Inspection·November 6, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #62 was cognitively intact. Resident #62 required substantial to maximal assistance for bathing and supervision or touching assistance for personal hygiene. Resident #62 had an indwelling catheter and an ostomy. Review of Resident #62's care plan dated 10/31/24 included Resident #62 had an ADL (activity of daily living) self-care performance deficit related to activity intolerance and had a catheter, ileostomy, and JP (Jackson Pratt) drain. Resident #62 would improve current functional status related to ADL's. Interventions included Resident #62 required extensive assistance with toilet use. Review of Resident #62's physician orders dated 11/04/24 revealed change ileostomy bag one time weekly and as needed, apply skin barrier, center the pouch over the stoma and apply to skin, press area directly around stoma to ensure adherence to skin, monitor stoma and surrounding skin for irritation, apply closure clip to bag, every night shift every seven days for routine skin care and as needed for routine skin care. Review of Resident #62's physician orders dated 11/04/24 revealed orders for ileostomy care every shift and as needed, empty pouch when one third to one half full with gas or stool, wipe tail opening clean, then clamp to prevent odor or spillage, every shift for ostomy care monitor surgical incision for signs and symptoms of infection, dehiscence and as needed for ostomy care. Review of Resident #62's physician orders dated 11/04/24 revealed orders for suprapubic catheter, cleanse with normal saline, apply drain sponge and secure with tape daily, every night shift for cath care. Review of Resident #62's physician orders dated 11/04/24 revealed for suprapubic catheter, change as needed. Observation on 11/06/24 at 8:50 A.M. of Resident #62 with Licensed Practical Nurse (LPN) #400 revealed he was sitting on the edge of his bed and a catheter bag was secured to his left leg and draining dark yellow urine. The bag was approximately half full and when asked how often Resident #62's catheter bag was emptied LPN #400 stated every shift and emptied the bag which had 200 cc of urine collected in it. Resident #62 had an ileostomy and the pouch covering the ileostomy was clean, intact and draining loose greenish colored stool. Interview on 11/06/24 at 3:15 P.M. of Unit Manager (UM) #401 revealed LPN #402 completed Resident #62's admission paperwork and she did not know why LPN #402 did not make sure Resident #62 had orders for his suprapubic catheter and ileostomy when his admission was done. UM #401 stated she was off for a few days and when she returned she was told Resident #62 did not have orders in place for the care of his ileostomy and suprapubic catheter, she obtained physician orders on 11/04/24 and placed them in Resident #62's electronic medical record. UM #401 stated the nurse who did the admission should have made sure Resident #62 had orders for his suprapubic catheter and ileostomy. UM #401 confirmed Resident #62 had a care plan completed on 10/24/24 for the care of his ileostomy and suprapubic catheter and stated the MDS nurse captured it on 10/24/24, and could not explain why orders were not obtained on 10/24/24. This deficiency represents non-compliance investigated under Complaint Number OH00159028. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 2 of 9 Printed: 05/15/2026 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 365388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure appropriate care and services were followed for Resident #158's PEG (percutaneous endoscopic gastrostomy) tube per physician orders. This affected one resident (Resident #158) out of three reviewed for appropriate care for PEG tubes. The facility census was 167. Findings include: Review of Resident #158's medical record revealed an admission date of 09/12/23 and a re-entry date of 10/16/24. Resident #158's diagnoses included epilepsy, type two diabetes mellitus with hyperglycemia, and chronic respiratory failure with hypoxia. Review of Resident #158's physician orders dated 10/16/24 revealed enteral feed order, every night shift for routine care cleanse around stoma site with normal saline, apply DCD (dry clean dressing), four by four, monitor stoma and surrounding skin for irritation every shift. Review of Resident #158's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status was not completed due to resident was rarely, never understood. Resident #158 was dependent for all activities of daily living (ADL's). Resident #158 received 51 percent or more of total calories through tube feeding. Review of Resident #158's Medication Administration Record (MAR) dated 11/05/24 revealed enteral feed order, every night shift for routine care cleanse around stoma site with normal saline, apply DCD (dry clean dressing) four by four, monitor stoma and surrounding skin for irritation every shift was signed off it was completed. Observation on 11/06/24 at 9:50 A.M. with Licensed Practical Nurse (LPN) #400 of Resident #158's PEG tube and dressing revealed the dressing was dated 11/04/24. LPN #400 confirmed the dressing was dated 11/04/24 and it should be changed daily and as needed. Further observation revealed there was a moderate amount of crusty brownish-red drainage on the PEG tube and PEG tube dressing, and the surrounding skin was reddened. The redness was also noted on Resident #158's upper left side, just below the PEG tube insertion site, and it looked like the redness could have been caused by fluid running down Resident #158's side. LPN #400 stated it looked like the redness could have been caused from the tube feeding running down Resident #158's side. Review of Resident #158's progress notes dated 10/26/24 through 11/06/24 did not reveal documentation Resident #158 had brownish-red drainage from around the PEG tube site or Resident #158's skin around the PEG tube was reddened. This deficiency represents non-compliance investigated under Complaint Number OH00159028. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 3 of 9 Printed: 05/15/2026 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 365388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #158's tracheostomy was properly cared for to keep the surrounding tissue clean. This affected one resident (Resident #158) out of three residents reviewed for respiratory care. The facility census was 167. Residents Affected - Few Findings include: Review of Resident #158's medical record revealed an admission date of 09/12/23 and a re-entry date of 10/16/24. Resident #158's diagnoses included epilepsy, type two diabetes mellitus with hyperglycemia, and chronic respiratory failure with hypoxia. Review of Resident #158's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status was not completed due to resident was rarely, never understood. Resident #158 was dependent for all ADL's. Resident #158 received oxygen therapy, suctioning and tracheostomy care. Review of Resident #158's physician orders dated 10/16/24 revealed orders for trach care every shift and as needed. Review of Resident #158's Treatment Administration Record (TAR) dated 11/05/24 revealed trach care every shift and as needed was signed off it was completed on the day, evening and night shift. Observation on 11/06/24 at 9:31 A.M. of Resident #158 with Licensed Practical Nurse (LPN) #400 revealed Resident #158's trach dressing was not dated, had a moderate amount of of greenish brown crusty drainage on the dressing and around Resident #158's tracheostomy, and the skin around the tracheostomy was purplish-red in color. Further observation of Resident #158's bedside table revealed his tracheostomy suction canister was half full and 600 cc of mucousy greenish-yellow fluid could be seen. LPN #400 confirmed Resident #158's trach dressing was not dated, there was a moderate amount of greenish-brown crusty drainage on the dressing and around the tracheostomy , the skin was purplish-red around the tracheostomy tube, and the suction canister should have been emptied. Review of Resident #158's progress notes dated 10/20/24 through 11/06/24 did not reveal documentation of Resident #158's skin integrity under his trach ties, or redness around the trach tube. Review of the facility policy titled, Tracheostomy Care, undated included an objective was to keep the surrounding tissue clean and free from infection. Trach care should be done daily and as needed. Clean and inspect the skin under the trach ties all around the neck using a gauze pad soaked in sterile water. Use cotton tipped applicators to clean under the flange of the trach tube itself. The skin should not be reddened or swollen at all. Place a four-by-four gauze pad under and around the trach tube. Documentation should include the date and time, integrity of skin under the trach ties, and change in the color, consistency, or odor of secretions. This deficiency represents non-compliance investigated under Complaint Number OH00159028. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 4 of 9 Printed: 05/15/2026 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 365388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure medications were administered in accordance to current nursing standards of practice. This affected two residents (Resident #4 and Resident #158) out of four residents reviewed for medication administration. The facility census was 167. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 10/19/24 and diagnoses included unspecified fracture of the shaft of the right fibula, subsequent encounter for closed fracture with routine healing, type two diabetes with diabetic neuropathy, and shortness of breath. Review of Resident #4's physician orders dated 10/19/24 revealed orders for Fluticasone Proprionate Diskus inhalation aerosol powder breath activated 100 mcg per ACT, one puff orally two times a day for SOB (shortness of breath). Review of Resident #4's Medication Administration Record (MAR) revealed on 11/06/24 at 9:00 A.M., Licensed Practical Nurse (LPN) #400 signed off she administered Cetirizine HCl oral tablet 10 mg for allergies, Cholecalciferol tablet 1000 units for supplement, Cyanocobalamin tablet 1000 mcg for supplement, Flomax capsule 0.4 mg for benign prostatic hyperplasia, Fluoxetine HCl oral capsule 20 mg for depression, Rexulti (antipsychotic) oral tablet 0.5 mg for MDD (Major Depressive Disorder), Vitamin D3 oral tablet 5000 units for vitamin D deficiency, Calcium Carbonate oral tablet 1250 mg for supplement, Docusate Sodium oral capsule 100 mg for constipation, Loperamide HCl oral capsule 2 mg for diarrhea, Magnesium Oxide oral tablet 400 mg for supplement, Metformin HCl oral tablet 1000 mg for diabetes mellitus, Tylenol (acetaminophen) oral tablet for pain, and Methocarbamol 750 mg oral tablet for spasms. Review of Resident #4's MAR dated 11/06/24 in the morning revealed Resident #4's Fluticasone Proprionate Diskus inhalation powder was not administered with his other morning medications. Observation on 11/06/24 at 9:31 A.M. of LPN #400 revealed she was standing at the medication cart preparing medications to be administered to Resident #4. LPN #400 prepared Resident #4's medications and placed the medications in a small plastic cup. UM #401 did not stand at the medication cart and watch LPN #400 prepare Resident #4's medication, but walked to the medication cart when LPN #400 finished preparing the medications, took Resident #4's medications, walked into his room and administered the medications to Resident #4. UM #401 did not administer Resident #4's Fluticasone Proprionate Diskus inhalation powder with the other medications. Interview on 11/06/24 at 10:25 A.M. of LPN #400 confirmed she prepared Resident #4's medications, UM #401 was not standing and watching her prepare Resident #4's medications, and when she was finished she gave Resident #4's medications to UM #401 to administer to him. LPN #400 confirmed she signed Resident #4's medications off that she administered them, but the medications were administered by UM #401. Interview on 11/06/24 at 10:42 A.M. of the Director of Nursing (DON) revealed it was not okay for LPN #400 to prepare Resident #4's medications and give to UM #401 to administer. The DON stated UM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 5 of 9 Printed: 05/15/2026 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 365388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 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 0726 #401 should have prepared Resident #4's medications if she was planning to administer the medications. Level of Harm - Minimal harm or potential for actual harm Interview on 11/06/24 at 11:34 A.M. of UM #401 revealed LPN #400 prepared Resident #4's medications, and she did not prepare the medications herself. UM #401 confirmed she administered Resident #4's medications which were prepared by LPN #400. UM #401 confirmed she did not administer Resident #4's Fluticasone Proprionate Diskus inhalation powder with the other medications. Residents Affected - Few Review of the facility policy titled Preparation and General Guidelines, Medication Administration dated 11/2021 included medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The person who prepared the dose for administration was there person who administered the dose. 2. Review of Resident #158's medical record revealed an admission date of 09/12/23 and a re-entry date of 10/16/24. Resident #158's diagnoses included epilepsy, type two diabetes mellitus with hyperglycemia, and chronic respiratory failure with hypoxia. Review of Resident #158's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status was not completed due to resident was rarely, never understood. Resident #158 was dependent for all ADL's. Resident #158 received oxygen therapy, suctioning and tracheostomy care. Review of Resident #158's MAR dated 11/06/24 at 9:00 A.M. revealed LPN #400 signed off she administered Ascorbic Acid tablet 500 mg for supplement, Aspirin oral tablet 81 mg chewable, Ferrous Sulfate liquid 5 ml, Glycolax powder 17 Gm for constipation, multiple vitamins, minerals tablet for supplement, Zinc Sulfate capsule 220 mg for zinc deficiency, Docusate Sodium liquid 50 mg per 5 ml, 10 ml for constipation, Levetiracetam oral solution 500 mg per 5 ml, give 2000 mg for seizures, Observation on 11/06/24 at 9:31 A.M. of LPN #400 revealed she was standing at the medication cart preparing medications for Resident #158. Review of Resident #158's MAR revealed LPN #400 signed off medications she had not yet administered to Resident #158. LPN #400 confirmed she signed off Resident #158's medications including levetiracetam for seizures, but had not administered the medications. LPN #400 stated she signed Resident #158's medications off she administered them because she had to stop preparing Resident #158's medications to prepare Resident #4's medications for administration by UM #401. LPN #400 confirmed she signed off Resident #158's medications before she gave them. Interview on 11/06/24 at 10:42 A.M. of the DON revealed it was not okay to sign resident medications off on the MAR before the medications were given. The DON stated LPN #400 should not have signed Resident #158's medications off before she administered them. Review of the facility policy titled Preparation and General Guidelines, Medication Administration dated 11/2021 included medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The individual who administered the medication dose recorded the administration on the residents MAR directly after the medication was given. Right resident, right drug, right dose, right route and right time are applied for each medication being administered. This deficiency represents non-compliance investigated under Complaint Number OH00158785. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 6 of 9 Printed: 05/15/2026 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 365388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure staff donned appropriate PPE (Personal Protective Equipment) when providing care for Resident's 62 and #158 and failed to ensure enhanced barrier precautions were implemented for Resident #62 timely. This affected two residents (Resident's #62 and #158) of three residents reviewed for infection control. The facility census was 167. Residents Affected - Few Findings include: 1. Review of Resident #62's medical record revealed an admission date of 10/19/24 and diagnoses included benign neoplasm of the cecum, schizoaffective disorder, depressive type, and obstructive and reflux uropathy. Review of Resident #62's progress notes dated 10/19/24 at 3:31 P.M. revealed Resident #62 was admitted to the facility with 28 staples to the abdomen and a JP drain to the left side of his abdomen. Resident #62 had a suprapubic catheter and ileostomy bag. Review of Resident #62's care plan dated 10/24/24 included Resident #62 was at risk for infection and, or trauma related to use of a suprapubic catheter and obstructive uropathy. Resident #62 would be free from infection and, or injury related to foley (indwelling catheter) use. Interventions included to change suprapubic catheter per physician order and as needed; monitor ostomy site for redness, irritation, signs and symptoms of infection and report abnormalities to physician; indwelling suprapubic catheter per physician order, provide catheter care, catheter changes and CD (continuous drainage) bag changes per facility policy; irrigate suprapubic catheter as ordered. Resident #62 had an ileostomy. Resident #62 would maintain a patent colostomy (ileostomy) and have no evidence of peristomal breakdown or skin irritation. Interventions included change colostomy bag (ileostomy) one time weekly and as needed; apply skin barrier, center the pouch over the stoma and apply to skin, press area directly around stoma to maximize adherence, apply closure clip to bag; empty ostomy bag every shift and as needed; monitor stoma and surrounding skin for irritation; rinse pouch keep pouch tail free of stool. Review of Resident #62's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was cognitively intact. Resident #62 required substantial to maximal assistance for bathing and supervision or touching assistance for personal hygiene. Resident #62 had an indwelling catheter and an ostomy. Review of Resident #62's physician orders dated 10/30/24 revealed orders for Enhanced Barrier Precautions (EBP), use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes and care of any device (trach, central line, tube feeding, catheter), every shift for reducing the chance of spreading infection. Review of Resident #62's care plan dated 10/31/24 included Resident #62 had an ADL (activity of daily living) self-care performance deficit related to activity intolerance and had a catheter, ileostomy, and JP (Jackson Pratt) drain. Resident #62 would improve current functional status related to ADL's. Interventions included Resident #62 required extensive assistance with toilet use; Enhanced Barrier Precautions with high-contact care, use gown and gloves for dressing, bathing, showering, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 7 of 9 Printed: 05/15/2026 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 365388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 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 0880 transfers, toileting, hygiene, linen changes, dressing changes and device care. Level of Harm - Minimal harm or potential for actual harm Observation on 11/06/24 at 8:50 A.M. of the door leading into Resident #62's room revealed a CDC (Centers for Disease Control and Prevention) Enhanced Barrier Precautions sign was posted at the entrance to the room. The sign indicated everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), wound care, any skin opening requiring a dressing. Residents Affected - Few Observation on 11/06/24 at 8:50 A.M. of Resident #62 with Licensed Practical Nurse (LPN) #400 revealed he was sitting on the edge of his bed and a catheter bag was secured to his left leg and draining dark yellow urine. The bag was approximately half full and when asked how often Resident #62's catheter bag was emptied LPN #400 stated every shift and emptied the bag which had 200 cc of urine collected in it. LPN #400 did not don an isolation gown when she emptied Resident #400's catheter bag. Resident #62 had an ileostomy and the pouch covering the ileostomy was clean, intact and draining loose greenish colored stool. LPN #400 confirmed she did not don an isolation gown before emptying Resident #62's catheter bag. Interview on 11/06/24 at 3:15 P.M. of Unit Manager (UM) #401 confirmed Resident #62's physician orders for Enhanced Barrier Precautions were not written until 10/30/24 and did not know why it took so long to implement Resident #62's Enhanced Barrier Precautions when he was admitted with an ileostomy, suprapubic catheter, and JP drain. Review of the facility policy titled Enhanced Barrier Precautions reviewed 11/30/23 included Enhanced Barrier Precautions (EBP) was an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs). EBP were to be used for residents with wounds, indwelling medical devices (for example, central line, urinary catheter, feeding tube, tracheostomy, ventilator), known infection or colonization with a novel or targeted MDRO when contact precautions did not apply. Gowns and gloves were to be used for high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (for example residents with wounds or indwelling medical devices). Examples of high-contact resident care activities requiring gown and glove use for EBP included dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, ventilator, wound care, any skin opening requiring a dressing. 2. Review of Resident #158's medical record revealed an admission date of 09/12/23 and a re-entry date of 10/16/24. Resident #158's diagnoses included epilepsy, type two diabetes mellitus with hyperglycemia, and chronic respiratory failure with hypoxia. Review of Resident #158's physician orders dated 10/16/24 revealed orders for Enhanced Barrier Precautions (EBP), use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes and care of any device (trach, central line, tube feeding, catheter), every shift for reducing the chance of spreading infection. Review of Resident #158's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status was not completed due to resident was rarely, never understood. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 8 of 9 Printed: 05/15/2026 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 365388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #158 was dependent for all ADL's. Resident #158 received 51 percent or more of total calories through tube feeding. Resident #158 received oxygen therapy, suctioning and tracheostomy care. Observation on 11/06/24 at 9:50 A.M. of the door leading into Resident #158's room revealed a CDC (Centers for Disease Control and Prevention) Enhanced Barrier Precautions sign was posted at the entrance to the room. The sign indicated everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), wound care, any skin opening requiring a dressing. Observation on 11/06/24 at 9:50 A.M. of Licensed Practical Nurse (LPN) #400 revealed she provided Resident #158's tracheostomy and PEG tube care. LPN #400 did not don an isolation gown before providing tracheostomy and PEG tube care for Resident #158. During the care LPN #400's clothing brushed against Resident #158's bed linens and Resident #158's gown. LPN #400 confirmed she did not don and isolation gown before providing Resident #158's tracheostomy and PEG tube care, stated she should have, and confirmed the presence of the EBP sign posted by the entrance to Resident #158's room. Review of the facility policy titled Enhanced Barrier Precautions reviewed 11/30/23 included Enhanced Barrier Precautions (EBP) was an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs). EBP were to be used for residents with wounds, indwelling medical devices (for example, central line, urinary catheter, feeding tube, tracheostomy, ventilator), known infection or colonization with a novel or targeted MDRO when contact precautions did not apply. Gowns and gloves were to be used for high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (for example residents with wounds or indwelling medical devices). Examples of high-contact resident care activities requiring gown and glove use for EBP included dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, ventilator, wound care, any skin opening requiring a dressing. This deficiency represents non-compliance investigated under Complaint Number OH00159028. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 9 of 9