Franciscan Woods

Based on observation, interview, and record review, the Facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R6, R7, R8) of 3 residents reviewed for pressure injuries.

*R6 developed a deep tissue injury (DTI) which was discovered on 2/19/25 by a Licensed Practical Nurse (LPN).

There is no documentation that the DTI was evaluated by a Registered Nurse until the Wound Nurse Practitioner saw it on 2/27/25.

Additionally, R6 did not have nutritional interventions attempted and R6's care plan was delayed in being updated.

The DTI declined to a stage 3 pressure injury.

*R8 developed a Stage 2 pressure injury to left buttocks on 3/10/25.

The wound was not comprehensively assessed until 3/13/25.

Treatment for the pressure injury was not obtained until 3/13/25 and R8's care plan was not updated until 3/13/25.

*Facility staff documented R7 developed a new wound to R7's mid back on 3/9/25.

The wound was not comprehensively assessed until 3/13/25 when the Wound Nurse Practitioner (NP)-M documented that the wound was a stage 2 pressure injury. R7's care plan was not updated with new interventions until 3/13/25, 4 days after the development of the pressure injury. On 3/16/25, R7's wound care was not documented as completed.

Findings include:

1.) R6 was admitted to the facility on [DATE]with pertinent diagnoses that include type 2 diabetes mellitus, cardiomyopathy, heart failure, cognitive communication deficit, mild cognitive impairment, and vascular dementia. On 1/30/25, the following diagnoses were added: unspecified severe protein-calorie malnutrition and encounter for palliative care.

R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/16/2024, documents a Brief Interview for Mental Status (BIMS) score of 04, indicating that R6 has severe cognitive impairment.

The MDS documents that R6 was assessed to have no behaviors exhibited during the look back period. R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, R6 was assessed to have a mechanically altered diet.

The MDS assesses no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months.

The MDS documents that no pressure injury was present, but that R6 is at risk of developing pressure injuries. R6 has an activated Power of Attorney (POA).

525528

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525528 B.

Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Franciscan Woods 19525 W North Ave Brookfield, WI 53045