COLORADO SPRINGS, CO - Mount St Francis Nursing Center faced serious federal violations after inspectors discovered the facility failed to adequately protect residents from sexual abuse and maintained unsafe infection control practices that put vulnerable patients at risk.
Sexual Abuse Response Failures Put Residents at Risk
Federal inspectors found that Mount St Francis Nursing Center failed to implement proper safeguards after a documented sexual abuse incident between residents in November 2024. The facility's inadequate response to Resident #58's history of inappropriate sexual behavior created ongoing safety risks for other residents.
The inspection revealed that Resident #58 had a documented pattern of sexually inappropriate touching and verbal comments toward staff members. Despite this known history, the facility failed to update his care plan with appropriate interventions following a November 14, 2024 incident where he made unwanted sexual contact with another resident, causing her to feel uncomfortable and unsafe.
The facility's response to this serious incident was marked by significant delays and inadequate oversight. Social services staff did not provide education to Resident #58 about his inappropriate behavior until 25 days after the sexual abuse incident. Even more concerning, the facility did not refer him for psychiatric evaluation until two months later, in January 2025.
During interviews, staff members revealed they had warned each other about Resident #58's behavior patterns when new employees started work. One certified nursing aide reported being told by other staff that the resident "would touch staff inappropriately" and described an incident where he grabbed her breasts despite her repeated refusals for physical contact.
The facility implemented 15-minute safety checks for both the victim and perpetrator following the incident but discontinued these protections in early January 2025 without establishing alternative safety measures. The director of nursing acknowledged that no safeguards were put in place to prevent similar incidents from occurring once the formal monitoring stopped.
Medication Safety Violations Compromise Treatment Effectiveness
Inspectors documented multiple medication storage and labeling violations that could have reduced the effectiveness of critical treatments for residents. The facility failed to properly label medications with opening dates and remove expired drugs from storage areas.
During the inspection, Trelegy Ellipta inhalers - medications used to treat chronic obstructive pulmonary disease and asthma - were found without proper dating labels. These inhalers must be discarded six weeks after opening according to manufacturer guidelines, but staff were unable to determine how long the medications had been in use.
The facility's registered pharmacist consultant confirmed that using medications beyond their recommended discard dates could significantly reduce their effectiveness, potentially compromising respiratory treatments for residents with serious breathing conditions.
Additional medication storage violations included unlabeled lidocaine vials, improperly stored tuberculin testing supplies that should have been discarded 30 days after opening, and Symbicort inhalers without opening dates. The director of nursing attributed some problems to incorrect reference information provided by a previous pharmacist consultant.
Infection Control Breaches Create Disease Transmission Risks
The facility failed to maintain proper infection control protocols during wound care procedures and Enhanced Barrier Precautions, creating risks for both residents and staff. Inspectors observed multiple instances where healthcare workers did not follow established safety protocols designed to prevent the spread of dangerous infections.
During wound care for a resident on Enhanced Barrier Precautions - protocols specifically designed to prevent transmission of multi-drug resistant organisms - staff initially failed to wear required gowns and gloves for high-contact care activities. These precautions are critical for residents with open wounds and medical devices who face elevated infection risks.
Inspectors documented serious hand hygiene failures during wound care procedures. Licensed practical nurses and charge nurses touched contaminated surfaces, moved between different wound sites, and handled medical equipment without changing gloves or performing proper hand sanitation between tasks.
The infection control violations included using unsterilized scissors to cut wound dressings, touching bedside tables and bed frames with contaminated gloves, and failing to establish proper sterile fields for wound care supplies. These practices significantly increase the risk of cross-contamination between different areas of a patient's body and between different residents.
Healthcare experts emphasize that proper infection control during wound care is essential to prevent serious complications. Cross-contamination can lead to wound infections, delay healing, and contribute to the development of antibiotic-resistant bacteria that are extremely difficult to treat.
Staff Training and Oversight Deficiencies
The inspection revealed systemic failures in staff training and performance monitoring that contributed to multiple safety violations. The facility failed to provide required follow-up education to three certified nursing aides based on their annual performance reviews, missing opportunities to address skill gaps and reinforce safety protocols.
Management acknowledged that staff received informal warnings about problematic behaviors but lacked formal training on appropriate interventions and documentation requirements. The director of nursing was unaware of federal requirements to provide regular in-service education following performance evaluations.
Multiple staff members reported that they had warned previous administrators about Resident #58's escalating sexual behaviors but felt their concerns were not adequately addressed. This communication breakdown contributed to the November incident and ongoing safety risks.
Medical Context and Industry Standards
These violations represent serious departures from established healthcare standards that exist to protect nursing home residents' safety and well-being. Sexual abuse in long-term care facilities requires immediate intervention, comprehensive safety planning, and ongoing monitoring to prevent additional incidents.
Proper medication management is fundamental to effective treatment, particularly for residents with chronic respiratory conditions who depend on precisely timed medication administration. When inhalers lose potency due to improper storage, residents may experience increased breathing difficulties, emergency situations, and potentially life-threatening complications.
Infection control protocols serve as the primary defense against healthcare-associated infections, which can be particularly dangerous for elderly residents with compromised immune systems. Multi-drug resistant organisms pose especially serious threats because they resist standard antibiotic treatments and can spread rapidly through healthcare facilities.
Enhanced Barrier Precautions specifically target residents at highest risk for acquiring dangerous infections - those with open wounds, medical devices, or existing colonization with resistant bacteria. When these protocols fail, the consequences can include serious wound infections, bloodstream infections, and deaths from antibiotic-resistant organisms.
Additional Issues Identified
The inspection also documented failures in care plan updates following the sexual abuse incident, inadequate documentation of behavioral interventions, and insufficient interdisciplinary team review of serious incidents. The facility's risk management documentation noted that Resident #58 "has been deemed a danger to other residents" but failed to implement comprehensive long-term safety measures.
Administrative oversight problems included delayed psychiatric referrals, inaccurate quarterly assessments that failed to reflect documented behavioral incidents, and inadequate staff communication about safety protocols and intervention strategies.
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.
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