Mount St Francis Nursing Center: Sexual Behavior Failures - CO
The inspection, completed March 6, 2025, found that the nursing center had failed to protect Resident 16 from Resident 58, a man the facility knew had a history of sexual behaviors and the potential to repeat them. The vice president of clinical services acknowledged the failures herself during the inspection, listing them one by one: no tracking of the sexual behaviors, no specific interventions in place, no move of Resident 58 off the hallway where Resident 16 lived, and no training for staff on how to report what they witnessed or how to redirect him.
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See the Derila PillowThe 15-minute checks were the kind of basic safeguard that facilities put in place when they know a resident poses a risk. Someone stopped them. Nobody told the vice president.
When inspectors raised the issue, the vice president said staff were still keeping an eye on Resident 58, just not writing any of it down. Informal watching had replaced a documented protocol, without any formal decision to make that change and without anyone in leadership knowing the structured checks had ended.
She told inspectors she believed Resident 58 had the potential to revert to his previous behaviors if he thought he was no longer being watched.
That detail is worth sitting with. The facility's own clinical leadership believed this resident was monitoring whether oversight was in place and adjusting his behavior accordingly. The response to that belief was to remove the documented oversight and replace it with nothing formal.
The vice president did not dispute the findings. She told inspectors the facility had failed to keep residents safe. She said more safeguards were needed, including visual checks, to prevent incidents from occurring.
What the inspection report does not describe is what Resident 58 actually did, or what Resident 16 experienced. The narrative is built around the gap between what the facility knew and what it did. The facility knew Resident 58 had sexual behaviors. It knew those behaviors could recur. It knew Resident 16 was on the same hallway. It had, at some point, put 15-minute checks in place to address exactly that risk. Then those checks stopped, and no one in a position of authority was informed.
CMS rated the harm level as minimal harm or potential for actual harm, with few residents affected. That classification reflects the regulatory framework, not necessarily what Resident 16's experience was like during the period when the checks had lapsed and staff were watching informally, if at all.
The facility is a 120-bed nonprofit nursing center operated by the Franciscan Sisters of Our Lady of Perpetual Help, located on the northwest side of Colorado Springs. It serves long-term residents and those in short-term rehabilitation.
Sexual behaviors among residents with dementia or cognitive impairment are a recognized and persistent challenge in nursing facilities. Managing them requires exactly what Mount St Francis did not have in place: documented tracking, individualized interventions, staff training, and clear reporting protocols. The vice president's own accounting of the failures read like a checklist of what the facility had skipped.
She said staff were not formally documenting their observations of Resident 58. She said no one had trained staff on what to report or how to redirect him. She said the facility had not moved him off Resident 16's hallway despite knowing the risk he posed.
Resident 16 remained on that hallway throughout.
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 15-minute checks were the kind of basic safeguard that facilities put in place when they know a resident poses a risk.
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.