01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-08-15 | 16 | 2024-08-15 | 12 |
| Cycle 2 | 2023-02-16 | 5 | 2023-02-16 | 6 |
| Cycle 3 | 2021-10-21 | 5 | 2021-10-21 | 4 |
CMS CCN 0651132026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Medallion Post Acute Rehabilitation
1719 E Bijou St · Colorado Springs, CO 80909 · El Paso County
Certified beds60CMS provider file
Recent citation rows48current CMS citation release
Penalty rows4current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
48 rows in the current release
7 rows carry G–L scope/severity codes; 2 carry J–L. 10 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-16 · HEALTHF0925Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has plan of correction · 2026-07-10 · complaint2025-04-22 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-05-14 · complaint2025-02-13 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2025-02-04 · complaint2024-08-15 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0561Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0565Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0660Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0791Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-08-15 · FIREK0133Severity F · widespread; potential for more than minimal harm
Construction Deficiencies
Install a two-hour-resistant firewall separation.
Correction field: Deficient, Provider has date of correction · 2024-10-152024-08-15 · FIREK0271Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2024-10-152024-08-15 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2024-10-152024-08-15 · FIREK0293Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2024-10-152024-08-15 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-10-152024-08-15 · FIREK0343Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Correction field: Deficient, Provider has date of correction · 2024-10-1503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-04-22 | Fine | $24,382 | 0 |
| 2025-02-13 | Fine | $12,617 | 0 |
| 2024-08-15 | Fine | $40,905 | 0 |
| 2024-04-11 | Fine | $8,819 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BURNAM, SOONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/09/2024
- COOK, RONALDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/10/2025
- SHEPHERD, DAVIDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/07/2022
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/09/2024
- JORGENSEN, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2017
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2017
- PORT, BARRYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2017
- COOK, RONALDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/10/2025
- BIJOU HEALTH HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/01/2022
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2017
- STANDARD BEARER HEALTHCARE OP LPOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/01/2022
- THE ENSIGN GROUP INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/01/2022
- COOK, RONALDIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/08/2025
- SHEPHERD, DAVIDIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/12/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.25per resident day
RN hours0.46per resident day
Weekend nurse hours2.75per resident day
Staff turnover55.6%CMS reported field
06 / LOCAL RECORDS
Open the Colorado Springs ledger →Other published facilities nearby
Advanced Health Care Of Colorado Springs34 beds · CMS overall 5/531 citation rowsBear Creek Senior Living45 beds · CMS overall 4/526 citation rowsBrookdale Skyline82 beds · CMS overall 5/546 citation rowsCenter At Centennial, The80 beds · CMS overall 5/537 citation rowsColonial Rehabilitation And Nursing, Llc80 beds · CMS overall 1/553 citation rowsFalcon Heights Rehabilitation And Nursing Llc107 beds · CMS overall 2/562 citation rowsFountain View Rehabilitation And Nursing Llc90 beds · CMS overall 3/525 citation rowsGardens, The45 beds · CMS overall 5/521 citation rows