Mount St Francis Nursing Center
Colorado Springs, El Paso County, Colorado · CCN 065325 · Non-profit (Corporation) · part of Commonspirit Health (18 facilities, chain average 2.7 stars)
CMS rates Mount St Francis Nursing Center 2 of 5 overall as of August 2026. 110 certified beds, 95 residents a day on average. 20 citations on record from the current inspection cycles; no fines on record.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 2 / — of 5 |
Staffing
| Total nurse staffing | 3.49792 hours per resident per day |
|---|---|
| Registered nurses | 1.18223 hours per resident per day |
| Weekend total | 3.12047 hours per resident per day |
| Nursing staff turnover | 55% (registered nurses 43.2%) |
| Administrators who left | 2 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-03-06 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · tag F0730 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-05 |
| 2025-03-06 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-05 |
| 2025-03-06 complaint survey |
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. Resident Rights Deficiencies · tag F0622 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-05 |
| 2025-03-06 | 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-05 |
| 2025-03-06 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-05 |
| 2023-11-30 complaint survey |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · tag F0882 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-01-17 |
| 2023-11-30 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-01-05 |
| 2023-08-17 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-09-16 |
| 2023-08-17 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-09-16 |
| 2023-08-17 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · tag F0806 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-10-30 |
| 2023-08-17 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-09-16 |
| 2023-08-17 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · tag F0563 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-15 |
| 2023-08-17 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-28 |
| 2023-08-17 complaint survey |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-16 |
| 2023-08-17 complaint survey |
Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-16 |
| 2023-08-17 | 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. Nursing and Physician Services Deficiencies · tag F0726 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-16 |
| 2023-08-17 complaint survey |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · tag F0744 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-09-16 |
| 2019-08-15 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2019-09-18 |
| 2019-08-15 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-09-18 |
| 2019-08-15 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-09-18 |
Fines and payment denials
No fines or payment denials on record since 2023.
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Commonspirit Health Organization | 5% or greater direct ownership interest | 100% | 2023-11-28 |
| Commonspirit Mountain Region Organization | operational/managerial control | — | 2023-11-28 |
| Mcginn, Thomas Individual | corporate director | — | 2023-11-28 |
| Melfi, Mitch Individual | corporate director | — | 2023-11-28 |
| Morissette, Daniel Individual | corporate director | — | 2023-11-28 |
| Donohoe, Thomas Individual | corporate officer | — | 2023-11-28 |
| Gaasch, Andrew Individual | corporate officer | — | 2023-11-28 |
| Carpenter, Debra Individual | operational/managerial control | — | 2023-11-28 |
| Behre, Almaz Individual | w-2 managing employee | — | 2023-11-28 |
| Shepherd, David Individual | w-2 managing employee | — | 2023-11-28 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Mount St Francis Nursing Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in El Paso County.