SNF

MEDALLION POST ACUTE REHABILITATION

CCN: 065113 · COLORADO SPRINGS, CO 80909 · El Paso County

ℹ CCRC

Overview

Address
1719 E BIJOU ST, COLORADO SPRINGS, CO 80909
Phone
7193814963
Certified beds
60
Avg daily residents
57 (95% of beds filled)
Ownership
For-profit LLC
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1970-09-21
Setting
Urban
1 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 1/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 1/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 4/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 5/5
Short-Stay Quality Measures ★★★★★ 3/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 3.24 3.66 3.42 ≥ 3.48 Below floor
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 0.44 0.64 0.47 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 0.98 0.81 1.03 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 1.82 2.21 1.92 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 1.42 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.22 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
2.72
hrs / resident / day
RN (weekend)
0.25
hrs / resident / day
Total nurse (adjusted, weekend)
2.87
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
63.1%
annual
RN turnover
60.0%
annual
Administrators departed
New facility — insufficient data.

Resident acuity

Nursing Case-Mix Index
1.30
higher acuity than avg
Case-Mix Index Ratio
0.94
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2024-08-15 16 15 1 116 1 116
Cycle 2/3 (prior) 2023-02-16 5 3 2 119 1 119
Total weighted health score
116.8
lower is better

Deficiencies (25)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

1 A/B/C No actual harm — minor
17 D/E/F Actual harm — potential for minor
5 G/H/I Actual harm
2 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. G 2025-04-22 2025-05-14
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2025-02-13 2025-02-04
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. D 2024-08-15 2024-09-12
0558 Reasonably accommodate the needs and preferences of each resident. D 2024-08-15 2024-09-12
0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. E 2024-08-15 2024-09-12
0565 Honor the resident's right to organize and participate in resident/family groups in the facility. E 2024-08-15 2024-09-12
0584 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. E 2024-08-15 2024-09-12
0585 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. D 2024-08-15 2024-09-12
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2024-08-15 2024-09-12
0660 Plan the resident's discharge to meet the resident's goals and needs. D 2024-08-15 2024-09-12
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. E 2024-08-15 2024-09-12
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. G 2024-08-15 2024-09-12
0692 Provide enough food/fluids to maintain a resident's health. D 2024-08-15 2024-09-12
0760 Ensure that residents are free from significant medication errors. D 2024-08-15 2024-09-12
0761 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. E 2024-08-15 2024-09-12
0791 Provide or obtain dental services for each resident. D 2024-08-15 2024-09-12
0880 Provide and implement an infection prevention and control program. D 2024-08-15 2024-09-12
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2024-04-11 2024-04-17
0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. B 2023-02-16 2023-03-10
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. G 2023-02-16 2023-03-10
0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. D 2023-02-16 2023-03-10
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. G 2021-10-21 2021-11-12
0584 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. D 2021-10-21 2021-11-12
0585 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. G 2021-10-21 2021-11-12
0610 Respond appropriately to all alleged violations. E 2021-10-21 2021-11-12

Penalties (4)

Fines issued
4
last 3 years
Total fines
$86,723
Date Type Fine amount
2024-04-11 Fine $8,819
2025-02-13 Fine $12,617
2025-04-22 Fine $24,382
2024-08-15 Fine $40,905

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 20.2% Medicaid 57.8% Other 22.0%

Operating performance

Operating Margin
13.3%
Total Margin
13.8%
Occupancy Rate
94.5%
Cost per Resident Day
$106

Revenue & costs

Net Patient Revenue
$10.0M
Total Costs
$2.2M
Net Income
$1.4M

Balance sheet

Total Assets
$8.7M
Total Liabilities
$837K
Fund Balance
$7.8M
Current Ratio
10.19

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: THE ENSIGN GROUP

Chain ID
507
Facilities in chain
329
Legal business name
BIJOU HEALTHCARE LLC
Chain-average star ratings (for peer context)
Overall
3.2
Health
2.9
Staffing
2.7
QM
4.3

Owner / manager organizations (2)

Organization Role Association
ENDURA HEALTHCARE LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 12/21/2016
THE ENSIGN GROUP INC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 07/01/2017

Owner / manager individuals (5)

Name Role Association
COOK, RONALD OPERATIONAL/MANAGERIAL CONTROL since 01/10/2025
BURNAM, SOON CORPORATE OFFICER since 09/09/2024
JORGENSEN, DAVID CORPORATE OFFICER since 07/01/2017
KEETCH, CHAD CORPORATE OFFICER since 07/01/2017
PORT, BARRY CORPORATE OFFICER since 07/01/2017

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
Yes
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

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Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $106 metrics.cost_per_resident_day
Cost Report Current Ratio 10.19 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 57.8% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 20.2% metrics.medicare_day_share
Cost Report Net Income ($) $1,380,146 metrics.net_income
Cost Report Net Patient Revenue ($) $9,953,247 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 94.5% metrics.occupancy_rate
Cost Report Operating Margin (%) 13.3% metrics.operating_margin
Cost Report Total Assets ($) $8,676,989 metrics.total_assets
Cost Report Total Costs ($) $2,194,314 metrics.total_costs
Cost Report Total Fund Balances ($) $7,839,669 metrics.fund_balance
Cost Report Total Liabilities ($) $837,320 metrics.total_liabilities
Cost Report Total Margin (%) 13.8% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 1.03447 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 1.91780 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.46692 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.41920 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 2.86984 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote 26 Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 57.0 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.81155 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.20561 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.63968 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.65684 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.22312 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.9 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 3.2 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 4.3 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 2.7 Chain Average Staffing Rating
Provider Information Chain ID 507 Chain ID
Provider Information Chain Name THE ENSIGN GROUP Chain Name
Provider Information City/Town COLORADO SPRINGS City/Town
Provider Information CMS Certification Number (CCN) 065113 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community Y Continuing Care Retirement Community
Provider Information County/Parish El Paso County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1970-09-21 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 38.8358 Latitude
Provider Information Legal Business Name BIJOU HEALTHCARE LLC Legal Business Name
Provider Information Location 1719 E BIJOU ST,COLORADO SPRINGS,CO,80909 Location
Provider Information Long-Stay QM Rating 5 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -104.8 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home — Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 60 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 329 Number of Facilities in Chain
Provider Information Number of Fines 4 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.29545 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.94034 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 1 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type For profit - Limited Liability company Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 1719 E BIJOU ST Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name MEDALLION POST ACUTE REHABILITATION Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 200 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 4 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 116 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 1 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 15 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2024-08-15 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 116 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 16 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 3 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2023-02-16 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 119 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 2 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 119 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 5 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.25111 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 60.0 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.42203 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.97979 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 1.81643 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.21829 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.44224 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.23846 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 3 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 1 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State CO State
Provider Information Telephone Number 7193814963 Telephone Number
Provider Information Total Amount of Fines in Dollars 86723.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 2.71814 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 4 Total Number of Penalties
Provider Information Total nursing staff turnover 63.1 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 116.750 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 80909 ZIP Code