Federal inspectors found that Franciscan Care Center Sylvania failed to follow wound care orders for Resident 60, whose right leg had been amputated above the knee. The resident suffered from gangrene, infection following the procedure, and wound healing complications.
The problems began when staff obtained new orders from the resident's vascular surgeon on October 6. The surgeon changed the wound care from once daily to twice daily, requiring Betadine to be painted on the surgical site every 12 hours instead of every 24.
But the facility never updated its internal orders.
For more than a week, nurses continued following the old instructions, treating the amputation site just once daily. On October 12, Licensed Practical Nurse 507 changed the dressing and signed it with that date.
The next day, Registered Nurse 560 documented performing wound care on the same resident. The treatment record showed the dressing had been changed on October 13.
It hadn't.
When inspectors observed the wound care on October 14, they found the dressing still bore the October 12 date and LPN 507's signature. The bandage hadn't been changed in two days, despite RN 560's documentation claiming otherwise.
"Wound care was not completed to her RAKA site on 10/13/25," the resident told inspectors during an interview on October 14. She explained that her wound care orders had changed to twice daily when she saw the vascular surgeon, but the facility was only completing treatment once daily.
The resident was cognitively intact and did not refuse care, according to her assessment records. She required assistance with daily activities and had been at the facility since July following her amputation.
Licensed Practical Nurse 545, who was present during the October 14 observation, confirmed that the existing dressing dated October 12 had not been changed since LPN 507 applied it.
The facility's administrator admitted during an interview that RN 560's documentation was false. The wound care recorded as completed on October 13 had never happened, the administrator confirmed.
The administrator also acknowledged that the facility's wound care orders were incorrect and should have been updated on October 6 to reflect the surgeon's new twice-daily requirement.
LPN 545 confirmed the orders remained wrong more than a week after the surgeon's office had called with the changes. "The wound care order should have been updated on 10/06/25," the nurse told inspectors.
The vascular surgeon's nurse confirmed that the facility had been notified by phone on October 6 about the order changes. The surgeon's office had issued clear instructions requiring Betadine application twice daily to the amputation site.
Instead, the resident received inadequate care for her surgical wound while recovering from gangrene and infection complications. Her medical record showed diagnoses including disruption of wound healing, dehiscence of the amputated stump, acidosis, and peripheral vascular disease.
The facility's own policy, dated May 22, stated that wound treatments would be provided "in accordance with physician orders." But for eight days, staff ignored the surgeon's updated instructions while documenting care that didn't happen.
Federal inspectors determined the violation caused minimal harm or potential for actual harm to the resident. The facility houses 70 residents, and this wound care failure affected one of three residents reviewed during the inspection.
The case emerged from two complaint investigations filed with state health officials. Complaint numbers 2630848 and 2617497 triggered the inspection that uncovered the falsified documentation and inadequate wound care.
The resident's amputation wound required specialized attention given her complex medical conditions. Proper twice-daily Betadine application could help prevent infection and promote healing of the surgical site.
Instead, she received sporadic care while nurses created false records suggesting compliance with medical orders. The deception continued until federal inspectors arrived and discovered the unchanged bandage bearing a two-day-old signature.
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.