Deficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of sexual abuse between two residents, Resident #16 and Resident #58, and concerns about the facility's handling of the abuse, resident safety, and discharge procedures.
Complaint Details
The complaint investigation was substantiated. The facility confirmed the sexual abuse incident between Resident #16 and Resident #58 on 11/14/24 and identified multiple failures in care and safety measures. The investigation included interviews with residents, CNAs, RNs, social workers, and administrative staff.
Findings
The facility substantiated the sexual abuse of Resident #16 by Resident #58 based on staff and resident interviews and observations. The investigation revealed failures in protecting residents from abuse, inadequate care plan updates, insufficient staff training, lack of proper behavior tracking, and failure to implement appropriate safety measures. Additionally, the facility failed to properly initiate and document an appropriate facility-initiated discharge for Resident #58.
Deficiencies (2)
Failed to protect Resident #16 from sexual abuse by Resident #58.
Failed to initiate an appropriate facility-initiated discharge for Resident #58, including lack of assessment and physician documentation.
Report Facts
Residents reviewed for abuse: 46
Residents reviewed for appropriate discharge: 32
Discharge notice period: 15
15-minute checks duration: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Witnessed sexual abuse incident and reported it |
| CNA #2 | Certified Nurse Aide | Witnessed sexual abuse incident and reported it |
| UM | Unit Manager | Interviewed residents involved in abuse incident and provided education |
| RN #3 | Registered Nurse | Interviewed regarding documentation and staff training on sexually inappropriate behaviors |
| CNA #6 | Certified Nurse Aide | Reported history of Resident #58's inappropriate sexual behaviors |
| CNA #7 | Certified Nurse Aide | Reported history of Resident #58's inappropriate sexual behaviors and lack of administrative action |
| SW #1 | Social Worker | Interviewed about social services role and care plan updates |
| VPCS | Vice President of Clinical Services | Interviewed about facility processes and failures in managing Resident #58's behaviors |
| DON | Director of Nursing | Interviewed about awareness and management of Resident #58's behaviors and safety checks |
| DQS | Director of Quality and Safety | Communicated discharge notices and behavior contracts to resident representative |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of sexual abuse by one resident against another and concerns about appropriate discharge procedures and staff performance.
Complaint Details
The complaint investigation substantiated sexual abuse of Resident #16 by Resident #58 based on staff and resident interviews and observations. The facility also failed to follow proper discharge procedures for Resident #58 and had deficiencies in staff training and infection control.
Findings
The facility substantiated sexual abuse of Resident #16 by Resident #58 and identified failures in protecting residents from abuse, updating care plans, and implementing appropriate safety measures. The facility also failed to initiate an appropriate discharge for Resident #58 and did not provide regular in-service education for CNAs based on annual performance reviews. Additionally, medication storage practices were deficient, and infection control practices, including PPE use and wound care, were inadequate.
Deficiencies (5)
Failed to protect Resident #16 from sexual abuse by Resident #58 and failed to implement adequate interventions and monitoring after the incident.
Failed to initiate an appropriate facility-initiated discharge for Resident #58, including lack of physician documentation and assessment.
Failed to complete regular in-service education for CNAs based on the outcome of annual performance reviews for CNA #8, CNA #9, and CNA #10.
Failed to ensure medications were labeled with the date they were opened and failed to remove expired or discontinued medications from medication carts and storage refrigerators.
Failed to maintain an infection control program by not ensuring staff wore appropriate PPE for Resident #20 on enhanced barrier precautions, not following proper infection control and hand hygiene practices during wound care.
Report Facts
Residents reviewed for abuse: 46
Residents reviewed for discharge: 32
Certified nurse aides reviewed: 3
Medication storage carts observed: 3
Residents affected by deficiencies: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Witnessed sexual abuse incident and involved in investigation |
| UM | Unit Manager | Interviewed residents involved in sexual abuse incident and provided education |
| CNA #2 | Certified Nurse Aide | Witnessed sexual abuse incident and provided statements |
| CNA #6 | Certified Nurse Aide | Reported history of sexually inappropriate behavior by Resident #58 |
| CNA #7 | Certified Nurse Aide | Reported sexually inappropriate comments by Resident #58 |
| SW #1 | Social Worker | Social services assessment and abuse coordinator |
| SW #2 | Social Worker | Provided education to Resident #58 on behavior |
| RN #3 | Registered Nurse | Interviewed about Resident #58's behaviors and documentation |
| DON | Director of Nursing | Interviewed about sexual abuse incident, discharge, and infection control |
| VPCS | Vice President of Clinical Services | Interviewed about facility policies and deficiencies |
| DQS | Director of Quality and Safety | Provided discharge communications and interviewed about CNA education |
| LPN #2 | Licensed Practical Nurse | Observed and interviewed regarding wound care and PPE use |
| CN | Charge Nurse | Observed and interviewed regarding wound care and PPE use |
| WCP | Wound Care Physician | Interviewed about wound care practices and infection control |
| RPHC | Registered Pharmacist Consultant | Interviewed about medication storage and expiration |
| DON | Director of Nursing | Interviewed about medication storage and infection control |
| IP | Infection Preventionist | Provided statement about PPE signage and cart replacement |
Inspection Report
Routine
Deficiencies: 5
Date: Nov 30, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, including adherence to COVID-19 related precautions and policies.
Findings
The facility failed to maintain an effective infection control program on one of three floors, including improper use of PPE in COVID-19 positive rooms, failure to offer hand hygiene to residents before meals, inadequate disinfection of shared equipment, and failure to maintain proper isolation precautions such as signage and keeping resident doors closed. Additionally, the facility lacked a qualified infection preventionist with completed specialized training.
Deficiencies (5)
Failure to ensure proper personal protective equipment (PPE) was utilized in COVID-19 positive rooms.
Failure to ensure residents were provided with an opportunity to participate in hand hygiene before meals.
Failure to ensure shared equipment was properly disinfected between use.
Failure to provide accurate isolation precautions, including isolation signage and assuring resident doors remained closed.
Failure to designate a qualified infection preventionist responsible for the infection prevention and control program.
Report Facts
Modules completed for infection control certificate: 7
Date survey completed: Nov 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding PPE use, hand hygiene, and infection control certification progress. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided facility policies and interviewed about infection preventionist vacancy and signage procedures. |
| Vice President of Ambulatory Services | Vice President of Ambulatory Services (VPAS) | Interviewed about lack of infection control preventionist and corporate support. |
| Unit Nurse Manager | Unit Nurse Manager (UNM) | Interviewed about signage placement and isolation door policies. |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 5
Date: Aug 17, 2023
Visit Reason
The investigation was conducted due to allegations of resident-to-resident abuse involving multiple residents, specifically focusing on Resident #92's aggressive behaviors toward other residents.
Complaint Details
The complaint investigation was triggered by allegations of abuse involving Resident #92 physically assaulting multiple residents (#2, #4, #7, #27, and #43) over a two-month period. The facility failed to prevent these incidents until a 24-hour one-to-one sitter was implemented.
Findings
The facility failed to ensure five residents were kept free from abuse by Resident #92, who exhibited aggressive behaviors and wandered into other residents' rooms. The facility implemented a 24-hour one-to-one sitter after multiple altercations. Additional deficiencies included failure to provide showers per resident preference, inadequate communication assistance for a resident with language barriers, improper respiratory care for a resident using CPAP, and failure to provide appropriate dementia care for Resident #92.
Deficiencies (5)
Failed to protect residents from abuse by Resident #92, resulting in multiple resident-to-resident altercations.
Failed to provide Resident #86 with showers according to her preference of twice weekly, only receiving 56% of showers.
Failed to provide Resident #45 with adequate communication assistance despite language barriers and preferred language of Tagalog.
Failed to ensure proper physician orders, care planning, cleaning, sanitizing, and staff training for Resident #158's CPAP machine.
Failed to provide appropriate dementia care for Resident #92, including comprehensive assessment and person-centered interventions to prevent altercations and abuse.
Report Facts
Residents affected by abuse: 5
Sample residents reviewed: 48
Resident census: 104
Resident showers received: 9
Resident showers scheduled: 16
Resident #92 altercations: 5
BIMS scores: 9
BIMS scores: 5
BIMS scores: 15
BIMS scores: 6
BIMS scores: 13
BIMS scores: 9
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding Resident #92's aggressive behaviors and interventions. |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding Resident #92's aggressive behaviors and CPAP care for Resident #158. |
| Director of Health Information Management | Director of Health Information Management | Provided facility policies and interviewed regarding Resident #92's care and abuse investigations. |
| Medical Director | Medical Director | Interviewed regarding Resident #92's aggressive behavior and medication management. |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding Resident #92's room changes, sitter implementation, and overall facility response. |
| Certified Nurse Aide #8 | Certified Nurse Aide | Interviewed regarding shower scheduling and staffing issues. |
| Director of Nurses | Director of Nurses | Interviewed regarding shower scheduling and staffing. |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding communication barriers with Resident #45. |
| Certified Nurse Aide #7 | Certified Nurse Aide | Interviewed regarding communication barriers and use of translation services for Resident #45. |
| Certified Nurse Aide #8 | Certified Nurse Aide | Interviewed regarding communication with Resident #45. |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding Resident #45's language and MDS documentation. |
| Social Services Director | Social Services Director | Interviewed regarding language needs and interpreter use for Resident #45. |
Inspection Report
Routine
Census: 104
Deficiencies: 10
Date: Aug 17, 2023
Visit Reason
Routine inspection of Mount St Francis Nursing Center to assess compliance with regulatory requirements including resident rights, abuse prevention, activities of daily living, respiratory care, dementia care, food service, infection control, and staff competencies.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights to receive visitors, failure to prevent resident-to-resident abuse, inadequate activities of daily living support, improper respiratory care and CPAP management, insufficient dementia care interventions, poor food palatability and failure to accommodate resident food preferences, improper food handling and sanitation practices, and inadequate infection control practices including housekeeping and hand hygiene.
Deficiencies (10)
Failed to honor resident's right to receive visitors of their choosing at the time of their choosing.
Failed to protect residents from abuse by another resident, including multiple resident-to-resident altercations.
Failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living, including showering preferences and communication needs.
Failed to provide safe and appropriate respiratory care for a resident requiring CPAP, including lack of physician orders, improper cleaning and storage, and lack of staff training.
Failed to ensure nursing staff were competent in CPAP care, cleaning, sanitizing, and storage.
Failed to provide appropriate treatment and services to a resident with dementia to prevent resident-to-resident altercations and address behavioral issues.
Failed to consistently serve food that was palatable, attractive, and at appropriate temperatures.
Failed to provide food that accommodated resident allergies, intolerances, and preferences.
Failed to store, prepare, distribute, and serve food in a sanitary manner, including improper holding temperatures, moisture between stacked pans, and inadequate sanitation of utensils and food coolers.
Failed to maintain an infection control program ensuring proper cleaning and disinfection of resident rooms and high-touch surfaces, and failed to ensure staff performed hand hygiene between resident care.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Resident census: 104
Shower compliance: 56
Temperature: 111.3
Temperature: 119
Temperature: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Reported resident #92's aggressive behavior and training meeting participation |
| Registered Nurse #1 | RN | Interviewed about resident #92's behavior and CPAP care |
| Director of Health Information Management | DHIM | Provided facility policies and interviewed about resident #92 and CPAP care |
| Nursing Home Administrator | NHA | Interviewed about resident #92's behavior, CPAP care, and food service issues |
| Certified Nurse Aide #8 | CNA | Interviewed about shower scheduling and communication with resident #45 |
| Nutrition Services Supervisor | NSS | Interviewed about food service complaints and food handling |
| Culinary Supervisor | CS | Interviewed about food palatability and food committee |
| Housekeeper #1 | HSKP | Observed cleaning practices and interviewed about cleaning procedures |
| Director of Housekeeping | DOH | Interviewed about housekeeping policies and training needs |
| Infection Preventionist | IP | Interviewed about infection control and hand hygiene |
| Certified Nurse Aide #4 | CNA | Interviewed about hand hygiene practices during meal assistance |
| Licensed Practical Nurse #1 | LPN | Interviewed about hand hygiene and meal assistance |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Aug 15, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, medication administration, use of mechanical lifts, wander alarm bracelet assessments, physical therapy and restorative nursing programs.
Findings
The facility failed to ensure comprehensive and resident-centered care plans for multiple residents, did not follow physician orders for medication administration, failed to timely obtain physical therapy evaluations, did not reassess wander alarm bracelet use appropriately, and failed to implement restorative nursing programs as recommended by physical therapy for several residents.
Deficiencies (7)
Care plans did not include mechanical lift use for Resident #9 during transfers.
Care plans failed to document Resident #28's preferred time to get up in the morning.
Care plans failed to document level and type of incontinence care and appropriate mechanical lift use for Resident #38.
Failure to follow physician's orders to check blood pressure prior to administering Lisinopril to Resident #9.
Failure to timely obtain physical therapy evaluation for Resident #15 as recommended by medical provider.
Failure to reassess use of wander alarm bracelet for Resident #74 according to facility policy.
Failure to implement restorative nursing program as recommended by physical therapy for Residents #9, #8, and #65.
Report Facts
Residents sampled: 32
Residents affected: 4
Residents affected: 3
Residents affected: 3
Physical therapy walking distance: 220
Blood pressure documented: 114
Blood pressure documented: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Acknowledged care plan deficiencies and medication administration issues |
| Director of Rehabilitation | Director of Rehabilitation (DOR) | Provided information on physical therapy and restorative nursing referrals |
| Clinical Nurse Manager | Clinical Nurse Manager (CNM) | Interviewed regarding care plan and medication administration issues |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding wander alarm bracelet assessments and facility policies |
| Restorative Nursing Coordinator | Restorative Nursing Coordinator (RNC) | Interviewed regarding restorative nursing program implementation |
| Registered Nurse #7 | Registered Nurse (RN) | Interviewed regarding medication administration and blood pressure documentation |
| Certified Nurse Aide #2 | Certified Nurse Aide (CNA) | Interviewed regarding use of mechanical lift for Resident #9 |
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