MOUNT ST FRANCIS NURSING CENTER

The information listed below provides an in-depth look into the type and quality of care offered at Mount St Francis Nursing Center. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

MOUNT ST FRANCIS NURSING CENTER
7550 ASSISI HEIGHTS
COLORADO SPRINGS, CO 80919
(719) 598-1336

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only
Overall Rating

Percent of Beds Occupied

97%

Number of Residents and Certified Beds

  • Residents: 105
  • Certified Beds: 108

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By Non Profit - Church Related
  • Offers Only Resident Counseling
  • This Facility is Not Part of a Chain or Franchise

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Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Very High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Mount St Francis Nursing Center. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident ServicesResident ConditionsPercent of Service Days

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
ADL Index Range: 11-166.5%
ADL Index Range: 6-1023.0%
Total Percent:29.5%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-1618.0%
ADL Index Range: 6-1031.8%
ADL Index Range: 0-518.9%
Total Percent:68.7%
 

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 6-101.8%
Total Percent:1.8%
 

Rating Details For Mount St Francis Nursing Center

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per DayReportedExpected
Registered Nurse (RN) Hours44 Minutes58 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours47 Minutes40 Minutes
Certified Nursing Assistant (CNA) Hours2 Hours and 50 Minutes2 Hours and 23 Minutes
Total Licensed Nurse Hours1 Hour and 30 Minutes1 Hour and 38 Minutes
Total Nurse Hours4 Hours and 21 Minutes4 Hours and 1 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Colorado are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This FacilityColorado Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season90-100%88%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%87%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased10%15%
Percent of Long-Stay Residents Who Were Physically Restrained-4%
Percent of Long-Stay Residents Who Lose Too Much Weight9%8%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder35%48%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain-4%
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores-3%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder9%7%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores3%9%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection3%9%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse7%11%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair3%3%
Percent of Long-Stay Residents Who Are More Depressed or Anxious9%16%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%79%
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season90-100%81%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Have Pressure Sores14%9%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain20%23%
Percent of Short-Stay Residents Who Have Delirium8%3%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 08/09/2010.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Administration

Keep Accurate and Appropriate Medical Records.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008
Set Up or Keep a Group of People to Review and Ensure Quality.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Have a Program to Keep Infection from Spreading.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010

Mistreatment

1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008

Nutrition and Dietary

Make Sure That Residents Are Well Nourished.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008
Provide Special Eating Equipment and Utensils for Each Resident Who Needs Them.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010

Quality Care

Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008
Give Proper Treatment to Residents with Feeding Tubes to Prevent Problems (Such As Aspiration Pneumonia, Diarrhea, Vomiting, Dehydration, Metabolic Abnormalities, Nasal-Pharyngeal Ulcers) and Help Restore Eating Skills, if Possible.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008
Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life.
  • Inspection Date: 06/18/2009
  • Correction Date: 07/20/2009
Give Professional Services That Meet a Professional Standard of Quality.
  • Inspection Date: 06/18/2009
  • Correction Date: 07/20/2009
Provide Activities to Meet the Needs of Each Resident.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Make Sure That Residents Receive Treatment/Services to Continue to Be Able to Care for Themselves, Unless a Change is Unavoidable.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Make Sure That Each Resident's Nutritional Needs Were Met.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Give or Get Dental Care for Each Resident.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010

Resident Assessment

1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Do a New Assessment After Any Major Change in a Resident's Physical or Mental Health.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010

Resident Rights

Provide Services to Meet the Needs and Preferences of Each Resident.
  • Inspection Date: 07/24/2008
  • Correction Date: 08/29/2008
Listen to the Resident or Family Groups or Act on Their Complaints or Suggestions.
  • Inspection Date: 06/18/2009
  • Correction Date: 07/20/2009
Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Try to Resolve Each Resident's Complaints Quickly.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
  • Inspection Date: 08/09/2010
  • Correction Date: 09/01/2010

Fire Safety

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Mount St Francis Nursing Center had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 09/02/2010.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 08/13/2008
  • Correction Date: 08/29/2008
Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 07/09/2009
  • Correction Date: 07/24/2009
Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 09/02/2010
  • Correction Date: 09/21/2010

Exits and Egress

Exits That Are Accessible at All Times.
  • Inspection Date: 08/13/2008
  • Correction Date: 08/29/2008

Fire Alarm Systems

A Fire Alarm System That Can Be Heard Throughout the Facility.
  • Inspection Date: 07/09/2009
  • Correction Date: 07/13/2009

Furnishings and Decorations

Restrictions on the Use of Highly Flammable Materials.
  • Inspection Date: 07/09/2009
  • Correction Date: 07/24/2009

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 08/13/2008
  • Correction Date: 08/29/2008
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 07/09/2009
  • Correction Date: 07/24/2009
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 09/02/2010
  • Correction Date: 09/21/2010

Interior Finish

Fire-Resistant Interior Walls.
  • Inspection Date: 09/02/2010
  • Correction Date: 09/15/2010

Medical Gases and Anesthetizing Areas

Proper Fire Barriers, Ventilation and Signs for the Transport of Oxygen.
  • Inspection Date: 09/02/2010
  • Correction Date: 09/02/2010
Source: Medicare Nursing Home Compare; Colorado Department of Public Health and Environment - Retrieved 2011