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Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
1/5
Health inspection rating (on-site)
inspected Aug 15, 2024
7
Serious findings on record
most recent Apr 22, 2025
$86,723
Fines, last 3 years
3.44
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
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 quality measures from resident assessments and claims.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Feb 4, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Apr 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: May 14, 2025 (Deficient, Provider has date of correction)
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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Sep 12, 2024 (Deficient, Provider has date of correction)
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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Mar 10, 2023 (Deficient, Provider has date of correction)
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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 12, 2021 (Deficient, Provider has date of correction)
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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 12, 2021 (Deficient, Provider has date of correction)
Inspection findings in the public record
Showing the latest 3 of 26 inspection findings. Open the full record below to read every finding.
E · Potential for more than minimal harm, pattern
The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaintF-0925
G · Actual harm, isolated
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 complaintF-0684
J · Immediate jeopardy, isolated
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaintF-0689
View all 26 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
Date
Severity
What the facility was cited for
Jun 16, 2026
E · Potential for more than minimal harm, pattern
The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint · F-0925
Apr 22, 2025
▲ G · Actual harm, isolated
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 · F-0684
Feb 13, 2025
▲ J · Immediate jeopardy, isolated
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 · F-0689
Aug 15, 2024
▲ G · Actual harm, isolated
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Aug 15, 2024
E · Potential for more than minimal harm, pattern
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. · F-0561
Aug 15, 2024
E · Potential for more than minimal harm, pattern
The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · F-0565
Aug 15, 2024
E · Potential for more than minimal harm, pattern
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584
Aug 15, 2024
E · Potential for more than minimal harm, pattern
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. · F-0677
Aug 15, 2024
E · Potential for more than minimal harm, pattern
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. · F-0761
Aug 15, 2024
D · Potential for more than minimal harm, isolated
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. · F-0550
Aug 15, 2024
D · Potential for more than minimal harm, isolated
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. · F-0558
Aug 15, 2024
D · Potential for more than minimal harm, isolated
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. · F-0585
Aug 15, 2024
D · Potential for more than minimal harm, isolated
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658
Aug 15, 2024
D · Potential for more than minimal harm, isolated
The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · F-0660
Aug 15, 2024
D · Potential for more than minimal harm, isolated
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692
Aug 15, 2024
D · Potential for more than minimal harm, isolated
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. · F-0760
Aug 15, 2024
D · Potential for more than minimal harm, isolated
The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · F-0791
Aug 15, 2024
D · Potential for more than minimal harm, isolated
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. · F-0880
Apr 11, 2024
▲ J · Immediate jeopardy, isolated
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 · F-0689
Feb 16, 2023
▲ G · Actual harm, isolated
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
Feb 16, 2023
D · Potential for more than minimal harm, isolated
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. · F-0849
Feb 16, 2023
B · Potential for minimal harm, pattern
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. · F-0582
Oct 21, 2021
▲ G · Actual harm, isolated
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. · F-0550
Oct 21, 2021
▲ G · Actual harm, isolated
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. · F-0585
Oct 21, 2021
E · Potential for more than minimal harm, pattern
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. · F-0610
Oct 21, 2021
D · Potential for more than minimal harm, isolated
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 15).
Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2021
All citations:
4
Serious citations (G–L):
2
2023
All citations:
3
Serious citations (G–L):
1
2024
All citations:
16
Serious citations (G–L):
2
2025
All citations:
2
Serious citations (G–L):
2
2026
All citations:
1
Serious citations (G–L):
0
All bars start at zero. Exact values and supporting details remain below.
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.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
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)
Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityColorado averageU.S. average
Total nurse staffing (hours per resident per day)
This facility:
3.44
Colorado average:
3.89
U.S. average:
3.95
Registered Nurse hours
This facility:
0.49
Colorado average:
0.86
U.S. average:
0.69
Weekend total nurse staffing
This facility:
2.91
Colorado average:
3.44
U.S. average:
3.50
All bars start at zero. Exact values and supporting details remain below.
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 for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.25 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 1/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
No verified facility-specific private-pay price is available in our data for Medallion Post Acute Rehabilitation. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Before you compare prices
Request the room type, effective date and itemized daily rate in writing.
Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
All 14 owning or managing parties CMS has on file are shown — none excluded.
Other facilities in the same chain
CMS lists this facility under the chain The Ensign Group — 342 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
CMS records place this facility in El Paso, CO — 20 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Facility data as of CMS processing date 2026-08-01. CCN 065113.
This page is the printable visit checklist. If your browser did not open the print dialog automatically, use File → Print (Ctrl/⌘-P).
The Care File
Visit checklist — Medallion Post Acute Rehabilitation
1719 E Bijou St, Colorado Springs, CO 80909 · (719) 381-4963
Health inspection rating 1/5 · CMS overall 1/5· Fines (3y): $86,723
Most serious findings on record:
▲ Feb 13, 2025 (F-0689, Immediate jeopardy, isolated): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Apr 11, 2024 (F-0689, Immediate jeopardy, isolated): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Apr 22, 2025 (F-0684, Actual harm, isolated): The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Questions for the administrator:
☐ "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?"
☐ "Your weekend nurse staffing is reported below the Colorado midpoint — how does the weekend schedule differ from a weekday?"
☐ "Can I see the plan of correction for the findings in your most recent state inspection?"
☐ "CMS reports 56% total nursing staff turnover here — who on the care team has been with you longest?"
☐ "The ownership record on file lists 14 owning or managing parties — who makes the decisions about staffing levels?"
☐ "Can I visit again unannounced, at a mealtime or on a weekend?"
While you're there, notice:
☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)
Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 065113 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)