Mount St Francis Nursing Center

F-F622 for failure to follow appropriate discharge and transfer requirements.

3. Record review

Review of Resident #58's mood and behavior care plan, revised 11/14/24, identified the resident had a diagnosis of major depression and anxiety. He had episodes of inappropriately touching staff sexually and making vulgar sexual comments to staff. He was involved in an incident on 11/14/24 where he made unwanted sexual contact with another resident, causing her to feel uncomfortable and unsafe. Interventions (revised on 10/16/24, prior to the incident) included attempting non-pharmological interventions as able, one-on-one visits, offering to toilet the resident, offering food and drink and administering medications as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 065325 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 -The facility failed to update the care plan with new interventions following the incident with Resident #16 on 11/14/24. Level of Harm - Minimal harm or potential for actual harm Review of Resident #58's March 2025 CPO revealed the following physician orders:

Residents Affected - Few Clinical staff to perform every 15-minute checks to determine the resident's location and to ensure the safety of the other residents due to this resident's history of sexually inappropriate behavior, ordered on 3/4/25 (during the survey).

Behavior monitoring for exhibiting sexual behaviors such as inappropriate touching and inappropriate verbal language of a sexual manner, ordered on 3/4/25 (during the survey).

Two CNAs at all times when providing care, ordered on 6/11/24.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 065325 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 The UM was interviewed on 3/4/25 at 11:00 a.m. The UM said Resident #58 had a history of sexually inappropriate language and touching towards staff when they were alone providing him care. She said the Level of Harm - Minimal harm or management team instructed the staff to set boundaries for the resident to stop and then tell the nurse or potential for actual harm charge nurse what was happening. The UM said the CNAs did not document the resident's behaviors and that was something the nurses were responsible for documenting. Residents Affected - Few CNA #6 was interviewed on 3/4/25 at 3:30 p.m. CNA #6 said the date she gave her written statement was on 11/21/24 (one week after the incident between Resident #16 and Resident #58). She said when she was hired on 9/5/23, she was warned by other staff that Resident #58 would touch staff inappropriately. She said there was an incident when Resident #58 would not let her go but when she called in another staff member and he let her go. She said she was adjusting his wheelchair and he kept trying to get hugs from her despite her telling him she did not give hugs. CNA #6 said during that same incident, he grabbed her breasts and

she was told by the nurse to not go into his room without another CNA. CNA #6 said she was currently responsible for staff scheduling and tried to put male CNAs on Resident #58's unit.

CNA #7 was interviewed on 3/4/25 at 3:56 p.m. CNA #7 said the CNAs and nurses had advised the prior nursing home administrator (NHA) about Resident #58's sexually inappropriate behaviors. CNA #7 said the prior NHA did not take action on the reports. CNA #7 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 vice president of clinical services (VPCS), SW #1, SW #2, and the director of nursing (DON) were interviewed together on 3/4/25 at 5:07 p.m. SW #1 said the facility process regarding a resident with sexually inappropriate behaviors was to bring any incidents to the social services department to begin interviewing residents. SW #1 said the facility would offer to send the victim to the hospital for a rape kit, if applicable, and begin 15-minute checks on the victim and the perpetrator. SW #1 said the social services department acted as the abuse coordinators for the facility, but she said the corporate director of quality and safety (DQS) determined if incidents were reportable.

SW #1 said after an investigation, she would update the care plans of the victim and the perpetrator. She said new behavioral interventions would be entered in the residents' care plans. She said care plans were reviewed by each department quarterly.

SW #1 said behaviors would be indicated on the perpetrator's MDS assessment if they occurred during the assessment the look-back period. She said social services utilized progress notes, staff interviews, chart

review and clinical meetings to collect information on residents in order to accurately complete assessments.

She said the 1/14/25 MDS assessment should have reflected Resident #58's behaviors and the 11/14/24 incident. SW #1 said the care plan coinciding with the 1/14/25 MDS assessment should have been reviewed and updated for Resident #58 and Resident #16. SW #1 said she did not know why the MDS assessment, care plan and social services assessments had not been updated or kept accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 065325 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 The DON said 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. She said Level of Harm - Minimal harm or 15-minute checks were started on both residents for safety after the incident. She said a behavior tracking potential for actual harm physician's order would be obtained to monitor sexually inappropriate behaviors on the TARs, but she said

she was only able to find a depression behavior tracking order on the TARs for Resident #58. Residents Affected - Few

The DON said 15-minute checks were stopped for both Resident #58 and Resident #16 on 1/7/25 because

the facility had a meeting with Resident #16 and her family. The DON said Resident #16 did not want to remain on safety checks and asked for Resident #58 to also be removed from safety checks. She acknowledged she had 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.

The VPCS said she believed Resident #58 had the potential to revert to repeating his behaviors if he believed he was no longer being watched. She said she was unaware the 15-minute safety checks had been stopped. She said the facility kept an eye on Resident #58 but staff were not formally documenting it. The VPCS acknowledged the facility needed to put more safeguards in place, 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 065325