Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MEDALLION POST ACUTE REHABILITATION
COLORADO SPRINGS, CO · 60 certified beds · Last Life Safety survey August 15, 2024
CMS Certification Number 065113 · first certified September 1970
Ownership
Operated by THE ENSIGN GROUP · For profit - Limited Liability company
- Ownership changed July 1, 2017 (change of ownership)from CHI LIVING COMMUNITIES
Position within CO
22 citations — more than 66% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 12 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (January 2026 to August 2026). Most CO facilities have been surveyed by October 2026. This facility’s last Life Safety survey was August 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-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.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 21, 2021 | 4 |
| February 16, 2023 | 6 |
| August 15, 2024 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2024-08-15 |
| K-0293 | Have properly located and lighted "Exit" signs. | 3 | 2024-08-15 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-08-15 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-08-15 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2024-08-15 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2021-10-21 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-08-15 |
| K-0133 | Install a two-hour-resistant firewall separation. | 1 | 2024-08-15 |
What the citations cover
- Smoke Deficiencies 12
- Egress Deficiencies 5
- Services Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Egress Deficiencies | 5 |
| Services Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 15, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (October 15, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 15, 2024) |
February 16, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (May 14, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 14, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (May 14, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 14, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 14, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (May 15, 2023) |
October 21, 2021 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 15, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 30, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 5, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 27, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.