Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MOUNT ST FRANCIS NURSING CENTER
COLORADO SPRINGS, CO · 110 certified beds · Last Life Safety survey March 6, 2025
CMS Certification Number 065325 · first certified July 1994
Ownership
Operated by COMMONSPIRIT HEALTH · Non profit - Corporation
- Ownership changed November 28, 2023 (change of ownership)to MOUNT SAINT FRANCIS NURSING CENTER from ST FRANCIS NURSING CENTER
Position within CO
4 citations — more than 18% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
When is the next survey likely?
The window is open now: August 2026 to March 2027. This facility’s last Life Safety survey was March 2025. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
4 of the 4 citations on file are Emergency Preparedness E-tags — every citation here is about the program, not the building. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 4 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 4 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 15, 2019 | 0 |
| August 17, 2023 | 0 |
| March 6, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 1 | 2025-03-06 |
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2025-03-06 |
| E-0036 | Establish emergency prep training and testing. | 1 | 2025-03-06 |
| E-0001 | Establish an Emergency Preparedness Program (EP). | 1 | 2025-03-06 |
What the citations cover
- Emergency Preparedness Deficiencies 4
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 4 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 6, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 5, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (April 5, 2025) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (April 5, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 5, 2025) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.