D

MOUNT ST FRANCIS NURSING CENTER

7550 ASSISI HTS, COLORADO SPRINGS, CO 80919
Score: 48 / 100

Mount St Francis Nursing Center faces challenges in its CMS ratings, earning a D grade with a score of 48/100. The facility ranks in the 42th percentile among Colorado nursing homes, suggesting significant room for improvement.

Staffing at Mount St Francis Nursing Center is near the national average, with 4.11 total nursing hours per resident per day (national average: 3.8 hours).

Recent inspections identified 20 deficiencies at Mount St Francis Nursing Center. While none were classified as the most serious level, families should review the detailed inspection history below.

Score Breakdown

Overall CMS Rating 16 / 40 pts
2 ★ CMS rating
Health Inspections 10 / 25 pts
2 ★ inspection rating
Staffing 16 / 20 pts
4 ★ staffing rating
Quality Measures 6 / 15 pts
2 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 4.11 3.8 Average
Registered Nurses (RN) 1.33 0.7 Above Average
Licensed Practical Nurses (LPN) 0.55 0.7 Below Average
Certified Nursing Assistants (CNA) 2.23 2.4 Average
Weekend Total Nursing 3.94 3.8 Average
Weekend RN Hours 1.09 0.7 Above Average

🔍 Inspection & Deficiency History

20
Total Deficiencies
Mar 5, 2025
Most Recent Inspection
🟠 20 Moderate
View recent deficiencies (5 shown)
  • Tag 0730 Severity E
    Observe each nurse aide's job performance and give regular training.
    Mar 5, 2025 · Nursing and Physician Services Deficiencies
  • Tag 0761 Severity D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologi
    Mar 5, 2025 · Pharmacy Service Deficiencies
  • Tag 0880 Severity D
    Provide and implement an infection prevention and control program.
    Mar 5, 2025 · Infection Control Deficiencies
  • Tag 0600 Severity D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    Mar 5, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
  • Tag 0622 Severity D
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is tr
    Mar 5, 2025 · Resident Rights Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 4.8% 4.5% Average
Falls with major injury 6.8% 3.0% Worse
On antipsychotic medication 17.0% 14.5% Worse
Urinary tract infections 1.1% 2.5% Better
ADL decline (daily activities) 31.6% 14.0% Worse
Excessive weight loss 4.6% 7.5% Better
New/worsened incontinence 27.3% 45.0% Better

How This Grade Was Calculated

This facility's grade of D is based on a score of 48 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 2★ → 16 pts (max 40)
  • Health Inspection Rating: 2★ → 10 pts (max 25)
  • Staffing Rating: 4★ → 16 pts (max 20)
  • Quality Measures Rating: 2★ → 6 pts (max 15)

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
Non profit - Corporation
Certified Beds
110
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
Mar 5, 2025
Deficiencies (Cycle 1)
5