Mount St Francis Nursing Center Sexual Abuse Risks CO
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.
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
MOUNT ST FRANCIS NURSING CENTER in COLORADO SPRINGS, CO was cited for abuse-related violations during a health inspection on March 6, 2025.
The facility's inadequate response to **Resident #58's history of inappropriate sexual behavior** created ongoing safety risks for other residents.
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.