About Mount St Francis Nursing Center
Mount St Francis Nursing Center, located in COLORADO SPRINGS, CO, is a non-profit organization that accepts Medicare and Medicaid.
Why Families Choose Mount St Francis Nursing Center
- Top Ranked: Ranked #5 out of 21 facilities within 25 miles.
- More Nursing Time: Staff spends 3.91 hours per resident daily (National Avg: 3.87).
Key Performance Indicators
- CMS Overall Rating 2 Stars
- Nursing Hours 3.91 hrs
- Safety Record Issues
Chain Affiliations & Network
This facility is part of the COMMONSPIRIT HEALTH network. This chain operates 19 facilities.
Chain Performance Overview
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Nursing Staff Analysis
Staffing levels are a critical indicator of quality care. We analyze the daily hours of care provided by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs).
Above Average Staffing
Mount St Francis Nursing Center provides more care hours than the state average and more than the national average.
Registered Nurses (RN)
Licensed Practical Nurses
Certified Assistants
CMS Quality Ratings
| Category | Rating | Stars |
|---|---|---|
| Overall Rating | 2 |
|
| Health Inspection | 2 |
|
| Quality Measures | 2 |
|
| Staffing | 4 |
|
Health Inspection History
| Inspection Cycle | Score | Date |
|---|---|---|
| Cycle 1 (Most Recent) | 24 | Mar 06, 2025 |
| Weighted Average | 40 | Combined Score |
Detailed Quality Measures
Rates are from CMS quality measures (claims-based and MDS-based) for the reporting period ending May 01, 2026. Some measures may be omitted when CMS does not report a numeric rate for this facility.
Medicare claims-based measures
Typically includes short-stay outcomes, hospitalizations, and ED use from Medicare claims.
| Measure | Rate |
|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursi... (QM521) | N/A |
| Percentage of short-stay residents who had an outpatient emergency depar... (QM522) | N/A |
| Number of hospitalizations per 1000 long-stay resident days (QM551) | 1.4% |
| Number of outpatient emergency department visits per 1000 long-stay resi... (QM552) | 1.5% |
MDS-based measures
Resident assessment data; often used for long-stay care quality.
| Measure | Rate |
|---|---|
| Percentage of long-stay residents whose need for help with daily activit... (QM401) | 32.5% |
| Percentage of long-stay residents who lose too much weight (QM404) | 5.2% |
| Percentage of long-stay residents with a catheter inserted and left in t... (QM406) | 0.5% |
| Percentage of long-stay residents with a urinary tract infection (QM407) | 0.8% |
| Percentage of long-stay residents who have depressive symptoms (QM408) | 8.4% |
| Percentage of long-stay residents who were physically restrained (QM409) | 0.0% |
| Percentage of long-stay residents experiencing one or more falls with ma... (QM410) | 7.0% |
| Percentage of long-stay residents assessed and appropriately given the p... (QM415) | 99.7% |
| Percentage of short-stay residents assessed and appropriately given the... (QM430) | 88.3% |
| Percentage of short-stay residents who newly received an antipsychotic m... (QM434) | 3.7% |
| Percentage of long-stay residents whose ability to walk independently wo... (QM451) | 26.4% |
| Percentage of long-stay residents who received an antianxiety or hypnoti... (QM452) | 15.5% |
| Percentage of long-stay residents assessed and appropriately given the s... (QM454) | 100.0% |
| Percentage of short-stay residents who were assessed and appropriately g... (QM472) | 85.2% |
| Percentage of long-stay residents with pressure ulcers (QM479) | 4.9% |
| Percentage of long-stay residents with new or worsened bowel or bladder... (QM480) | 26.2% |
| Percentage of long-stay residents who received an antipsychotic medicati... (QM481) | 16.7% |
Complaints & Deficiencies
Complaint History by Year
This chart shows the number of complaints filed each year.
Summary:
- 2023: 4 complaints
- 2024: 2 complaints
- 2025: 2 complaints
- Total: 8 complaints on record
Recent Complaints (Since Jan 2023)
| Date | Description |
|---|---|
| Apr 05, 2025 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Apr 05, 2025 | 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. |
| Jan 17, 2024 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. |
| Jan 05, 2024 | Provide and implement an infection prevention and control program. |
| Sep 28, 2023 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Sep 16, 2023 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. |
| Sep 16, 2023 | Provide safe and appropriate respiratory care for a resident when needed. |
| Sep 16, 2023 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. |
Nearby Hospitals
CENTURA HEALTH-PENROSE ST FRANCIS HEALTH SERVICES
COLORADO SPRINGS, CO
UCH-MEMORIAL HEALTH SYSTEM
COLORADO SPRINGS, CO
Evans ACH (FT Carson)
Fort Carson, CO
UCHEALTH GRANDVIEW HOSPITAL
COLORADO SPRINGS, CO
ST FRANCIS HOSPITAL - INTERQUEST
COLORADO SPRINGS, CO
UCHEALTH PIKES PEAK REGIONAL HOSPITAL
WOODLAND PARK, CO
CHILDREN'S HOSPITAL COLORADO - COLORADO SPRINGS
COLORADO SPRINGS, CO
CEDAR SPRINGS HOSPITAL
COLORADO SPRINGS, CO
PEAK VIEW BEHAVIORAL HEALTH
COLORADO SPRINGS, CO
Owner & Operator Information
Business Entity
CATHOLIC HEALTH INITIATIVES COLORADO
Ownership Structure
- COMMONSPIRIT HEALTH Direct: 100%
Management & Direction
- ALMAZ BEHRE W-2 MANAGING EMPLOYEE
- DEBRA CARPENTER OPERATIONAL/MANAGERIAL CONTROL
- COMMONSPIRIT MOUNTAIN REGION OPERATIONAL/MANAGERIAL CONTROL
- THOMAS DONOHOE CORPORATE OFFICER
- ANDREW GAASCH CORPORATE OFFICER
- THOMAS MCGINN CORPORATE DIRECTOR
- MITCH MELFI CORPORATE DIRECTOR
- DANIEL MORISSETTE CORPORATE DIRECTOR
- DAVID SHEPHERD W-2 MANAGING EMPLOYEE
Associated Doctors
Local Comparison
| Facility | Distance | Rating |
|---|---|---|
| Advanced Health Care of Colorado Springs | N/A | 5 |
| The Gardens | N/A | 5 |
| Bear Creek Senior Living | N/A | 4 |
| The Center at Centennial | N/A | 5 |
| Mount St Francis Nursing Center | N/A | 2 |
| Sunny Vista Living Center | N/A | 3 |
| Life Care Center of Colorado Springs | N/A | 5 |
| Forest Ridge Health and Rehab LLC | N/A | 4 |
| Brookdale Skyline | N/A | 3 |
| The Center at Cordera, LLC | N/A | 3 |
Related Analysis
Best Nursing Homes in COLORADO SPRINGS, CO
Compare Mount St Francis Nursing Center to the top-rated facilities in the area.
Ownership Details
Complete list of registered owners, including direct and indirect ownership.
Noted Deficiencies
Detailed history of deficiencies with descriptions and correction dates.
Nursing Hours Analysis
Detailed breakdown of staffing hours per resident by role.
Frequently Asked Questions
- Skilled Nursing Care: 24/7 medical supervision and complex medical treatments
- Long-term Residential Care: Assistance with daily living activities for extended stays
- Short-term Rehabilitation: Recovery services after hospital stays or surgeries
- Memory Care: Specialized programs for residents with dementia and Alzheimer's disease
- Level of care needed (skilled nursing vs. long-term care)
- Room type (private vs. semi-private)
- Insurance coverage (Medicare, Medicaid, private insurance)
- Length of stay and specific services required
For current rates and to discuss payment options, contact Mount St Francis Nursing Center directly at 7195981336. Their admissions team can help determine coverage and out-of-pocket expenses.
Environment & Cleanliness
- Overall cleanliness and odors
- Resident room conditions
- Common area maintenance
- Safety features and accessibility
Staff & Care Quality
- Staff-to-resident ratios
- How staff interact with residents
- Response time to resident needs
- Staff knowledge and professionalism
Ask to speak with current residents and their families, tour at different times of day, and review the facility's most recent inspection reports.