Resident 77 had been collecting "random items" throughout Franciscan Care Center Sylvania and storing them in his room, according to the facility's administrator. The resident knew he wasn't supposed to have facility chemicals, and staff had previously educated him when hazardous materials were found among his belongings.
But the hoarding continued.
On September 2, 2025, around 2:00 P.M., CNA 521 responded to the resident's call light. Resident 77 complained that his feet were hurting. When she looked down, she noticed his socks were soaking wet.
The aide removed the socks. The tops of both feet were bright red, inflamed, and blistered.
She immediately called for LPN 578 to assess the resident. He was taken to the hospital.
Federal inspectors found that facility staff had done nothing to address Resident 77's behavioral deterioration, despite clear warning signs stretching back months. The resident's psychiatric nurse practitioner, who had treated him through June 2025 and saw him again on October 8, said the resident had experienced "an increase in behaviors" in March and April.
Psychiatric Nurse Practitioner 602 described Resident 77 as having schizophrenia with disorganized thoughts and paranoia. But the practitioner was unaware of the recent hospitalizations.
The administrator confirmed there was no evidence the interdisciplinary team had attempted to address the resident's behavioral changes. There was no evidence the facility had tried to implement a psychosocial care plan.
This represented a fundamental failure of the facility's own policies. Franciscan Care Center's Behavioral Health Services policy, dated March 16, 2022, requires staff to ensure behavioral health care services are person-centered and reflect residents' goals while maximizing dignity, autonomy, privacy, socialization, independence, choice, and safety.
The policy specifically states that residents who weren't admitted with mental health issues shouldn't develop patterns of decreased social interaction or increased withdrawn, angry, or depressive behaviors while living at the facility.
Resident 77's care plan should have been reviewed when interventions proved ineffective or when he experienced changes in condition.
None of this happened.
Instead, a resident with a serious mental illness was left to collect potentially dangerous items throughout the facility. His compulsive hoarding behavior escalated unchecked. Staff occasionally found hazardous chemicals in his possession and provided education, but implemented no systematic intervention.
The chemical burns were the predictable result.
Federal inspectors cited the facility for failing to provide necessary behavioral health services under a violation that encompasses multiple complaints dating back over a year. The inspection was conducted in response to complaint number 2630848, which also incorporated four additional complaints numbered 2617726, 2617497, 2609625, and 1305377.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
But for Resident 77, the harm was real. His mental illness made him vulnerable to exactly the kind of dangerous behavior that proper care planning should have prevented. The facility's policies promised person-centered care that would maximize his safety and dignity.
Instead, he suffered chemical burns on both feet while staff watched his condition deteriorate for months without intervention.
The resident's psychiatric condition made him prone to collecting items he shouldn't have. His previous encounters with staff over hazardous materials should have triggered a comprehensive behavioral assessment and intervention plan.
The facility knew he had schizophrenia with disorganized thoughts and paranoia. They knew his behaviors had increased earlier in the year. They knew he was hoarding facility chemicals despite repeated education about the dangers.
They did nothing systematic to protect him from himself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Franciscan Care Ctr Sylvania from 2025-11-13 including all violations, facility responses, and corrective action plans.