Franklin Plaza Extended Care

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

admission date of 05/28/21 with diagnoses including congestive heart failure, anxiety, dementia, and schizoaffective disorder. Review of the care plan dated 06/08/21 revealed Resident #102 had an activity of daily living self-care deficit related to dementia and weakness. Interventions included supervision or touching assistance with toilet transfer and toileting hygiene. Review of the quarterly MDS assessment dated [DATE REDACTED] revealed Resident #102 had impaired cognition. He required supervision with toileting hygiene and transfers. He was occasionally incontinent with urine but always continent of bowel. Attempted

interview on 08/25/25 at 9:56 A.M. with Resident #102, but he was unable to participate due to cognitive ability. Review of the medical record for Resident #65 revealed an admission date of 10/21/13 with diagnoses including paranoid schizophrenia, Alzheimer's disease, and constipation. Review of the care plan dated 06/08/21 revealed Resident #65 had an activity of daily living self-care deficit related to dementia and weakness. Interventions included supervision or touching assistance with toilet transfer and toileting hygiene. Review of the quarterly MDS assessment dated [DATE REDACTED] revealed Resident #65 had impaired cognition. He required supervision with toileting hygiene and transfers. He was always continent of urine and bowel. Attempted interview on 08/25/25 at 10:02 A.M. with Resident #65, but he was unable to participate due to cognitive ability. Observation on 08/25/25 at 9:58 A.M. in the bathroom shared by Residents #65, #87, and #102 revealed in the toilet was a moderate amount of bowel movement. Interview

on 08/25/25 at 10:00 A.M. with Registered Nurse (RN) #674 verified the toilet was unable to flush, and she would notify maintenance. She verified Residents #65, #87, and #102 utilized the toilet. Interview and

observation with the Administrator and Maintenance Director #772 on 08/28/25 at 10:09 A.M. verified there was bowel movement in the toilet in Residents #65, #87, and #102's bathroom. Maintenance Director #772 attempted to flush the toilet, and the toilet would not flush. Maintenance Director #772 revealed he was not aware the toilet was not working. He revealed he needed to schedule to shut off the water on non-dialysis days. Review of the facility policy labeled, Resident Rights and Facility Responsibilities, dated 01/06/25, revealed the rights of residents of a home shall include the right to safe and clean-living environment which included lightly, sound, closet space, clean bed and lines and general maintenance of sanitary interior. This deficiency represents non-compliance investigated under Master Complaint Number 2603375 and Complaint Numbers 2589394 and 2568834.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Franklin Plaza Extended Care

3600 Franklin Boulevard Cleveland, OH 44113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

10:14 A.M., and Resident #156 should not have had dried yellow-brown urine stains if timely incontinence care was provided. Review of the facility policy labeled, Incontinence Care, dated 01/06/25, revealed the purpose of the policy was to keep the resident's skin clean, dry, free of irritation, and odor, identify skin problems as soon as possible, prevent skin breakdown, and prevent infection. The policy did not identify frequency incontinence care was to be completed. This deficiency represents non-compliance investigated under Complaint Number 2588569.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Franklin Plaza Extended Care

3600 Franklin Boulevard Cleveland, OH 44113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Level of Harm - Minimal harm or potential for actual harm

sense of meaningfulness or purpose). The job description also stated the Social Worker is responsible to address the residents' need for legal services and to refer residents/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. This deficiency represents noncompliance investigated under Complaint Number 2588569.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Franklin Plaza Extended Care

3600 Franklin Boulevard Cleveland, OH 44113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, staff interview and facility policy review, the facility failed to maintain the kitchen area

in a clean and sanitary manner and failed to ensure foods were labeled and dated properly. This had the potential to affect all but four (Residents #3, #158, #99 and #153) identified by the facility who received nothing by mouth and did not receive food from the kitchen. The facility census was 163. Findings include:Tour of the facility kitchen area on 08/25/25 between 8:28 A.M. and 9:00 A.M. with Dietary Manager (DM) #713 revealed the following undated containers of the following in the walk-in cooler including: Four cups of milk 12 bowls of chocolate pudding Nine cups of prune juice 28 bowls of Jell-O Two chocolate pies

in original packaging with broken seals A brown, crusty substance stuck on the outside of nine cups and 12 bowls in the walk-in cooler. A large amount of greasy food residue on the left outside wall of an oven. DM #713 was unable to say when that oven was last cleaned. Black spotted substance on right inside wall of ice bin; DM #713 stated it appears to be mold. All of the above findings were confirmed by the Dietary Manager #713 upon discovery during the initial kitchen tour on 08/25/25. Review of the undated policy entitled Food Preparation and Storage revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. The policy also stated foods will be received, checked and stored properly as soon as they are delivered and food in broken packages or swollen or dented cans, cans with a compromised seal, or food with an abnormal appearance or odor will not be served. This deficiency represents noncompliance investigated under Complaint Number

1. 2560412. Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Franklin Plaza Extended Care

3600 Franklin Boulevard Cleveland, OH 44113

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the medical record revealed Resident #11 was admitted to the facility on [DATE REDACTED] with diagnoses including hypertension, chronic kidney disease, congestive heart failure, type two diabetes, chronic pulmonary disease, anemia, depression and lymphedema. Review of the quarterly MDS assessment dated [DATE REDACTED] revealed Resident #11's cognition was intact. Resident #11 had no hallucinations or delusions, and rejection of care was not exhibited. Observation on 08/28/25 at 10:42 A.M. of Resident #11's room revealed

a plastic baseboard that led towards Resident #11's bathroom had a section peeled away from the wall that protruded outward. Maintenance Director #772 verified the baseboard needed repaired at the time of the

observation. 7. review of the medical record revealed Resident #155 was admitted to the facility on [DATE REDACTED] with diagnoses including respiratory failure, type two diabetes, colostomy, chronic obstructive pulmonary disease, congestive heart failure, atherosclerotic heart disease, pulmonary hypertension, myocardial infarction, adjustment disorder, and dependence on oxygen. Review of the physician order dated 06/14/25 revealed Resident #155 was to have oxygen at three liters per minute via nasal cannula. Review of the quarterly MDS assessment dated [DATE REDACTED] revealed Resident #155's cognition was intact. Resident #155 did not display hallucinations or delusions but had rejected care one to three days during the seven-day look back period. Observation on 08/28/25 at 10:35 A.M. of Resident #155's room revealed three empty oxygen tanks in the room. Housekeeping Supervisor #642 verified the three empty oxygen tanks in the room and stated nurse's aides were to take the oxygen tanks out of resident's rooms. 8. Review of the medical record revealed Resident #160 was admitted to the facility on [DATE REDACTED] with diagnoses including fibromyalgia, multiple sclerosis, hyperlipidemia, neuromuscular dysfunction of bladder, hypothyroid, anxiety, borderline personality disorder, overactive bladder, difficulty walking, and lack of coordination. Review of the quarterly MDS assessment dated [DATE REDACTED] revealed Resident #160's cognition was intact. Resident #160 did not exhibit hallucinations or delusions and did not reject care. Observation on 08/28/25 at 10:42 A.M. revealed Resident #160's door had a large circular area of chipped paint on its front surface. Maintenance Director #772 verified that the chipped region measured five by five (inches) and confirmed that the paint chip could be peeled off the door. 9. Observation on 08/28/25 at 10:20 A.M. revealed on floor tile block on the 200-hall by the receptionist desk had a loose tile that moved back and forth when stepped on. The Administrator verified the loose tile and stated the tile was loose due to the shifting of the building. 10. Observation on 08/08/25 at 10:25 P.M. of the Two [NAME] shower rooms revealed dark mildew on the shower's right wall and floor and four ceiling tiles exhibiting a blackish substance. The shower on the left side had rust like stains at the corners where the walls met. Maintenance Director #772 verified these findings and stated that

the showers needed recaulking. Review of the undated facility document titled Room Inspection Checklist revealed housekeeping was to keep bathroom floors free of debris check all crevices, scrub and clean for mold and mildew, scrub and clean toilets and put in maintenance work-orders for wall patch paint any scuffs, chips, holes or damage. Review of the facility policy labeled, Resident Rights and Facility Responsibilities, dated 01/06/25, revealed the rights of residents of a home shall include the right to safe and clean-living environment which included lightly, sound, closet space, clean bed and lines and general maintenance of sanitary interior. Review of the facility policy labeled, Incontinence Care, dated 01/06/25, revealed to dispose of soiled linen appropriately but did not have anything in the policy not to place soiled linen on the floor. This deficiency represents non-compliance investigated under Master Complaint Number 2603375 and Complaint Numbers 2589394, 2568834 and 2560412.

Event ID:

Facility ID:

If continuation sheet