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Nursing HomeMedicaid Investigative

Mount St Francis Nursing Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

7550 Assisi Hts, Northwest Colorado Springs · Colorado Springs, CO 80919110 bedsLicensed & Active
Source: CO CDPHE — view official record
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.1/5

based on 83 Google reviews

5
4
3
2
1
Mount St Francis Nursing Center Nursing Home in Colorado Springs, CO — Street View
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5/ 10
high Risk

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

Source: Medicare data

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 details
Food8.0Staff6.0Clean9.0Activities7.0Meds2.0Memory7.0Comms3.0ValueN/A

Strengths

  • 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

234'16(3)'18(16)'20(15)'22(11)'24(1)'25(4)

Distribution · 84 analyzed

5
54
4
10
3
6
2
3
1
11

How They Respond to Reviews

13%response rate

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.

Rehab patient · 2021★★★★

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.

Memory care family member · 2020★★★★★

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

Long-term resident's family · 2023☆☆☆☆
Source: 83 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
1.20hrs
OK
Registered nurses for medical care
Total Nursing
3.91hrs
95%
All nurses + aides combined
Staff Turnover
50%
Lower is better (< 30% = good)
RN Turnover
39%
Lower is better (< 30% = good)

Total 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

Medicare Rating
2/ 5
Better Than Avg

6

measures

Worse Than Avg

5

measures

Mixed Results

6

measures

Long-Stay Residents
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility32.5%
Worse than Avg
Here
32.5%
US
14.4%
CO
13.8%
El paso
15.2%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility26.4%
Worse than Avg
Here
26.4%
US
15.3%
CO
14.4%
El paso
14.6%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility26.2%
Worse than Avg
Here
26.2%
US
19.4%
CO
21.7%
El paso
16.8%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.7%
Better than Avg
Here
99.7%
US
93.4%
CO
93.6%
El paso
94.8%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
95.5%
CO
94.7%
El paso
94.5%
⚠️

Residents who fell and were seriously hurt

↓ Lower is better
This Facility7.0%
Worse than Avg
Here
7.0%
US
3.2%
CO
3.4%
El paso
2.6%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility88.3%
Better than Avg
Here
88.3%
US
81.8%
CO
76.3%
El paso
82.9%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility85.2%
Better than Avg
Here
85.2%
US
79.7%
CO
75.6%
El paso
82.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility3.7%
Worse than Avg
Here
3.7%
US
1.6%
CO
1.5%
El paso
2.7%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

5deficiencies
Near state avg (8.8)
8 complaint-triggered

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, 2025Routine
7
0001Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish an Emergency Preparedness Program (EP).

0015Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0036Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0730Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

0761Potential for harm · IsolatedCorrected

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Mar 6, 2025Complaint
2
0600Potential for harm · IsolatedCorrected

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.

0622Potential for harm · IsolatedCorrected

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, 2023Complaint
2
0882Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Aug 17, 2023Routine
6
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0806Potential for harm · PatternCorrected

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.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0563Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

0726Potential for harm · IsolatedCorrected

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, 2023Complaint
4
0600Potential for harm · IsolatedCorrected

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.

0676Potential for harm · IsolatedCorrected

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.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0744Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Aug 15, 2019Routine
3
0676Potential for harm · PatternCorrected

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.

0656Potential for harm · IsolatedCorrected

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.

0658Potential for harm · IsolatedCorrected

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

8total
2deficiencies
Sep 15, 2025Follow-up
CleanReport

No deficiencies found during this inspection.

May 5, 2025Complaint
CleanReport

No deficiencies found during this inspection.

Mar 25, 2025Routine
N/A0000, 0293, 0321 and 6 more

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
N/A0000, 0001, 0015 and 7 more

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, 2024Complaint
CleanReport

No deficiencies found during this inspection.

Mar 21, 2024Complaint
CleanReport

No deficiencies found during this inspection.

Feb 8, 2024Complaint
CleanReport

No deficiencies found during this inspection.

Dec 4, 2023Follow-up
CleanReport

No deficiencies found during this inspection.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Mount St Francis Nursing Center

Organization Type

nonprofit

Chain Affiliation

Chain Name

Commonspirit Health

Chain Size

19 facilities nationwide

Chain avg rating: 3.0/5 · Rank 12 of 19

Ownership & Management

Owners

Commonspirit Health

Owner · Organization

100%

Key personnel

Behre, AlmazW-2 Managing EmployeeShepherd, DavidW-2 Managing EmployeeMcginn, ThomasOfficer / DirectorMelfi, MitchOfficer / DirectorMorissette, DanielOfficer / Director
Source: Medicare provider data

Contact

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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