Mount St Francis: Sexual Abuse Response Failures - CO

Federal inspectors found Mount St Francis Nursing Center failed to update care plans or implement new safety measures after Resident 58 made "unwanted sexual contact" with Resident 16 on November 14, 2024. The facility's vice president of clinical services admitted staff "failed to keep residents safe" by not tracking sexual behaviors, not training staff properly, and not moving the perpetrator away from his victim's hallway.

Resident 58 had a documented history of "inappropriately touching staff sexually and making vulgar sexual comments." His mood and behavior care plan, revised the day of the November incident, listed episodes of sexual misconduct toward staff. Yet the facility's response to his assault on another resident was delayed and inadequate.

The social worker assigned to educate Resident 58 about his behavior didn't meet with him until December 9 — twenty-five days after he sexually abused Resident 16. The facility didn't refer him for psychiatric evaluation until January 24, more than two months later.

During those crucial weeks, staff documented that management had "deemed" Resident 58 "a danger to the other residents" and placed him on 15-minute safety checks. But those checks stopped abruptly on January 7, 2025, after Resident 16 and her family requested their removal.

The director of nursing told inspectors that Resident 16 "did not want to remain on safety checks and asked for Resident 58 to also be removed from safety checks." She acknowledged having "no alternative safety measures put in place to prevent Resident 58 from inappropriately touching another female resident once the 15-minute safety checks were stopped."

Staff had been warning administrators about Resident 58's escalating behavior for months before the November assault. CNA 6, who gave her written statement a week after the incident, told inspectors she was warned about Resident 58 when she was hired in September 2023. "She was warned by other staff that Resident 58 would touch staff inappropriately," the inspection report states.

During one encounter, CNA 6 said Resident 58 "would not let her go" until another staff member arrived. While she was adjusting his wheelchair, "he kept trying to get hugs from her despite her telling him she did not give hugs." Then "he grabbed her breasts and she was told by the nurse to not go into his room without another CNA."

CNA 7 was more direct about management's failures. She told inspectors that CNAs and nurses "had advised the prior nursing home administrator about Resident 58's sexually inappropriate behaviors" but "the prior NHA did not take action on the reports." She said she "knew Resident 58 was going to escalate and offend another resident but the administration did not handle his behaviors prior to the incident."

The facility's documentation revealed a pattern of delayed responses and missed opportunities. A social services quarterly assessment from January 17 incorrectly stated that Resident 58 "had not had staff reported behaviors within the look back period" — despite the November sexual abuse incident occurring within that three-month window.

A psychoactive medication meeting in December failed to address or even mention Resident 58's sexual assault on another resident. The facility's interdisciplinary team never reviewed the incident, according to inspection records.

Staff were left to manage Resident 58's dangerous behavior without proper training or clear protocols. RN 3 told inspectors the requirement for two CNAs during care "was passed on to her from other staff and not by the management team." She said nurses documented behaviors in progress notes because Resident 58 "did not have a physician's order to track sexually inappropriate behaviors."

The management team "did not do a training with the staff on interventions to use with Resident 58 when he displayed sexually inappropriate behaviors," RN 3 said.

Even basic safety measures were implemented inconsistently. The facility didn't order formal behavior monitoring for sexual misconduct until March 4, 2025 — during the federal inspection. The same day, administrators finally ordered clinical staff to perform 15-minute checks "due to this resident's history of sexually inappropriate behavior."

Those orders came nearly four months after the sexual abuse incident and two months after the facility had stopped all safety monitoring.

CNA 6, who became responsible for staff scheduling, said she "tried to put male CNAs on Resident 58's unit" as an informal protection measure. But the unit manager told inspectors that CNAs "did not document the resident's behaviors" because "that was something the nurses were responsible for documenting."

Social Worker 1 described the facility's standard process for sexual abuse cases: interviewing residents, offering hospital rape kits when applicable, and starting 15-minute checks on both victim and perpetrator. She said care plans should be updated with new behavioral interventions after investigations.

But Social Worker 1 couldn't explain why none of those steps were properly executed for Resident 58. "She said she did not know why the MDS assessment, care plan and social services assessments had not been updated or kept accurate," inspectors noted.

The director of nursing admitted she "was not aware of Resident 58's past behavior towards staff until after the 11/14/24 incident with Resident 16, when staff started to come forward and she reviewed his records." This occurred despite multiple staff warnings and documented incidents dating back more than a year.

When 15-minute checks ended in January, the facility kept "an eye on Resident 58 but staff were not formally documenting it," according to the vice president of clinical services. She was unaware the formal safety checks had been discontinued.

The vice president acknowledged the facility "needed to put more safeguards in place, including visual checks, to prevent incidents from occurring." But those safeguards were never implemented.

Between January 7 and the March inspection, Resident 58 remained on the same hallway as other vulnerable residents, including his previous victim, with no documented safety measures beyond informal staff awareness.

The inspection revealed a facility that recognized a dangerous resident but failed to protect others from him. Despite acknowledging Resident 58 posed a threat to other residents, Mount St Francis Nursing Center removed the only formal protection it had put in place and offered no alternative safeguards.

Staff members who tried to warn management about escalating risks were ignored. Proper assessments were delayed for months. Training never occurred. The victim's needs took precedence over facility-wide safety, leaving other residents exposed to a known predator.

Resident 16 felt "uncomfortable and unsafe" after the November assault, according to facility records. But she wasn't the only resident at risk. CNA 7's prediction that Resident 58 would "escalate and offend another resident" remained a live threat as long as the facility continued housing him without adequate protections.

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

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