Franklin Plaza Extended Care

Inspectors wroteBased on closed record review, hospital record review, facility policy review and interview, the facility failed to ensure staff provided Resident #168 with necessary, adequate and safe assistance during activities of daily living (ADL)/personal care to prevent fall with major injury, and failed to provide Resident #162 sufficient supervision and intervention to prevent the resident from exiting the facility unsupervised. This affected two residents (Resident #162 and #168) of three reviewed for accidents. Actual harm occurred on 09/14/25 at approximately 7:00 P.M. when Resident #168, who was cognitively impaired, a quadriplegic, and required two-person assistance with ADLs, was being changed (provided personal care) by one staff, Certified Nursing Assistant (CNA) #514, resulting in the resident falling out of bed and landing on the floor. [...]

Inspectors wroteBased on observations, interviews and facility policy, the facility failed to ensure the environment was maintained in a safe, clean, homelike manner. This affected Resident #31, #46, #74, #95, #109, #128, #130, #141, #148 and had the potential to affect all 164 residents. 1. Observation on 02/19/26 at 8:42 A.M. revealed an unlocked cleaning supply closet on the second floor. Observation on 02/19/26 at 8:53 A.M. revealed Housekeeper #474 had entered the unlocked cleaning room on the second floor and had placed her cleaning cart inside and had left the door unlocked after exiting. Interview with Housekeeper #474 confirmed the cleaning closet had been unlocked and stated she did not have keys to unlock it. Observation on 02/19/26 at 9:07 A.M. revealed an unlocked cleaning supply closet on the third floor. Observation on 02/19/26 at 9:22 A.M. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy, the facility failed to ensure the menu was followed. This had the potential to affect 160 out of 164 residents who ate meals in the facility's kitchen, as four residents (Residents #7, #89, #123, and #146) received enteral nutrition and did not receive meals from the kitchen. The facility census was 164.

Inspectors wroteBased on observation, interview, record review, and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 160 out of 164 residents who ate meals in the facility's kitchen as four residents (Residents (#7, #89, #123, and #146) received enteral nutrition and did not receive meals from the kitchen. The facility census was 164.

Inspectors wroteBased on record review, observations, interviews and facility policy the facility failed to implement safe smoking policies and procedures. This had the potential affect all 37 smokers at the facility. The facility census was 164.

Inspectors wroteBased on interview, observation and record review the facility failed to ensure a comprehensive wound management system was in place to properly assess and treat Resident #52's new vascular wounds, and failed to ensure Resident #58's were clean and in good condition. This affected one resident (Resident #58) of four observed for assistive devices, and one resident (Resident #52) of two residents reviewed for skin impairments.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure timely incontinence care was provided to Resident #64 and adequate catheter care was provided to Resident #153. This affected one resident (Resident #64) of three observed for incontinence care and one resident (Resident #153) of two observed for catheter care. The facility census was 164.

Inspectors wroteBased on resident and staff interviews, observation, review of the facility's Self-Reported Incident (SRI) and investigation, record review, and review of the facility policy, the facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse. This affected one (Resident #1) of three residents reviewed for sexual abuse. The facility census was 165.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure a safe, clean, comfortable and homelike environment for six (Residents #18, #146, #130, #65, #87 and #102) of 12 residents reviewed for environment. This had the potential to affect all residents residing in the facility. The facility census was 163.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure a safe, functional, sanitary and comfortable environment. This affected 10 (Residents #11, #37, #53, #94, #103, #143, #144 #155, #156, and #160) out of 12 residents reviewed for environment and had the potential to affect all residents residing in the facility. The facility census was 163.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure advanced directives were accurate. This affected one (Resident #129) of one resident reviewed for advanced directives. The facility census was 163.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #59 was free from restraint. This affected one (Resident #59) out of one resident reviewed for use of a device/restraint. The facility census was 163.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete resident assessments. This affected one (Resident #15) of three residents reviewed for resident assessments. The facility census was 163.

Inspectors wroteBased on record reviews, interviews and observations, the facility failed to revise care plans for Resident #62 and Resident #63. This affected two (Residents #62 and #63) of two residents reviewed for revision of care plans. The facility census was 163.

Inspectors wroteBased on observation, interview, record review, time punch review and review of the facility policy, the facility failed to ensure timely incontinence care was provided. This affected one (Resident #156) out of two residents reviewed for incontinence care. This had the potential to affect 63 (Residents #1, #2, #3, #6, #9, #13, #22, #26, #30, #31, #36, #37, #39, #44, #50, #53, #55, #57, #58, #59, #60, #67, #70, #73, #78, #81, #89, #91, #92, #97, #99, #100, #103, #105, #114, #117, #125, #126, #128, #131, #133, #134, #135, #138, #140, #143, #144, #145, #150, #154, #155, #156, #157, #158, #160, #161, #162, #165, #167, #168, #170, #171, and #174) identified by the facility as incontinent. The facility census was 163.

Inspectors wroteBased on record reviews, interviews, facility policy review and review of facility staff training, the facility failed to provide trauma-informed care to Residents #17 and #28. This affected two (Residents #17 and #28) out of two residents reviewed for trauma-informed care. The facility reported nine Residents #2, #4, #17, #18, #28, #74, #93, #117 and #119) who had trauma-related diagnoses. The facility census was 163.

Inspectors wroteBased on record review, interviews and job description review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for Resident #26. This affected one (Resident #26) of two residents investigated for medically related social services. The facility census was 163.

Inspectors wroteBased on observation, interviews, review of diet spreadsheets, and review of facility policy, the facility failed to ensure residents on a controlled carbohydrate diet (CCD) diet with regular or mechanically altered consistency, liberalized renal diet with a regular or mechanically altered consistency, or a renal diet with a regular or mechanically altered consistency received the appropriate food items at meals. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to timely order Resident #62 ileostomy and catheter care to ensure treatment was in place. This affected one resident (Resident's #62) out of three reviewed for catheter and ostomy care. The facility census was 167.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure facility garbage and refuse was maintained in a sanitary condition. This had the potential to affect all 157 residents residing in the facility. The facility census was 157.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide reasonable accommodations during meals for Resident #128 with visual impairments and failed to provide appropriate length beds for Resident's #5 and #140. This affected three (Resident's #128, #5 and #140) of eight residents reviewed for reasonable accommodation of needs. The facility census was 169.

Inspectors wroteBased on record review, observations, and interview the facility failed to date and/or change supplemental oxygen tubing in a timely manner. This affected two (Resident's #27 and #38) of 12 residents reviewed for oxygen therapy. The facility census was 169. Findings Included: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including unspecified dementia and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had intact cognition. Review of physician order dated 04/13/22 revealed Resident #27 was to receive supplemental oxygen via nasal cannula every shift for shortness of breath. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to date opened insulin vials to ensure purity and potency. This affected four (Resident's #1, #41, #80 and #122) of 29 residents reviewed for insulins. The facility census was 169.

Inspectors wroteBased on observations and interviews, the facility failed to maintain infection control standards when serving food. This affected one (Resident #20) of 20 residents observed for dining. The facility census was 169.

Inspectors wroteBased on observation, policy review, interview, and review of manufacturer's recommendations, the facility failed to ensure dishes were maintained in a clean and sanitary manner. This had the potential to affect 162 who ate meals in the facility's kitchen. Four residents (#11, #50, #128, and #374) received enteral nutrition as their only source of nutrition. The facility census was 162.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure isolation rooms were cleaned properly. This affected one resident (Resident #144) of five residents reviewed for infections and these cleaning practices had the potential to affect all residents residing in the facility. The facility census was 162 residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident medications were stored properly in medication carts. This affected three of six medication carts in the facility. The facility census was 162.

Inspectors wroteBased on record review and interview the facility failed to ensure the advance directive orders were accurate and consistent in the electronic and non-electronic charting. This affected two residents (Resident # 138 and Resident # 324) of 37 residents reviewed for advanced directives. The facility census was 162 Findings Include: 1. Record review revealed Resident #138 was admitted on [DATE] with diagnoses including chronic kidney disease, heart disease, a pressure ulcer located on the base of the spine. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required extensive physical assistance activities of daily living. [...]

Inspectors wroteBased on interview and observation, the facility failed to ensure smokers (#139 and #373) were supervised during smoke break on the secured unit. This affected two out of the four residents (#73, #131, #139 and #373) that smoked on the secure unit. The facility census was 162.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the outside dumpster garbage disposal area was maintained in a clean manner. This had the potential to affect all facility residents. The facility census was 162.