617 |
| Aug 15, 2024 | Fine | $40,905 |
| Apr 11, 2024 | Fine | $8,819 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.44 | 3.89 | 3.95 | bottom 33% in Colorado; bottom 34% in the U.S. |
| Registered Nurse hours | 0.49 | 0.86 | 0.69 | bottom 10% in Colorado; bottom 36% in the U.S. |
| Weekend total nurse staffing | 2.91 | 3.44 | 3.50 | bottom 23% in Colorado; bottom 26% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.61 | 0.48 | bottom 6% in Colorado; bottom 31% in the U.S. |
| Total nursing staff turnover (%) | 55.6 | 47.1 | 45.8 | bottom 24% in Colorado; bottom 24% in the U.S. |
| RN turnover (%) | 55.6 | 44.6 | 42.9 | bottom 27% in Colorado; bottom 28% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.25, RN 0.46, weekend 2.75. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bijou Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| Burnam, Soon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/09/2024 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Cook, Ronald | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/10/2025 |
| Cook, Ronald | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/10/2025 |
| Cook, Ronald | Individual | ADP of the SNF | NOT APPLICABLE | 04/08/2025 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2017 |
| Jorgensen, David | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2017 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2017 |
| Port, Barry | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2017 |
| Shepherd, David | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/07/2022 |
| Shepherd, David | Individual | ADP of the SNF | NOT APPLICABLE | 04/12/2025 |
| Standard Bearer Healthcare Op LP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Advanced Health Care of Colorado Springs | 1.1 mi | Colorado Springs, CO | ★★★★★ | 5/5 | |
| Life Care Center of Colorado Springs | 1.2 mi | Colorado Springs, CO | ★★★★★ | 4/5 | |
| Sunny Vista Living Center | 1.3 mi | Colorado Springs, CO | ★★★☆☆ | 3/5 | |
| Fountain View Rehabilitation and Nursing LLC | 1.7 mi | Colorado Springs, CO | ★★★☆☆ | 3/5 | |
| Kiowa Hills Rehabilitation and Nursing, LLC | 2.1 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | |
| Falcon Heights Rehabilitation and Nursing LLC | 2.3 mi | Colorado Springs, CO | ★★☆☆☆ | 2/5 | abuse |
| Pikes Peak Post Acute | 2.4 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | abuse |
| Colonial Rehabilitation and Nursing, LLC | 2.6 mi | Colorado Springs, CO | ★☆☆☆☆ | 2/5 | abuse |
| Springs Village Care Center | 2.7 mi | Colorado Springs, CO | ★★☆☆☆ | 2/5 | |
| Mountain View Post Acute | 2.9 mi | Colorado Springs, CO | ★★☆☆☆ | 1/5 | abuse |
| Bear Creek Senior Living | 3.2 mi | Colorado Springs, CO | ★★★★☆ | 4/5 | |
| The Healthcare Resort of Colorado Springs | 3.7 mi | Colorado Springs, CO | ★★★☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 065113.