Franciscan Care CTR Sylvania

In the surveyor’s words

From the most serious findings on record at Franciscan Care CTR Sylvania, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 13, 2025

  Based on observation, staff interview, medical record review, hospital record review, and review of facility policy, the facility failed to ensure hazardous chemicals were properly stored in a secured area and outside the reach of residents. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcomes on 09/02/25 when Resident #77 applied a mixture of cleaning chemicals to the top of both feet resulting in second degree chemical burns, followed by a repeat incident 30 days later on 10/01/25 when Resident #77 applied an assortment of chemicals to his peri-area and a verbal order was obtained on 10/02/25 to send Resident #77 out to the hospital for evaluation due to altered mental status. […]

• Actual harm, isolatedF686Nov 20, 2025

  Based on medical record review, staff interview, and policy review, the facility failed to ensure adequate and timely wound assessments were completed, physician notifications were made promptly, and treatments were completed as ordered for newly discovered pressure ulcers. This resulted in actual harm when a resident (#514) was discovered to have an open wound to the skin on [DATE] with no notification to the physician made or adequate assessment of the area completed. The resident continued with no treatment orders or notification of the wound to the physician until [DATE] when the wound was assessed to be larger in size, and on [DATE], was determined to be a stage IV pressure ulcer. […]

• Actual harm, isolatedF686Nov 2, 2023

  Based on medical record review, staff interview, and review of facility policy, the facility failed to follow their policy to for skin assessments, failed to assess the presence of a new pressure ulcer, failed to provide pressure relief interventions as ordered, and failed to ensure the resident was kept dry without a saturated dressing. Actual harm occurred when Resident #1 was discovered with irritant dermatitis to the left buttock with no initial treatment ordered and no additional pressure relieving interventions were implemented. On 10/16/23 the resident was discovered with a stage 3 pressure ulcer to the coccyx identified to be of five days duration. […]

• Actual harm, isolatedF686Jan 11, 2021

  Based on medical record review, staff interview, and review of facility Pressure Ulcers/Skin Breakdown clinical protocol , the facility failed to ensure interventions for pressure reduction were consistently implemented and failed to timely obtain a treatment once skin breakdown occurred. This resulted in actual harm when a resident developed avoidable pressure injury/deep tissue injuries to the left heel, left medial foot, coccyx, and left buttock. This affected for one (#1) of three residents reviewed for skin breakdown. The facility census was 80. Findings include: Review of the closed medical record for Resident #1 revealed an admission date of [DATE], with the [DIAGNOSES REDACTED]. […]

• No harm, potential for more than minimal, widespreadF812May 26, 2026

  Based on observation, staff interview, medical record review, and review of facility policies, the facility failed to maintain the kitchen in a clean and sanitary manner, failed to ensure temperatures for food storage were properly monitored to prevent spoilage, failed to ensure the dishwasher temperature was adequately monitored to prevent food-borne illness, and failed to ensure residents were provided with sanitary eating utensils. This had the potential to affect all 65 residents who received food from the facility kitchen. The facility identified one resident (#11) as receiving nothing by mouth. The facility census was 66.Findings include: 1. Observation on 05/17/26 at 7:37 A.M. […]