The three-day delay at Franciscan Woods violated the facility's own policies and left the resident without proper treatment orders for her reopened wound. The resident, identified as R8, spent most of her time sitting in a recliner on pillows, avoiding her bed and declining the wheelchair cushion staff offered.
"She prefers to sit on a pillow due to pressure injuries developing on her buttocks," R8 told inspectors during a March 18 interview. The cognitively intact resident had previously healed from a similar wound in the same location, which had closed by February 20 but reopened within three weeks.
Federal inspectors found that certified nursing assistant CNA-T notified a nurse immediately after finding the wound during R8's bath. But no comprehensive assessment was completed that day or the next. Instead, facility staff performed a "skin sweep" on March 12 — using a separate electronic system that floor nurses couldn't access.
The unit manager acknowledged that comprehensive assessments should be completed "right away" but claimed the facility had 24 hours to complete them. When pressed about the three-day gap, she said she would investigate.
Meanwhile, the wound grew larger. By March 20, the injury measured 0.6 x 0.6 x 0.1 centimeters, compared to 0.2 x 0.2 x 0.1 when first properly assessed on March 13. The wound care nurse practitioner attributed the growth to "noncompliance" — R8's refusal to sleep in her bed or use proper cushioning.
R8 also missed wound care treatments on March 15 and declined them on March 16, going two days without care for her stage 2 injury.
The facility's wound care failures extended beyond delayed assessments. Another resident, R6, experienced severe weight loss that contributed to pressure injury development, but staff implemented no new interventions to address the decline.
R6 lost 24 pounds over six months, dropping from 131 pounds in July 2024 to 107 pounds by January 2025 — an 18.3% weight loss. The resident with severe cognitive impairment required total assistance with eating and had been stable for years before the decline began.
The facility's registered dietitian repeatedly documented R6's weight as "stable" in quarterly assessments even as the pounds disappeared. In September, when R6 weighed 120.8 pounds — down from 131 in July — the dietitian wrote: "Weight 120.8 pounds, stable the past 6 months. No new interventions needed at this time."
The pattern continued in November. With R6 at 118 pounds, the dietitian again noted: "Weight 118 pounds, stable the past 6 months. No new interventions needed."
Only after R6's weight plummeted to 107 pounds did staff acknowledge "significant weight loss" and begin hospice discussions. By then, R6 had developed pressure injuries on both heels, including one that progressed to stage 3.
The facility's medical director, who makes rounds at several locations, wasn't directly notified of R6's weight loss. "Staff should contact the on-site NP who will then contact MD-Z if there are concerns," he told inspectors. He last saw R6 in February and knew about the 10-pound monthly loss but expected decline given R6's advanced dementia.
R6's power of attorney said the weight loss had been mentioned only "casually" by staff. She brought food from home that R6 ate without difficulty and worried that poor nutrition affected her mother's skin integrity.
Meal documentation revealed gaps in care. In January 2025, staff failed to record whether R6 was offered 44 of 93 meals, leaving no evidence that the totally dependent resident received proper nutrition assistance.
The facility's infection control program also showed deficiencies. During a February influenza A outbreak affecting 14 residents on the third floor, staff created a line list but never completed an investigative summary to identify how the outbreak started or spread.
The infection preventionist acknowledged not documenting investigation summaries for outbreaks and failed to track infection organisms unless they were reportable to health authorities. Surveillance logs listed infections but omitted the specific organisms causing them, hampering prevention efforts.
Director of Nursing B told inspectors she wasn't aware of R6's weight loss issues and said nursing wouldn't typically be involved in nutrition interventions. She couldn't explain why the facility's dietitian consistently documented declining weights as "stable."
The inspection also found that staff installed bed rails on R9's bed at family request without completing the required comprehensive assessment. The device evaluation form was marked "no device needed" despite bilateral mobility devices being installed and maintained on the bed.
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.