Franklin Plaza Extended Care: Oxygen Safety Failures - OH
Inspectors visited Franklin Plaza Extended Care on August 28, 2025, as part of an investigation into four separate complaints filed against the facility. What they found in one resident's room that morning became the clearest illustration of how basic oversight had broken down.
The resident, identified in inspection records as Resident 155, lives with respiratory failure, congestive heart failure, pulmonary hypertension, chronic obstructive pulmonary disease, and a history of myocardial infarction. A physician order dated June 14, 2025, required three liters of oxygen per minute via nasal cannula. The resident's cognition was intact. At 10:35 in the morning, inspectors walked into the room and counted three empty tanks.
The Housekeeping Supervisor confirmed the tanks were empty and said nurse's aides were responsible for removing them from residents' rooms. Nobody had.
The inspection report does not say whether the resident was without oxygen at that moment, or for how long the tanks had been sitting there empty. What it does say is that a cognitively intact resident with multiple serious cardiac and pulmonary conditions had three depleted oxygen tanks in the room and no documented explanation for why they hadn't been replaced or removed.
That finding sat alongside a series of physical plant failures that inspectors documented throughout the same visit.
In the room of Resident 160, a woman living with multiple sclerosis, neuromuscular bladder dysfunction, and difficulty walking, inspectors noted a large section of chipped paint on the front of her door. The Maintenance Director confirmed the damaged area measured five inches by five inches and acknowledged the paint chip could be peeled away from the surface. The resident's door.
Out on the 200-hall near the receptionist desk, a floor tile rocked back and forth when stepped on. The administrator confirmed it was loose. The building was shifting, the administrator said.
The shower rooms told a longer story of neglect. Inspectors who visited on August 8, more than two weeks before the main inspection sweep, found dark mildew on the right wall and floor of one shower, four ceiling tiles coated in a blackish substance, and rust-colored staining in the corners where the walls of the other shower met. The Maintenance Director looked at all of it and said the showers needed recaulking.
The facility's own Room Inspection Checklist, a document with no date on it, instructed housekeeping staff to keep bathroom floors free of debris, check all crevices, and scrub for mold and mildew. The checklist also directed staff to submit maintenance work orders for any wall damage, paint chips, or holes. The mildew in the shower rooms was visible enough that inspectors documented it in detail. Whether anyone had submitted a work order before inspectors arrived, the report does not say.
Franklin Plaza's own policy on resident rights, dated January 2025, states that residents are entitled to a safe and clean living environment, including general maintenance of sanitary interior spaces.
The inspection was tied to complaints filed under four separate complaint numbers, the earliest of which predates the August shower room observation. That means concerns about conditions at Franklin Plaza had been reaching regulators for some time before inspectors walked through the door.
The Housekeeping Supervisor who confirmed the empty oxygen tanks said removing them was the nurse's aides' job. The Maintenance Director who confirmed the chipped paint said the door needed repair. The administrator who confirmed the rocking floor tile blamed the building. Everyone acknowledged what inspectors pointed to. Nobody offered an account of how any of it had been allowed to persist.
Resident 155, whose physician had ordered continuous supplemental oxygen, was cognitively intact. The inspection report notes the resident had refused care on one to three days in the week before the assessment. It does not say whether the resident knew the tanks were empty, or whether anyone had told them help was coming.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Franklin Plaza Extended Care from 2025-09-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
FRANKLIN PLAZA EXTENDED CARE in CLEVELAND, OH was cited for violations during a health inspection on September 2, 2025.
Inspectors visited Franklin Plaza Extended Care on August 28, 2025, as part of an investigation into four separate complaints filed against the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.