Nursing homeActive
Mount St Francis Nursing Center
7550 Assisi Hts, Colorado Springs, CO 809197195981336110 certified beds · 95 residentsNon profit - CorporationMedicare and Medicaid
Surveys on file
4
since 2019
Deficiencies
20
● 0● 20● 0
Penalties · 3 yrs
—
none on file
Last survey
2025-03-06
Standard
CMS overall
2 / 5
stars as published by CMS
CMS overall 2/5
Health 2
Staffing 4
Quality 2
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Colorado Department of Public Health & Environment · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2025-03-06 | Standard | 050 | CMS-2567 (Care Compare) | — |
| 2023-11-30 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-08-17 | Standard | 0100 | CMS-2567 (Care Compare) | — |
| 2019-08-15 | Standard | 030 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Colorado Department of Public Health & Environment publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-05Record 065325-20250306-F600
F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-05Record 065325-20250306-F622
F730Observe each nurse aide's job performance and give regular training.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-05Record 065325-20250306-F730
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-05Record 065325-20250306-F761
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-05Record 065325-20250306-F880
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-05Record 065325-20231130-F880
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-01-17Record 065325-20231130-F882
F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-15Record 065325-20230817-F563
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-28Record 065325-20230817-F600
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-16Record 065325-20230817-F676
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-16Record 065325-20230817-F695
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-16Record 065325-20230817-F726
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-16Record 065325-20230817-F744
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-16Record 065325-20230817-F804
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-30Record 065325-20230817-F806
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-09-16Record 065325-20230817-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-09-16Record 065325-20230817-F880
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-09-18Record 065325-20190815-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-09-18Record 065325-20190815-F658
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-09-18Record 065325-20190815-F676
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day1.18
Facility
Colorado
National
Colorado 0.82 · National 0.69
Total nurse hours per resident day3.50
Facility
Colorado
National
Colorado 3.72 · National 3.86
Weekend total nurse hours3.12
Facility
Colorado
National
Colorado 3.30 · National 3.42
Total nursing staff turnover55%
Facility
Colorado
National
Colorado 47% · National 46%
Registered nurse turnover43%
Facility
Colorado
National
Colorado 45% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Colorado | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 5.0% | 3.4% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 7.1% | 3.4% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 16.2% | 20.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 1.1% | 1.4% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 32.3% | 13.4% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 4.4% | 4.7% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 14.6% | 11.5% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Commonspirit Health Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Carpenter, Debra Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Commonspirit Mountain Region Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Behre, Almaz Individual | W-2 MANAGING EMPLOYEE | NOT APPLICABLE | — | — |
| Donohoe, Thomas Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Gaasch, Andrew Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Mcginn, Thomas Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Melfi, Mitch Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Morissette, Daniel Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Shepherd, David Individual | W-2 MANAGING EMPLOYEE | NOT APPLICABLE | — | — |
Part of a chain
Commonspirit Health — 18 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Colorado.
No county cost figures on file for El Paso.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Center At Centennial, The Colorado Springs | 4.7 mi | 2024-10-23 | 021 |
| The Healthcare Resort Of Colorado Springs Colorado Springs | 5.4 mi | 2025-06-26 | 1161 |
| Gardens, The Colorado Springs | 6.1 mi | 2025-12-11 | 020 |
| Springs Village Care Center Colorado Springs | 6.1 mi | 2026-01-06 | 0323 |
| Sundance Skilled Nursing And Rehabilitation Colorado Springs | 6.9 mi | 2026-02-26 | 0221 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |