Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount St Francis Nursing Center during CMS and state inspections, most recent first.
The facility did not provide regular in-service education based on the outcomes of annual performance reviews for three CNAs. While annual reviews were completed, there was no documentation or evidence that follow-up education was provided as required. Leadership interviews confirmed a lack of awareness and documentation regarding this requirement.
A resident was not protected from sexual abuse by another resident, who had a history of inappropriate behavior. The facility failed to update care plans and implement timely interventions, resulting in inadequate protection and monitoring. Staff were not trained on managing the resident's behavior, and the facility did not ensure a safe environment.
A facility failed to properly initiate a discharge for a resident involved in an incident of unwanted sexual contact. The resident, who was cognitively intact and required assistance for daily activities, did not have an updated care plan or documented physician assessment justifying the discharge. Despite issuing a discharge notice, the facility's records showed no active discharge plan and no recent behaviors. Communication with the resident's family involved a behavior contract, which the facility refused to modify, leading the family to appeal the discharge.
Surveyors identified that medications, including inhalers and injectable drugs, were not consistently labeled with the date opened or discarded after expiration or discontinuation. Staff interviews confirmed that these medications remained in use or storage beyond recommended timeframes, contrary to manufacturer guidelines and facility policy.
Staff failed to consistently use appropriate PPE and follow infection control protocols for a resident on enhanced barrier precautions, including not wearing gowns during high-contact care and not performing proper hand hygiene or sanitizing equipment during wound care. Supplies were set up without a clean barrier, and staff touched multiple surfaces with contaminated gloves, leading to cross-contamination risks.
Failure to Provide In-Service Education Based on CNA Performance Reviews
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and did not provide regular in-service education based on the outcome of these reviews for three certified nurse aides. Although annual performance reviews were conducted for the nurse aides in question, there was no documentation that regular in-service education was provided as a result of these reviews, as required by facility policy and federal regulations. The documentation reviewed confirmed that while the performance reviews were completed, the follow-up in-service education tailored to the outcomes of these reviews was not documented or performed. Interviews with facility leadership, including the director of quality and safety, vice president of clinical services, and director of nursing, revealed a lack of awareness regarding the requirement to provide in-service education based on performance review outcomes. The DON stated that while performance reviews were conducted, they were not focused on educational needs, and any education or counseling provided was not consistently documented. The leadership acknowledged that specific in-service education following performance reviews was not a standard practice, and they were unable to provide evidence that such education had occurred.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident occurred when a resident entered another resident's room uninvited and engaged in inappropriate physical contact, including patting the resident's buttocks and attempting to kiss her. The victim expressed discomfort and fear, requesting staff intervention to prevent further incidents. Despite the resident's admission of inappropriate behavior, the facility's response was inadequate, as evidenced by the lack of timely psychosocial assessments and updates to care plans. The assailant had a documented history of sexually inappropriate behavior towards staff, including attempts to touch and make vulgar comments. However, the facility did not update the care plan with new interventions following the incident. The facility's investigation revealed multiple instances of inappropriate behavior by the resident, yet there was a significant delay in implementing behavior monitoring and increased supervision. Staff interviews indicated a lack of training and communication regarding interventions for managing the resident's behavior. The facility's management team failed to ensure the safety of residents by not adequately tracking sexual behaviors, not implementing specific interventions, and not relocating the assailant to a different area. The facility's interdisciplinary team did not review or discuss the incident, and there was a lack of formal documentation of safety measures. The facility's failure to address the resident's behavior and protect other residents from potential harm resulted in a deficiency in providing a safe environment.
Inadequate Facility-Initiated Discharge Process
Penalty
Summary
The facility failed to appropriately initiate a facility-initiated discharge for a resident, identified as Resident #58, who was involved in an incident of unwanted sexual contact with another resident. The resident, a 73-year-old male with diagnoses including unspecified dementia and hydrocephalus, was cognitively intact and required varying levels of staff assistance for daily activities. Despite the incident, the facility did not update the resident's care plan with new interventions following the initiation of an involuntary discharge notice on November 18, 2024. The facility did not complete an assessment with attempted interventions prior to issuing the discharge notice, nor did it ensure there was documented evidence from the physician that the resident's needs could not be met at the facility, necessitating discharge. The resident's electronic medical record lacked documentation of the physician's assessment and basis for discharge. Additionally, the social services quarterly assessment indicated no active discharge plan and noted no behaviors during the assessment period, contradicting the facility's discharge notice. Communication between the facility and the resident's representative revealed attempts to address the situation through a behavior contract, which the family sought to modify. The facility, however, refused to alter the original contract and advised the family to either appeal the discharge with the State Agency or allow the discharge to proceed. The family chose to continue appealing the discharge decision.
Failure to Properly Label and Discard Medications
Penalty
Summary
Surveyors found that the facility failed to ensure proper storage and labeling of medications in one medication storage room and three medication carts. Specifically, medications such as Trelegy Ellipta inhalers, Symbicort inhalers, and lidocaine vials were either not labeled with the date they were opened or were not discarded after their expiration or discontinuation. For example, an opened Trelegy Ellipta inhaler was found with an outdated opened date, and other inhalers and a lidocaine vial were not labeled with any opened date. Additionally, an opened tuberculin purified protein derivative (PPD) vial was found in the medication refrigerator past its recommended discard date. Staff interviews confirmed that medications should have been labeled with the date they were opened and discarded according to manufacturer guidelines or facility policy. The registered pharmacist consultant and the director of nursing both acknowledged that the medications in question were not managed according to these standards, with some medications remaining in use or storage beyond their recommended timeframes. The facility's own policy required nurses to check medication labels and discard improperly stored medications, but this was not consistently followed.
Failure to Maintain Infection Control During Wound Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on one of its units, specifically by not ensuring staff consistently used appropriate personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP). The resident in question had an indwelling urinary catheter and multiple open wounds, which, according to CDC guidelines, required the use of gown and gloves during high-contact care activities. Observations revealed that staff entered the resident's room to perform wound care and incontinence care without donning gowns, despite signage indicating EBP requirements. Staff only put on gowns after being reminded by another staff member, and at one point, the necessary signage and PPE cart were missing from the resident's room. During wound care procedures, staff did not adhere to proper infection control and hand hygiene practices. One LPN and a charge nurse performed wound care without consistently performing hand hygiene at required intervals, such as after removing old dressings, after touching potentially contaminated surfaces, and before applying new dressings. Supplies were set up on the bedside table without a proper barrier, and wound care scissors were not sanitized between uses on different wounds. Staff also touched various surfaces in the room, including the bedside table, mattress, and bed controls, with the same gloves used for wound care, further increasing the risk of cross-contamination. Interviews with staff confirmed knowledge of the correct procedures, including the need for hand hygiene between tasks and when moving from one wound to another, but these procedures were not followed during the observed care. The wound care physician and director of nursing both acknowledged the importance of EBP and proper infection control practices, but the observed failures indicated a lack of consistent implementation during resident care activities.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 103 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center At Centennial, The | 4.7 mi | ★★★★★ | 0 | 0 |
| The Healthcare Resort Of Colorado Springs | 5.4 mi | ★★★★★ | 0 | 0 |
| Gardens, The | 6.1 mi | ★★★★★ | 12 | 0 |
| Springs Village Care Center | 6.1 mi | ★★★★★ | 1 | 0 |
| Liberty Heights | 6.4 mi | ★★★★★ | 3 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.