Mount St Francis Nursing Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 83 Google reviews

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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (2/5 stars)
- High staff turnover (50%)
Below average in CO · Meets national RN staffing standard · Above recommended total nurse staffing · Below chain average · No penalties on record · Abuse citation
What this means for your family
While the facility is widely praised for its beautiful setting and dedicated rehab team, there are recurring, serious reports of medical neglect and administrative failures. Families should conduct a thorough tour, ask specifically about the facility's medical oversight protocols, and ensure they have a clear, reliable point of contact before committing to residency.
Google Reviews
Google Reviews
83 reviews on Google“Mount St. Francis Nursing Center is frequently praised for its beautiful, serene, and clean facility, with many families expressing gratitude for the compassionate care provided to their loved ones. However, there are significant, recurring reports of poor administrative communication, management issues, and concerns regarding staffing levels and medical oversight that potential families should investigate thoroughly.”
Quality Themes
Tap a score for detailsStrengths
- Beautiful, serene, and well-maintained facility
- Kind and compassionate nursing and CNA staff
- Excellent physical therapy services
- Faith-based, mission-oriented environment
Concerns
- Poor administrative communication and unprofessional admissions process (mentioned by 4 reviewers)
- Understaffing and high staff turnover (mentioned by 3 reviewers)
- Serious medical neglect or medication management errors (mentioned by 3 reviewers)
- Management structure issues and poor staff treatment (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 84 analyzed
How They Respond to Reviews
This facility rarely responds to reviews.
Questions for Your Tour
- 1Given the facility's beautiful, mission-oriented environment, how do you integrate the faith-based values into the daily activities and spiritual support for residents?
- 2I noticed the CMS health inspection rating is currently a 2/5; what specific steps is the leadership team taking to address those findings and improve the quality of care?
- 3Could you walk me through the current process for family communication, specifically how you ensure updates reach us promptly regarding changes in a resident's health or care plan?
- 4With medication management being a critical part of resident safety, what protocols and double-check systems do you have in place to ensure accuracy and prevent errors?
- 5How does the facility handle staff retention and training to ensure that the compassionate care mentioned by many families remains consistent despite industry-wide turnover challenges?
- 6In the event of a medical emergency, what is the immediate chain of communication to ensure family members are notified and involved in the decision-making process?
Personalized based on this facility's data
Key Review Excerpts
“The physical therapy staff was excellent and the cna staff was kind and thorough. The food was delicious and ample.”
“I can rest at night knowing my mom is loved and cared for every day. I'm a frequent visitor and anytime I show up I'm always thankful for being able to visit knowing the level of care she is being given.”
“My mom almost died in here if i didnt visit her when i did she wouldve died that nite i had an ambulance there immediately 5 hours in ER and 7 days in hospital her oxygen level was 70 and they didnt even put her on oxygen”
Staffing
Staffing Hours
per resident/day · Medicare 2026Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
6
measures
5
measures
6
measures
Residents needing more daily help over time
Residents whose walking got worse
Residents whose bladder or bowel control got worse
Residents vaccinated for pneumonia
Residents vaccinated for the flu
Residents who fell and were seriously hurt
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Mount St Francis Nursing Center shows concerning patterns with families filing multiple complaints triggering inspections, including serious issues around resident protection from abuse and neglect that recurred across surveys. The facility has struggled most with infection control, emergency preparedness, and nutrition/dietary services. While all deficiencies show correction dates, the repeated complaint-driven investigations and recurring protection concerns warrant careful consideration during any visit.
Mar 6, 2025Routine7
Emergency Preparedness Deficiencies
Establish an Emergency Preparedness Program (EP).
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Mar 6, 2025Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Nov 30, 2023Complaint2
Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Aug 17, 2023Routine6
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Aug 17, 2023Complaint4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Aug 15, 2019Routine3
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
State Inspection History
State Inspections
Source: CO Dept. of Public Health & Environment
Sep 15, 2025Follow-upCleanReport
No deficiencies found during this inspection.
May 5, 2025ComplaintCleanReport
No deficiencies found during this inspection.
Mar 25, 2025Routine
Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.Difienceint items were confirmed with the maintenance team during the survey1.Fire Alarm Panel showing ground fault troubleNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complyi.. Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:Difienceint items were confirmed with the maintenance team during the survey1. Polarity retention report lists multiple receptacles as failed retention testing NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Ca.. Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: Difienceint items were confirmed with the maintenance team during the survey1. Fuel report for generator shows fuel failed8.1.1 The routine Maintenance and operational testing program shal.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101.Difienceint items were confirmed with the maintenance team during the survey1.Self closures need to repaired on doors for both transfer rooms garden level2. Storage needs to be removed from concealed space on garden level8.7.1.1* Protection from any area having a degree of hazard gr.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. Difienceint items were confirmed with the maintenance team during the survey1. Penetrations were found in 3rd-floor lounge firewall (3-hour), above corridor fire doors 3 floor and 2nd-floor dining room, and above the corridor barrier. Barriers should be repaired to maintain their listed r.. Based on observation, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. Difienceint items were confirmed with the maintenance team during the survey1. Commercial stove needs an approved device to return to its original position after cleaning2. Information on tag inspection suppression missing fusible links temperature and date changedNFPA 96, 12.1.2.3 The fire-extinguishing system shall .. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101Difienceint items were confirmed with the maintenance team during the survey1. Sprinkler Gauges Outdated2. Anti-freeze in open house written a deficiency on annual sprinkler report3. FDC needs to identify to which facility they serve4. No general infor.. This survey was conducted in accordance with the Federal Register at Section 42 CFR § 483.90The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility' s general characteristics.This facility is a three-story, Type II (111) structure with a garden level basement and a penthouse. The residents use the basement for the beauty shop and the massage room. The basement and the penthouse contain offices and su.. Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1Difienceint items were confirmed with the maintenance team during the survey1. Emergency lighting 30sec monthly inspection not available for review2. Exit lighting 30sec monthly inspection not available for review3. Exit lighting 90min annual inspection not available for review4 .Exit lighting ove..
Mar 6, 2025Complaint
A recertification survey with complaint #CO38668, #CO38670, #CO38703, #CO39273 and Incident #39413 was completed on 3/3/25 to 3/6/25. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 3/3/25 to 3/6/25. Four deficiencies were cited. Based on interviews and record review, the facility failed to initiate an appropriate facility-initiated discharge for one (#58) of three residents reviewed for appropriate discharge out of 32 sample residents. Specifically, the facility failed to:-Complete an assessment with attempted interventions prior to giving the resident a discharge notice; and,-Ensur.. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment for residents to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to:-Ensure staff wore the appropriate per.. Based on observations, record review and interview, the facility failed to develop and implement emergency preparedness policies and procedures based on the emergency plan that identified the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: food, .. Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in one of three medication storage rooms and three of three medication storage carts.Specifically, the facility failed to:-Ensure medications were labeled with the date they were opened; and,-Ensure expired or discontinued medicatio.. Based on record review and interview, the facility failed to develop and maintain an up-to-date emergency preparedness training and testing program that was based on the facility' s emergency preparedness (EP) program plan, annual risk assessment, facility EP policies and procedures and the communication plan that was delivered to all staf.. Based on record review and interview, the facility failed to establish and maintain a comprehensive emergency preparedness (EP) program that met all of the standards specified within the condition/requirement. To include a comprehensive approach to meeting the health, safety, and security needs of their staff and patient population durin.. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNA).Specifically, the facility to complete regular in-service education based on the o.. Based on record review and interviews, the facility failed to conduct two exercises annually to test the facility' s emergency plan and maintain documentation of the facility' s response to all drills, tabletop exercises, and emergency events, and then revise the facility' s emergency plan, as needed.Specifically, the facility failed to:-Participate in a c.. Based on record review and interviews, the facility failed to ensure one (#16) of two residents reviewed for abuse out of 46 sample residents was free from abuse. Specially, the facility failed to protect Resident #16 from sexual abuse by Resident #58.Findings include:I. Incident of sexual abuse between Resident #16 and Resident #58 on 11/14/..
Jul 29, 2024ComplaintCleanReport
No deficiencies found during this inspection.
Mar 21, 2024ComplaintCleanReport
No deficiencies found during this inspection.
Feb 8, 2024ComplaintCleanReport
No deficiencies found during this inspection.
Dec 4, 2023Follow-upCleanReport
No deficiencies found during this inspection.
Ownership & Operations
Who Operates This Facility
Mount St Francis Nursing Center
nonprofit
Chain Affiliation
Commonspirit Health
19 facilities nationwide
Chain avg rating: 3.0/5 · Rank 12 of 19
Ownership & Management
Owners
Commonspirit Health
Owner · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
83 reviews from families & visitors
Official Website
Visit mountain.commonspirit.org
Medicare data downloads
Original nursing home datasets
CO CDPHE — View Official Record
Public-record source of inspection history and licensure data shown on this page
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