Franciscan Woods: Resident Left 8 Hours Without Care - WI
BROOKFIELD, WI - Federal inspectors discovered that Franciscan Woods nursing home failed to report serious abuse allegations and properly investigate care concerns, including a case where a resident received no assistance for an entire 8-hour shift.
Resident Denied Care After Refusing Male Caregiver
The most concerning violation involved a female resident who declined care from a male certified nursing assistant on February 18, 2025. When the resident expressed her preference not to receive assistance from male staff, the CNA failed to notify anyone else about the resident's care needs. As a result, the resident went without any care or assistance for the entire 8-hour shift.
The facility's investigation into this incident was limited to a coaching feedback form for the male CNA, documenting that he was "re-educated on performance expectations." The nursing home administrator viewed this primarily as a communication issue rather than recognizing it as neglect. The incident was never reported to the Wisconsin State Survey Agency as required by federal regulations.
This represents a fundamental breakdown in care coordination. When residents express preferences about their caregivers, facilities must accommodate these requests while ensuring care continues uninterrupted. The failure to communicate the resident's needs to other staff members resulted in a complete absence of care - including assistance with basic needs like toileting, repositioning, and hygiene - for eight consecutive hours.
Pattern of Unreported Abuse Allegations
The inspection revealed a troubling pattern of unreported incidents involving multiple residents and staff members. A particularly disturbing case involved a float pool CNA who allegedly engaged in abusive behavior toward two different residents on January 29, 2025.
According to facility documentation, the CNA entered one resident's room at midnight for a care change and told the resident "not to call again." The staff member then threw the resident's blankets and clothing across the room, left the resident wearing only a brief in bed, and did not return for five hours. During this time, the resident remained exposed and unable to cover themselves or receive needed care.
The same CNA was accused by another resident of telling them to "quit looking at the clock" when they asked how long they had been waiting for care. When the resident said "ouch" during care provision, the CNA reportedly stated they would not help if the resident kept expressing pain. The staff member also instructed the elderly resident to turn off their television and light and go to bed against their wishes, adding "just because you're old doesn't mean you can't learn."
Despite these serious allegations documented in internal emails between corporate human resources and unit managers, neither the nursing home administrator nor the State Survey Agency were properly notified. The director of nursing later admitted she "did not know at the time" these concerns would be considered reportable incidents, despite clear facility policies requiring immediate reporting of all abuse allegations.
Pressure Injury Mismanagement Leads to Deterioration
The inspection also uncovered significant failures in wound care management that resulted in preventable deterioration of pressure injuries. A resident with severe cognitive impairment and diagnosed malnutrition developed a deep tissue injury to their right heel discovered on February 19, 2025.
Critical delays occurred in the assessment and treatment of this injury: - No registered nurse assessed the wound until eight days after discovery - Implementation of protective heel elevation boots was delayed by 24 hours - The resident's care plan wasn't updated with new interventions until 20 days after the injury was found
During this period of inadequate intervention, the deep tissue injury progressed to a Stage 3 pressure injury, representing full thickness tissue loss. A second pressure injury also developed on the resident's other heel area, which the wound care practitioner attributed to the resident "always kicks boots off" - suggesting ongoing failures in ensuring proper preventive equipment use.
The resident had experienced significant weight loss of 13.85% over six months and was receiving hospice care, yet no additional nutritional interventions were attempted to support wound healing. The facility's registered dietitian acknowledged not implementing more aggressive nutritional support, stating comfort was the primary goal under hospice care. However, proper nutrition remains essential for preventing skin breakdown even in end-of-life care.
Incomplete Investigations Leave Residents at Risk
The facility's investigation procedures consistently failed to meet professional standards and regulatory requirements. When investigating abuse allegations, staff interviewed only selected employees and residents rather than conducting comprehensive reviews.
In one case involving alleged rough handling and bruising, investigators failed to interview seven staff members who had worked with the affected resident during the period when injuries occurred. The investigation concluded without determining a root cause or implementing preventive measures, simply attributing injuries to "fragile skin" without addressing how future incidents could be prevented.
Another investigation into concerns about a resident being found "tossed into bed like a rag doll" with feet pressed against the footboard and lying in wet sheets failed to produce any documentation beyond initial interview notes. The facility provided no evidence of monitoring for similar occurrences despite claiming this as their closure plan.
Systemic Failures in Reporting Structure
The inspection revealed fundamental misunderstandings about reporting requirements at multiple leadership levels. The director of nursing stated she had only submitted two facility-reported incidents in nine months, believing the previous administrator was responsible for such reports. Unit managers similarly failed to recognize when incidents required formal investigation and reporting, instead handling serious allegations through informal discussions in morning meetings.
The facility's own policies clearly mandate reporting all allegations of abuse, neglect, or mistreatment to the administrator and state agencies within specific timeframes - immediately for cases involving serious bodily harm and within 24 hours for other incidents. Despite these written procedures, staff consistently failed to follow protocol, leaving serious allegations undocumented and unreported.
Multiple Residents Affected Over Extended Period
The violations affected at least six residents over a two-month period from late January through March 2025. Three residents experienced alleged abuse or neglect that went unreported to state authorities. Three additional residents developed or experienced worsening pressure injuries due to inadequate wound care protocols and delayed interventions.
The pattern of violations suggests systemic problems with the facility's quality assurance systems. Staff at multiple levels - from certified nursing assistants to the director of nursing - demonstrated lack of understanding about their reporting obligations and the serious nature of the documented incidents.
The facility's grievance log showed these concerns were known to management but classified as "customer service" issues rather than potential abuse requiring investigation. This minimization of serious care lapses prevented proper oversight and intervention that could have protected residents from ongoing harm.
These findings highlight the critical importance of robust reporting systems in nursing homes. When facilities fail to recognize, investigate, and report allegations of abuse and neglect, residents remain vulnerable to continued mistreatment. The delayed and inadequate responses to pressure injuries similarly demonstrate how lapses in clinical protocols can lead to preventable suffering and deterioration in residents' conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Franciscan Woods from 2025-03-20 including all violations, facility responses, and corrective action plans.
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