01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-06 | 5 | 2025-03-06 | 4 |
| Cycle 2 | 2023-08-17 | 10 | 2023-08-17 | 0 |
| Cycle 3 | 2019-08-15 | 5 | 2019-08-15 | 0 |
CMS CCN 0653252026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Mount St Francis Nursing Center
7550 Assisi Hts · Colorado Springs, CO 80919 · El Paso County
Certified beds110CMS provider file
Recent citation rows24current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
24 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-03-06 · FIREE0001Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2025-04-052025-03-06 · FIREE0015Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Correction field: Deficient, Provider has date of correction · 2025-04-052025-03-06 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2025-04-052025-03-06 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-04-052025-03-06 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-05 · complaint2025-03-06 · HEALTHF0622Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-05 · complaint2025-03-06 · HEALTHF0730Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2025-04-052025-03-06 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-052025-03-06 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-04-052023-11-30 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-01-05 · complaint2023-11-30 · HEALTHF0882Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Correction field: Deficient, Provider has date of correction · 2024-01-17 · complaint2023-08-17 · HEALTHF0563Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Correction field: Deficient, Provider has date of correction · 2023-11-152023-08-17 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-09-28 · complaint2023-08-17 · HEALTHF0676Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-09-16 · complaint2023-08-17 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2023-09-16 · complaint2023-08-17 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-09-162023-08-17 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2023-09-16 · complaint2023-08-17 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2023-09-162023-08-17 · HEALTHF0806Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2023-10-302023-08-17 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-09-162023-08-17 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2023-09-162019-08-15 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2019-09-182019-08-15 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2019-09-182019-08-15 · HEALTHF0676Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2019-09-1803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- COMMONSPIRIT HEALTHOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 11/28/2023
- BEHRE, ALMAZIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 11/28/2023
- SHEPHERD, DAVIDIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 11/28/2023
- MCGINN, THOMASIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/28/2023
- MELFI, MITCHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/28/2023
- MORISSETTE, DANIELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/28/2023
- DONOHOE, THOMASIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/28/2023
- GAASCH, ANDREWIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/28/2023
- COMMONSPIRIT MOUNTAIN REGIONOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/28/2023
- CARPENTER, DEBRAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/28/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.50per resident day
RN hours1.18per resident day
Weekend nurse hours3.12per resident day
Staff turnover55.0%CMS reported field
06 / LOCAL RECORDS
Open the Colorado Springs ledger →Other published facilities nearby
Advanced Health Care Of Colorado Springs34 beds · CMS overall 5/531 citation rowsBear Creek Senior Living45 beds · CMS overall 4/526 citation rowsBrookdale Skyline82 beds · CMS overall 5/546 citation rowsCenter At Centennial, The80 beds · CMS overall 5/537 citation rowsColonial Rehabilitation And Nursing, Llc80 beds · CMS overall 1/553 citation rowsFalcon Heights Rehabilitation And Nursing Llc107 beds · CMS overall 2/562 citation rowsFountain View Rehabilitation And Nursing Llc90 beds · CMS overall 3/525 citation rowsGardens, The45 beds · CMS overall 5/521 citation rows