Mount St Francis Nursing Center: Discharge Dispute - CO
The dispute at Mount St Francis Nursing Center came to light during a federal inspection completed in early March 2025. Inspectors cited the facility for its handling of a facility-initiated discharge, a process that nursing homes must follow with care and documentation. The violation was classified at a level of minimal harm or potential for actual harm, and affected few residents. But the record of what happened between the facility and the family tells a story of a negotiation that went nowhere.
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See the Derila PillowAt the center of the dispute was a behavior contract. The facility had drafted one governing the resident's stay. The family found it inadequate. They proposed a revised version, one that laid out specific expectations: the facility would provide the resident support, conduct regular assessments of his status, offer personalized care plans, and notify the family of any concerning behaviors. These were not unusual requests. They were the kind of commitments families routinely seek when a loved one's behavior has become a point of contention with staff.
The facility said no.
On January 23, 2025, the facility's Director of Quality Services emailed the resident's representative and made the position plain. The facility would not be modifying the original behavior contract. The representative had two options: appeal with the State Agency, or allow the facility to discharge the resident. There was no third path offered. No further negotiation. No counter-proposal.
The representative responded the same day. The family would continue to appeal the discharge.
When inspectors interviewed the vice president of clinical services on March 4, 2025, the answer was brief. The process for facility-initiated discharges, the vice president said, was to follow the regulations. That was it. No elaboration on what the facility had done to work with the family. No explanation of what behaviors had prompted the contract in the first place. No account of what assessments had been done, what care planning had occurred, or what conversations had taken place before the ultimatum arrived in the family's inbox.
The inspection report does not describe what the resident's behaviors were, or how long he had lived at the facility, or what the family's revised contract would have required in practical terms beyond the broad outline inspectors recorded. What the report does show is a family that believed the facility's original contract fell short of what their relative needed, and a facility that responded by telling them to take it or leave it.
Facility-initiated discharges are among the most consequential actions a nursing home can take. For a resident whose family is already engaged enough to draft a revised care contract, negotiate by email, and file a formal appeal with the state, displacement from a nursing home is not an abstract regulatory event. It means finding another placement, transitioning a vulnerable person to an unfamiliar setting, and doing it under the pressure of a discharge notice.
The family's appeal was still active when inspectors arrived. Whether the state agency has since ruled on it, the report does not say.
What the record shows is a family that asked for regular assessments, personalized care planning, and timely notification when something went wrong with their relative. A family that put those requests in writing and sent them back to the facility. A facility that read them, said no, and offered a deadline.
The resident was still there when inspectors walked through the door in March. His family was still fighting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mount St Francis Nursing Center from 2025-03-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 12, 2026 · Our methodology
MOUNT ST FRANCIS NURSING CENTER in COLORADO SPRINGS, CO was cited for violations during a health inspection on March 6, 2025.
The dispute at Mount St Francis Nursing Center came to light during a federal inspection completed in early March 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.