Mount St Francis Nursing Center

Name: Mount St Francis Nursing Center
Address: 7550 ASSISI HTS, Colorado Springs, CO, 80919, US
Telephone: 7195981336

7550 Assisi Hts, Colorado Springs, CO 80919 · El Paso County · 110 certified beds · avg 95 residents/day · certified since Jul 1, 1994

Abuse citation flag (CMS)

Part of chain: COMMONSPIRIT HEALTH (18 facilities, chain avg rating 2.7★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.15

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (20)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Mar 6, 2025	E · Potential for harm, repeated	The facility did not observe each nurse aide's job performance or provide regular training as required.
Mar 6, 2025	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 6, 2025	D · Potential for harm, one-off	The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint
Mar 6, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 6, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 30, 2023	F · Potential for harm, facility-wide	The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint
Nov 30, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Aug 17, 2023	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Aug 17, 2023	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Aug 17, 2023	E · Potential for harm, repeated	The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Aug 17, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 17, 2023	D · Potential for harm, one-off	The facility did not honor residents' right to receive the visitors they choose, at the times they choose.
Aug 17, 2023	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Aug 17, 2023	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint
Aug 17, 2023	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Aug 17, 2023	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Aug 17, 2023	D · Potential for harm, one-off	The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint
Aug 15, 2019	E · Potential for harm, repeated	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Aug 15, 2019	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Aug 15, 2019	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (10 → 5).

Year	Citations	Worst severity that year
2019	3	E
2023	12	F
2025	5	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Colorado avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.15	3.89	3.95	top 30% in Colorado; top 34% in the U.S.
Registered Nurse hours	1.40	0.86	0.69	top 6% in Colorado; top 6% in the U.S.
Weekend total nurse staffing	3.70	3.44	3.50	top 30% in Colorado; top 33% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.91	0.61	0.48	top 12% in Colorado; top 8% in the U.S.
Total nursing staff turnover (%)	55.0	47.1	45.8	bottom 26% in Colorado; bottom 25% in the U.S.
RN turnover (%)	43.2	44.6	42.9	top 46% in Colorado; bottom 47% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.50, RN 1.18, weekend 3.12. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
Commonspirit Health	Organization	5% or Greater Direct Ownership Interest	100%	11/28/2023
Behre, Almaz	Individual	W-2 Managing Employee	NOT APPLICABLE	11/28/2023
Carpenter, Debra	Individual	Operational/Managerial Control	NOT APPLICABLE	11/28/2023
Commonspirit Mountain Region	Organization	Operational/Managerial Control	NOT APPLICABLE	11/28/2023
Donohoe, Thomas	Individual	Corporate Officer	NOT APPLICABLE	11/28/2023
Gaasch, Andrew	Individual	Corporate Officer	NOT APPLICABLE	11/28/2023
McGinn, Thomas	Individual	Corporate Director	NOT APPLICABLE	11/28/2023
Melfi, Mitch	Individual	Corporate Director	NOT APPLICABLE	11/28/2023
Morissette, Daniel	Individual	Corporate Director	NOT APPLICABLE	11/28/2023
Shepherd, David	Individual	W-2 Managing Employee	NOT APPLICABLE	11/28/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How often do you evaluate your nurse aides and what ongoing training do they receive?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"Under what circumstances would you discharge or transfer a resident, and what notice and appeal rights would we have?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Who is your infection preventionist, and what training do they have?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Could I join residents for a meal to see the food quality and temperature for myself?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Center at Centennial, the	4.7 mi	Colorado Springs, CO	★★★★★	4/5
The Healthcare Resort of Colorado Springs	5.4 mi	Colorado Springs, CO	★★★☆☆	2/5
Gardens, the	6.1 mi	Colorado Springs, CO	★★★★★	5/5
Springs Village Care Center	6.1 mi	Colorado Springs, CO	★★☆☆☆	2/5
Liberty Heights	6.4 mi	Colorado Springs, CO	★★★★☆	2/5
Colonial Rehabilitation and Nursing, LLC	6.7 mi	Colorado Springs, CO	★☆☆☆☆	2/5	abuse
Sundance Skilled Nursing and Rehabilitation	6.9 mi	Colorado Springs, CO	★★☆☆☆	2/5
Pikes Peak Post Acute	7.2 mi	Colorado Springs, CO	★☆☆☆☆	1/5	abuse
Bear Creek Senior Living	7.7 mi	Colorado Springs, CO	★★★★☆	4/5
Kiowa Hills Rehabilitation and Nursing, LLC	8.0 mi	Colorado Springs, CO	★☆☆☆☆	1/5

Compare this facility with the 3 closest →

All facilities in Colorado Springs →

Facility data as of CMS processing date 2026-08-01. CCN 065325.

The Care File

Visit checklist — Mount St Francis Nursing Center

7550 Assisi Hts, Colorado Springs, CO 80919 · 7195981336

Health inspection rating 2/5 · CMS overall 2/5 · ▲ FEDERAL ABUSE CITATION FLAG· Fines (3y): $0

Questions for the administrator:

☐ "How often do you evaluate your nurse aides and what ongoing training do they receive?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "Under what circumstances would you discharge or transfer a resident, and what notice and appeal rights would we have?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Who is your infection preventionist, and what training do they have?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Could I join residents for a meal to see the food quality and temperature for myself?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 065325 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)