Complaint Investigation

Mount St Francis Nursing Center

March 6, 2025 · Colorado Springs, CO · 7550 Assisi Hts

Citations 3

CMS Rating 2/5

Beds 110

Provider ID 065325

Healthcare Facility

Mount St Francis Nursing Center

Colorado Springs, CO · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

MOUNT ST FRANCIS NURSING CENTER in COLORADO SPRINGS, CO — inspection on March 6, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical

had been stopped.

She said the facility kept an eye on Resident #58 but staff were not formally

including visual checks, to prevent incidents from occurring.

The VPCS said the facility failed to keep residents safe by not tracking sexual behaviors, not having specific interventions in place, not moving Resident #58 off of Resident 16's hallway and by not training staff on what to report and how to redirect Resident #58.

065325 03/06/2025

Mount St Francis Nursing Center 7550 Assisi Hts Colorado Springs, CO 80919

FF0622

Not transfer or discharge a resident without an adequate reason; and must provide documentation and

family of any behaviors.

The DQS emailed the resident's representative again on 1/23/25 via email and advised the representative the facility would not be modifying the original behavior contract and the representative had two options: appeal with the State Agency or allow the facility to discharge.

The representative responded on 1/23/25 via email that the family would continue to appeal the discharge.

II.

Staff interviews The vice president of clinical services (VPCS) was interviewed on 3/4/25 at 5:07 p.m.

The VPCS said the process for facility-initiated discharges was to follow the regulations.

FF622

Minimal harm or minute checks to determine the resident's location and to ensure the safety affected

Review of Resident #58's progress notes from 11/14/24 to 3/4/25 revealed the following:

SW #2 did not provide education to Resident #58 on his behavior towards Resident #16 until 12/9/24 (twenty-five days after the sexual abuse incident).

A social services quarterly assessment, dated 1/17/25, documented Resident #58 had not had staff reported behaviors within the look back period (period of three months).

Social services sent a referral for psychiatry services for Resident #58 on 1/24/25 (two months after the sexual abuse incident with Resident #16).

-There were no additional social services assessments or visit notes located in Resident #58's EMR between the 11/14/24 to 3/4/25 timeframe.

A psychoactive meeting note, dated 12/19/24, failed to reveal that Resident #58's sexual abuse incident towards Resident #16 had been reviewed or discussed by the facility's interdisciplinary team (IDT).

A Risk Management worksheet, dated 12/2/24, documented The resident (Resident #58) has been deemed a danger to the other residents. He has been placed on every 15-minute checks until he is discharged as a means to ensure the safety of the other residents.

Review of 15-minute check staff documentation revealed Resident #58 was on 15-minute checks 11/24/24 to 1/7/25.

II.

Staff interviews

RN #3 was interviewed on 3/4/25 at 10:10 a.m. RN #3 said Resident #58 was a two-person assist for staff safety due to his sexually inappropriate behaviors. RN #3 said the change in status for staff assistance for the resident was passed on to her from other staff and not by the management team. RN #3 said the nurses documented the resident's behaviors in the progress notes because he did not have a physician's order to track sexually inappropriate behaviors on the treatment administration records (TAR). RN #3 said the management team did not do a training with the staff on interventions to use with Resident #58 when he displayed sexually inappropriate behaviors.

065325

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065325 B.

Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount St Francis Nursing Center 7550 Assisi Hts Colorado Springs, CO 80919

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COLORADO SPRINGS, CO, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MOUNT ST FRANCIS NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.