CCN 065325

Mount St. Francis Nursing Center

7550 ASSISI HTS, Colorado Springs, CO 80919 · El Paso County

Phone: (719) 598-1336
Ownership: Non profit - Corporation
Certified beds: 110
Residents per day: 95.4
Health citations: 20
Penalties: 0
Fines: 0 · $0
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 2 · short-stay —.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

CMS has turned on the abuse icon. The September 2026 Technical Users' Guide applies that icon for abuse tags F600, F602, or F603: a citation at scope and severity G or higher on the most recent standard survey or on a complaint or focused infection-control survey in the past 12 months, or a repeat citation at D or higher across the recent windows described in the guide. While the icon is on, the health inspection rating is capped at two stars.

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 1.98; 2.21; 2.32
LPN/LVN: 0.33; 0.68; 0.86
Registered nurse: 1.18; 0.82; 0.69
Total nurse staff: 3.50; 3.72; 3.86
Weekend total: 3.12; 3.29; 3.42
Weekend RN: 0.91; 0.60; 0.48

Adjusted total nurse hours: 4.15. Adjusted RN hours: 1.40. Case-mix total: 3.23. Case-mix index: 1.182.

Total nursing staff turnover: 55.0%. RN turnover: 43.2%. Administrators who left: 2.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 0 fines totaling $0, and 0 payment denials.

The Penalties file has no individual penalty rows for this CCN.

Cycle 1 standard survey: March 6, 2025. Health deficiencies counted in cycle 1: 5. Cycle 1 total health score: 24.

Cycle 2 standard survey: August 17, 2023. Cycle 2/3 health deficiencies: 12. Total weighted health survey score: 40.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 20 citations for this home, including 0 at immediate jeopardy and 0 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

March 6, 2025

5 citations

Tag	What CMS cited	Scope and severity	Status
F730	Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 5, 2025
F600	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 · Complaint survey · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 5, 2025
F622	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 · Complaint survey · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 5, 2025
F761	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 · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 5, 2025
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 5, 2025

November 30, 2023

2 citations

Tag	What CMS cited	Scope and severity	Status
F882	Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Complaint survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 17, 2024
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 5, 2024

August 17, 2023

10 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F804	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F806	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 · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 30, 2023
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F563	Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 15, 2023
F600	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 · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2023
F676	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 · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F726	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 · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F744	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023

August 15, 2019

3 citations

Tag	What CMS cited	Scope and severity	Status
F676	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 · Standard survey · Cycle 3	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 18, 2019
F656	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 · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 18, 2019
F658	Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 18, 2019

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
Chain name in the file: Commonspirit Health (18 facilities). Chain average overall rating: 2.7.
Legal business name: Catholic Health Initiatives Colorado.
First approved for Medicare and Medicaid services: July 1, 1994.
Resident and family council: Resident.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for Mount St. Francis Nursing Center?

Mount St. Francis Nursing Center has an overall rating of 2 out of 5. The health inspection rating is 2, staffing is 4, and the quality measure rating is 2.

How many health citations does CMS list for Mount St. Francis Nursing Center?

The Health Deficiencies file lists 20 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 0 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for Mount St. Francis Nursing Center?

CMS reports 3.50 total nurse hours per resident per day, including 1.18 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

August 17, 2023

10 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F804	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F806	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 · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 30, 2023
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F563	Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 15, 2023
F600	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 · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 28, 2023
F676	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 · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F726	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 · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023
F744	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 16, 2023