Mount St Francis Nursing Center
MOUNT ST FRANCIS NURSING CENTER in COLORADO SPRINGS, CO — inspection on March 6, 2025.
Found 1 citation. 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
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