Inspection·July 10, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete which was sitting on the windowsill to the left of the steam table, revealed there were no spread sheets in the book. DM #487 confirmed at the time of observation there were no spread sheets in the book and went on to state I print them out daily and they were on my desk.Review of the week three's facility diet spread sheet for Mondays lunch on 07/07/25 at 1:07 P.M. and interview with DM #487 revealed the dietary manager confirmed the residents on a CCD regular or mechanical soft diet should have received regular sweet potatoes instead of candied sweet potatoes and the residents on either a liberal renal or renal regular or mechanical soft diet should have received buttered noodles instead of the candied sweet potatoes. When asked why the spread sheet hadn't been followed for the CCD, Liberal Renal or Renal diets, DM #487 replied that the facility usually had pretty liberal diets, and she hadn't double checked to ensure everyone was receiving the appropriate items for the diet. Interview on 07/08/25 at 3:15 P.M. with Dietitian #457 confirmed the dietary spread sheets should have been followed for lunch on 07/07/25.Review of the facility's undated policy Menu and Guidelines revealed there was nothing in the policy regarding following spreadsheets. This deficiency represents non-compliance investigated under Complaint Number OH00164551. Event ID: Facility ID: 365388 If continuation sheet Page 2 of 8 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 07/10/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure palatable meals were served to the residents. This affected two residents (#112 and #129) out of three residents reviewed for food/nutrition. The facility census was 162.Findings include: 1.Review of the medical record for Resident #112 revealed an admission date of 03/04/25. Diagnoses included type two diabetes mellitus, injury of head, hypertension (high blood pressure), and adult failure to thrive. Review of physician orders revealed an order dated 03/10/25 for CCD (carbohydrate controlled diet), regular Texture, thin liquids. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/11/25, revealed Resident #112 was cognitively intact, had no significant weight changes, and was prescribed a therapeutic diet. Review of Resident #112's care plan, dated 03/10/25, revealed the resident had altered nutritional status related to diabetes mellitus and hypertension. Interventions included diet per physician order.Further review of Resident #112's medical record revealed a progress note dated 04/04/25 where it was noted Resident #112 was complaining about the amount of salt in the food coming from the kitchen. An interview on 06/30/25 at 10:08 A.M. with Resident #112 revealed she stated the food was so salty and it lacked appeal due to how much salt was in the food. 2. Review of the medical record for Resident #129 revealed an admission date of 02/21/25. Diagnoses included end stage renal disease (ESRD), hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, dependence on renal disease, localized edema, and personal history of sudden cardiac arrest. Review of Resident #129's physician orders revealed an order dated 03/11/25 for a renal diet, regular texture, thin liquids. Review of the quarterly MDS 3.0 assessment, dated 06/06/25, revealed Resident #129 was moderately impaired cognitively, required setup or clean up assistance for eating, had no significant weight changes, and was on a therapeutic diet. Review of the care plan, dated 02/27/25, revealed Resident #129 had altered nutrition as evidenced by ESRD and needing hemodialysis, heart disease, and fluctuating weights. Interventions included diet per dietitian recommendation and physician order; encourage adequate meal intakes; monitor and record resident's intake of foods/fluids after each meal; monitor post-dialysis weights monthly or as needed; report weight loss/gain or more to the physician and dietitian; and visit at meal rounds. In an interview with Resident #129's spouse on 06/30/25 at 11:54 A.M. revealed Resident #129 had expressed to him that the food was too salty and she was concerned about it being too salty. 3. Review of week three day 16 (07/07/25) of the facility's menu revealed for lunch herb roasted pork, candied sweet potatoes, and buttered cabbage was to be served. Review of the recipe for buttered cabbage for 161 servings, revealed after the cabbage was cooked in water until fork tender, the cabbage was to be drained and one pound and ten ounces of margarine and one tablespoon and one fourth teaspoon salt if iodized was to be added to the cooked cabbage. There was no indication seasoned salt should have been added in addition to the iodized salt. Review of recipe for herb roasted pork loin for 161 servings revealed in a bowl three fourths of a cup of mince garlic, three fourths of a cup of basil leaves, six tablespoons and one teaspoon of dried thyme, three fourths of a cup of crushed rosemary, six tablespoons and one teaspoon of salt, and six tablespoons and one teaspoon of black pepper was to be mixed into one quart and one cup of vegetable oil. The marinade was to be rubbed over the entire surface of the pork loins and then roasted until the internal temperature reached 145 degrees F for four minutes and then sliced into serving portion. There was no indication brown gravy should have been added to the herb pork loin. Observation on 07/07/25 between 11:22 A.M. and 12:58 A.M. revealed on the steam table there was a large container of pork loin with gravy on it, candied sweet potatoes, and buttered cabbage, and there were smaller containers of ground pork with gravy, pureed pork, pureed candied sweet potatoes, and pureed Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 3 of 8 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 07/10/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete cabbage. There was one five pound container of seasoned salt sitting on the stainless counter to the side of the steam table. Interview on 07/07/25 with Dietary [NAME] #412 during tray line observation between 11:22 A.M. to 12:58 A.M. revealed she had made the items for the lunch meal. She stated she had added seasoned salt and brown gravy to the pork loin, had added brown sugar, cinnamon, butter, garlic powder, onion powder, seasoned salt, and black pepper to the sweet potatoes, and had added seasoned salt, garlic powder, onion powder, iodized salt, and butter to the cabbage. She stated she usually added either seasoned salt or iodized salt or both to the food items so the items would have a taste. She stated she hadn't followed any recipes for items for lunch that day since she knew how to make those items. Dietary [NAME] #412 stated recipes for meals items were located in the Cook's book. Observation on 07/07/25 at 12:56 P.M. of the binder labeled Cook's Book located on the window sill to the left of the steam table revealed there were no recipes in the binder. Interview at the time of observation with Dietary Manager (DM) #487 confirmed there were no recipes in the binder. She stated she usually put the recipes in the binder weekly, but she hadn't put any recipes in the binder for that week. Observation on 07/07/25 at 12:50 P.M. revealed the last food cart was being loaded with resident meal trays and a test tray was requested for that cart. At 12:57 P.M. a test tray was plated and left the kitchen at 12:58 P.M. At 1:00 P.M. the food cart was delivered to the two East unit and by 1:07 P.M. the last tray had been served. DM#487 at 1:08 P.M. took the test tray out of the covered food cart and took the test tray to the counter at the nurse's station. Using a facility thermometer DM #487 took the temperature of the food items. The pork loin was tender, tasted warm but tasted heavily salted to the point the salt flavor was the prominent flavor. The pork loin was served with brown gravy on it and was 121 degrees Fahrenheit (F). The candied sweet potatoes had a nice sweet flavor and tasted warm. The candied sweet potatoes were 161 degrees F. The cabbage tasted warm but also tasted heavily salted. The cabbage was 156 degrees F. After DM #487 had taken the temperature of all the test tray items, she then tasted the pork loin, cabbage, and candied sweet potatoes. DM487 # confirmed both the pork loin and cabbage were salty and gravy had been put on the pork loin and it should not have had gravy. An interview on 07/08/25 at 3:15 P.M. with Dietitian #457 confirmed recipes should have been followed as written and no extra seasonings should be added if it was not on the recipe. Review of the facility's undated policy Menu and Guidelines revealed there was nothing in the policy regarding following recipes as written. This deficiency represents non-compliance investigated under Complaint Number OH000165404. Event ID: Facility ID: 365388 If continuation sheet Page 4 of 8 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 07/10/2025 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 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 and record review the facility failed to ensure appropriate infection control techniques were used for residents on enhanced barrier precautions. This affected two residents (#14 and #147) of two observed for infection control precautions. The facility census was 162.Findings include:1. Review of Resident #14's medical records revealed an admission date of 06/09/22. Diagnoses included cerebral palsy, tracheostomy and gastrostomy.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had no cognition score due to being rarely understood. Resident #14 was dependent for eating, toileting and personal hygiene. Review of the care plan dated 05/20/25 revealed Resident #14 required Enhanced Barrier Precautions (EBP) related to feeding tube and tracheostomy. Interventions included utilize gown and gloves during high contact care that included care of feeding tube and/or trach.Review of current physician orders for July 2025 revealed Resident #14 was on EBP and the use of gown and gloves were required for high contact care.2. Review of Resident #147's medical records revealed an admission date of 10/16/24. Diagnoses included tracheostomy and gastrostomy.Review of the MDS 3.0 assessment dated [DATE] revealed Resident #147 had no cognition score due to being rarely understood. Resident #147 was dependent for eating, toileting and personal hygiene. Review of the care plan dated 04/26/25 revealed Resident #147 required Enhanced Barrier Precautions (EBP) related to feeding tube and tracheostomy. Interventions included utilize gown and gloves during high contact care that included care of feeding tube and/or trach.Review of current physician orders for July 2025 revealed Resident #147 was on EBP and the use of gown and gloves were required for high contact care.Observation on 07/07/25 at 5:30 A.M. revealed Licensed Practical Nurse (LPN) #343 had entered Resident #14's room and had not donned Personal Protective Equipment (PPE). LPN #343 had proceeded to administer Resident #14's tube feeding, checked tube feeding residual in Resident #14's feeding tube and had checked Resident #14's feeding tube site.Observation on 07/07/25 at 6:15 A.M. revealed LPN #343 had entered Resident #147's room and had not donned PPE. LPN #343 had proceeded to administer Resident #147's tube feeding and had checked Resident #147's tube feeding site. Interview with LPN #343 after completion of care for Resident #14 and #147 confirmed Resident #14 and #147 had signs posted outside of their room that had indicated Resident #14 and #147 were on EBP and the use of gowns and gloves were required prior to providing care. LPN #343 confirmed she had not donned PPE prior to providing care for Residents #14 and #147 and stated there was no PPE available in Resident #14 and #147's room. LPN #343 confirmed PPE was to be donned prior to providing care for residents on EBP.Review of facility policy titled Enhanced Barrier Precautions revised 01/06/25 revealed residents were to be placed on EBP for residents who had indwelling medical devices that included feeding tubes and PPE was to be donned during care that included gowns and gloves.This deficiency represents non-compliance investigated under Complaint OH00165512 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 5 of 8 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 07/10/2025 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record reviews, and facility policy, the facility failed to ensure their smoking policy was followed for the independent smokers. This affected three independent smoking residents (#42, #98, and #104) reviewed for smoking but had the potential to affect an additional 12 residents (#12,#17, #32, #36, #65, #93, #97, #99, #128, #146, #151, #153) the facility identified as being independent smokers. The facility identified 30 residents (#5, #11, #12 ,#17, #19, #25, #32, #36, #42, #49, #51, #64, #65, #66, #71, #81, #82, #89, #93, #97, #98, #99, #100, #104, #107, #109, #128, #146, #151, #153) as being smokers. The facility census was 162. Findings include: Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure the smoking policy was being implemented in the facility. This affected three residents (#42, #98, and #104) of three residents reviewed for smoking. The facility identified a total of 30 residents (#5, #11, #12 ,#17, #19, #25, #32, #36, #42, #49, #51, #64, #65, #66, #71, #81, #82, #89, #93, #97, #98, #99, #100, #104, #107, #109, #128, #146, #151, #153) as being smokers. The facility census was 162. Findings include:1.Reveiw of the medical for Resident #104 revealed an admission date of 06/05/25 and a discharge date of 07/03/25. Diagnoses included hypertensive and kidney disease and nicotine dependence.Review of Resident #104 06/12/25 Admission/Medicare Five Day Minimum Data Set (MDS 3.0 assessment revealed the resident cognitively intact and was identified as being a current tobacco user.Review of Resident #104's facility smoking evaluation , dated 06/25/25, revealed Resident #104 demonstrated compliance with smoking rules, knew where smoking materials were to be properly stored/kept, exhibited knowledge of facility smoking rules and policies, and was assessed to be an independent smoker. Further review of Resident #104's progress notes in the medical record revealed a progress note dated 06/25/25 and authored by Licensed Practical Nurse (LPN) Wound Nurse #413,which indicated the resident was observed with what appeared to be burn areas on face and nose. The resident refused to go to the emergency room for further evaluation but did agree to go to the burn clinic when an appointment could be made. On 06/30/25 the nurse practitioner made a late entry note progress note with an effective date of 06/25/25 which indicated nursing reported to her Resident #104's facial wounds were related to when a lighter blew up in his face. Review of Resident #104's care plan, dated 06/12/25, revealed Resident #104 had a potential problem related to tobacco use related injuries related to being a smoker. Interventions included: dispose smoking items in a sanitary and safe manner; if resident is non-compliant with smoking facility policy, review smoking facility policy and documents education; make sure that family is aware that they are not to give cigarettes and/or lighters directly to the resident but rather at the nurse's station; monitor for cognitive or physical functioning changes that may impede resident's ability to smoke; provide resident with education regarding where and how to dispose of tobacco; resident will observe facility smoking policy and smoke in designated areas; smoking evaluation upon admission and quarterly and updated prn. An interview on 06/30/25 at 11:54 A.M. with Certified Nursing Assistant (CNA) #309 revealed Resident #104 had been caught with smoking materials in his room numerous times. He had been educated by nurses and aides about not having smoking materials. His wife had also been educated since she would bring in cigarettes and lighters for the resident. Observation on 06/30/25 at 12:35 P.M. revealed Resident #104 had red scabbed area to the tip of his nose and a scabbed area under his nostrils. Clothes appeared free of any burn holes. Interview at the time of observation with Resident #104 revealed when asked what caused the scabbed areas to his nose and face, he stated he was checking his lighter in his room and the lighter got too close to his face, which caused reddened areas around his nose and for some of his facial hair around his nose to be singed off. An interview on 06/30/25 at 3:02 P.M. with the wife of Resident #104 revealed the resident had been keeping his Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 6 of 8 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 07/10/2025 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cigarettes and lighter in his room until he had the incident with the lighter and his cigarettes and lighter were no longer being kept in the room. A interview on 07/07/25 at 2:18 P.M. with Director of Nursing confirmed Resident #104 kept a lighter in his room.Interviews on 07/07/25 between 3:36 P.M. and 3:43 P.M. with CNA #478 and #477 revealed during residents who smoke should not keep smoking materials in their room.2. Review of the medical record for Resident #98 revealed an admission date of 04/01/23. Diagnoses included polyneuropathy (a condition where the peripheral nerves are damaged which can cause weakness and numbness to hands and feet), peripheral vascular disease (diseases of the blood vessels located outside heart and brain),anxiety disorder, and chronic respiratory failure, and chronic obstructive pulmonary disease (COPD). Review of Resident #98's annual MDS 3.0 assessment, 04/08/25, revealed the resident could make self-understood and understood others, was cognitively intact, exhibited no behaviors including rejection of care, was independent for all activity of daily living and could independently maneuver his manual wheelchair; and had no skin concerns including burns. Review of the Resident #98's facility smoking evaluation, dated 06/25/25, revealed Resident #104 demonstrated compliance with smoking rules; knew where smoking materials were to be properly stored/kept; exhibited knowledge of facility smoking rules and policies; and was assessed to be an independent smoke. Review of Resident #98's care plan dated 04/06/23 revealed the resident had potential for tobacco use related injuries related to the resident chose to smoke at the facility. Interventions included: if resident was non-compliant with smoking policy, review smoking policy and document education; make sure family was aware they were not to give cigarettes and/or lighters directly to the resident; monitor for cognitive or physical functioning changes that may impede resident's ability to smoke; smoking evaluation upon admission and quarterly and updated as needed; and supervise for safety during smoking and remind resident of smoking rules and policies as needed. Observations on 06/30/25 between 3:34 and 3:40 P.M. revealed Resident #98 was smoking in the parking lot. He had a blue folded mattress pad which appeared to have four cigarette burn holes in it. Interview at the time of observation revealed he had his own lighter in his pocket and refused to show the state surveyor and went on to state, I am not going to give it up. He stated he had dropped ashes while he smoked which was why he had the folded mattress pad on his lap. Observation on 07/02/25 at 11:32 A.M. revealed Resident #98 was outside smoking and had a folded mattress pad across his lap that with multiple burn holes. Interview at time of observation with Resident #98 revealed he kept his lighter on him and refused to give it up to anyone. 3. Review of the medical record for Resident #42 revealed an admission date of 11/09/23. Diagnoses included malignant neoplasm of prostate, secondary neoplasm of lymph nodes of head, face, and neck, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, and personal history of nicotine dependence. Review of Resident #42's physician orders revealed an order dated 01/24/24 for oxygen at two liters via nasal cannula every shift. Review of Resident #42's quarterly MDS 3.0 assessment revealed the resident was severely impaired cognitively; exhibited fluctuating inattention and disorganized thinking; exhibited no behaviors during the assessment reference period; required staff supervision for transfers; didn't walk but was able to maneuver manual wheelchair independently; was on oxygen; and was receiving Hospice services.Review of Resident #42's smoking evaluation, dated 06/17/25, revealed Resident #42 demonstrated compliance with smoking rules; knew where smoking materials were to be properly stored/kept; exhibited knowledge of facility smoking rules and policies; and was assessed to be an independent smoke.Review of Resident #42's care plan, dated 06/13/24, revealed Resident #42 had the potential for tobacco related injuries related to smoking. Interventions included: if resident was non-compliant with smoking policy, review smoking policy and document education; make sure family was aware they were not to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365388 If continuation sheet Page 7 of 8 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 07/10/2025 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete give cigarettes and/or lighters directly to the resident; monitor for cognitive or physical functioning changes that may impede resident's ability to smoke; smoking evaluation upon admission and quarterly and updated as needed; and supervise for safety during smoking and remind resident of smoking rules and policies as needed.Observation on 07/02/25 at 11:41 A.M. revealed Resident #42 was in his room being assisted by Hospice Aide #520. There was an oxygen concentrator in the room but Resident #42 wasn't using any oxygen at the time of observation. Further observation revealed two lighters were on Resident #42's bedside table in his room. Interview with Hospice Aide #520 at time of observation confirmed Resident #42 did wear oxygen at times and confirmed he had two lighters in his room.4. Review of the facility policy Resident Smoking, reviewed date of 01/06/25, revealed if the smoking evaluation determined a resident could safely smoke independently of observation and assistance, a resident would be permitted to smoke independently of supervision. Smoking materials including cigarettes, cigars, pipes, lighters, vapes, E-cigarettes needed to be locked up when not in use, and smoking materials would only be used by the resident personally during smoking times. Interviews conducted with various staff members throughout the survey revealed staff members were not well versed in the facility's smoking policy as evidences by:Interview on 06/30/25 at 3:12 P.M. with License Practical Nurse (LPN) #452 revealed residents who were independent smokers were allowed to have cigarettes but LPN #452 was not sure if residents who were independent smokers were allowed to keep their lighters with them. Interview on 06/30/25 at 3:26 P.M. with Activity Director #392 revealed she believed residents who were independent smokers were allowed to have cigarettes but were not allowed to have a lighter on them. Interview on 06/30/25 at 5:05 P.M. with Certified Nursing Assistant (CNA) #490 revealed residents who were independent smokers were allowed to keep their own cigarettes and lighters with them. Interview on 07/02/25 at 10:08 A.M. with CNA #328 revealed residents who were independent smokers were allowed to keep their own cigarettes and lighters with them. Interview on 07/02/25 at 11:58 A.M. with Receptionist #433 revealed the receptionists were responsible for stocking the container of cigarettes for the supervised smoking sessions. She stated the only cigarettes being stored behind the receptionist's desk were cigarettes for supervised smokers. She stated she didn't store any of the smoking materials for the independent smokers and didn't have a list of which residents were independent smokers. Observation of the room behind the receptionist's desk with Receptionist #433 revealed the only labeled cigarettes in the room were for residents who were supervised smokers. Interview on 07/02/25 at 1:37 P.M. with CNA #423 revealed residents who were independent smokers were allowed to keep their cigarettes with them in their room and some residents were also allowed to keep their lighters with them. Interview on 07/02/25 at 2:18 P.M. with Director of Nursing revealed residents who were independent smokers are allowed to have cigarettes with them since having cigarettes makes them feel better but were not allowed to have a lighter on them. Interview on 07/07/25 at 5:05 P.M. with Registered Nurse Supervisor #408 revealed residents who were independent smokers were allowed to keep their cigarettes and lighters with them.Interview on 07/09/25 at 4:24 P.M. with Administrator revealed for independent smokers cigarettes and lighters were to be kept at the front desk receptionist area where they are to ask for a lighter and cigarettes and were to then bring the lighter back to the receptionist. This deficiency represents non-compliance investigated under Master Complaint Number OH00166965 Event ID: Facility ID: 365388 If continuation sheet Page 8 of 8