Health inspection·April 25, 2019

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure indwelling urinary catheter tubing was secured per Resident #19 and Resident #114's plan of care to prevent the catheter from pulling and/or causing irritation or pain. This affected two residents (Resident #19 and #114) of three residents reviewed for urinary catheters. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #114 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbances, retention of urine and benign prostatic hyperplasia with lower urinary tract symptoms. Record review revealed the resident had an indwelling catheter due to the diagnosis of retention of urine. Resident #114 had a care plan in place to have the catheter tubing secured to her leg every morning. Review of physician's order, dated 02/24/19 revealed to change Foley catheter holding (bag) to opposite leg every day at 6:00 A.M Observation and interview with Resident #114 on 04/22/19 at 2:35 P.M. revealed Resident #114 was observed to have an indwelling catheter which was not secured to his leg. Resident #114 was interviewed and stated that the catheter was not secured and hurt when he walked. The resident also stated that staff were notified about the catheter but did not do anything about it. Observation and interview with Licensed Practical Nurse (LPN) #169 on 04/23/19 at 12:21 P.M. revealed LPN#169 verified that Resident #114's catheter was not secured in any fashion and stated that all catheters should be secured to the resident's leg to prevent pulling and pain. 2. Review of the medical record for Resident #19 revealed the resident was admitted to the facility on [DATE] with diagnoses including central cord syndrome at unspecified level of cervical spinal cord, muscle weakness and chronic kidney disease, stage 4. Record review revealed Resident #19 had an indwelling catheter related to her diagnoses. Resident #19 had a care plan to have the catheter tubing secured to her leg every morning. Review of the physician's order, dated 06/13/18 revealed to change Foley catheter holding (bag) to opposite leg every day at 6:00 A.M Observation and interview with Resident #19 on 04/22/19 at 4:13 P.M. revealed Resident #19 was observed to have an indwelling catheter that was not secured to her leg. Resident #19 stated the catheter was not secured and hurt when staff turned her to the side. The resident stated the catheter was secured when she was first admitted but had not been secured for a while. Resident #19 stated staff were aware of it but did not secure it. Observation and interview with LPN #164 on 04/23/19 at 12:15 P.M. revealed LPN #164 observed Resident #19's catheter and verified the catheter was not secured in any fashion. Review of the undated urinary catheter insertion and removal policy revealed catheter tubing was to be secured to the inner thigh of the resident with a leg strap to prevent movement and urethral traction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 2 of 7 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 365567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slovene Home for the Aged 18621 Neff Rd Cleveland, OH 44119 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide the appropriate portion of the planned menu items during the lunch meal on 04/22/19 according to the dietary spreadsheet. This had the potential to affect all 125 residents who received meal trays from the kitchen. The facility identified two residents (Resident #31 and #73) who received nothing by mouth. The facility census was 127. Findings include: Observations during the lunch meal service on 04/22/19 from 12:23 P.M. through 12:41 P.M. revealed residents were served either one or two meatballs with their spaghetti. Observations on the [NAME] Park dining room on 4/22/19 at 12:30 P.M. revealed residents were served one meatball with the spaghetti. Observations on the [NAME] dining room revealed residents were served two meatballs with their spaghetti Observations on the St [NAME] dining room revealed residents were served one meatball. Interview with Dietary Aide #279 on 04/22/19 at 12:41 P.M. revealed she had earlier how many meatballs to serve and [NAME] #271 had told her it did not matter. Interview with Director of Dietary #285 on 4/22/19 at 3:40 P.M. revealed he was not sure how many meatballs should have been served with the meal. Review of the spreadsheet for the meal revealed three ounces of protein were to be served. Interview on 4/22/19 at 4:28 P.M. with Director of Dietary #285 revealed the meatballs were pre-made and were one-ounce meatballs. The facility failed to serve the proper serving size for the lunch meal based on the spreadsheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 3 of 7 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 365567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slovene Home for the Aged 18621 Neff Rd Cleveland, OH 44119 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #324's liquids were properly thickened as ordered by the physician. This affected one resident (Resident #324) of four residents reviewed for thickened liquids. Findings Include: Review of Resident #324's medical record revealed an admission date of 04/07/19 with diagnoses including Parkinson's disease, dementia with behavioral disturbance, heart failure, chronic pulmonary disease and major depressive disorder. Review of a physician's orders revealed Resident #324 was ordered a dysphagia II carbohydrate controlled no added salt diet with nectar thick liquids. Review of Resident #324's baseline care plan dated 04/07/19 revealed the resident was on dysphagia II no added salt diet with nectar thick liquids with a goal to maintain adequate nutrition. Review of Resident #324's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and required extensive assistance from staff for eating. Review of Resident #324's tray ticket under preferences revealed Resident #324 was to get ground meat, extra gray and sauces, pureed bread, nectar thick soup, nectar thick packet, nectar thick coffee, nectar thick milk and nectar thick juice. Observation on 04/22/19 at 12:54 P.M. revealed Resident #324's tray had regular Italian wedding soup, pureed spaghetti, pureed meatballs, mashed potatoes, and pureed vegetables. This was verified by State Tested Nursing Assistant (STNA) #121. STNA #121 thickened the coffee with the packet of thickener that was on the tray and started to walk away but did not thicken the Italian wedding soup. Review of facility's diet policy for Therapeutic Diets revealed that liquids are to be thickened to proper consistency. Interview with the Director of Dining Services on 4/22/19 at 3:40 P.M. revealed the resident's soup should have been thickened with the packet provided and that instant thickened coffee packets were provided for coffee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 4 of 7 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 365567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slovene Home for the Aged 18621 Neff Rd Cleveland, OH 44119 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure a therapeutic diet was provided to Resident #324 as ordered by the physician. This affected one resident (Resident #324) of five residents who received therapeutic a dysphagia II diet. Findings include: Review of Resident #324's medical record revealed an admission date of 04/07/19 with diagnoses including Parkinson's disease, dementia with behavioral disturbance, heart failure, chronic pulmonary disease and major depressive disorder. Review of the physician's orders revealed Resident #324 was ordered a dysphagia II carbohydrate controlled no added salt diet with nectar thick liquids. Review of Resident #324's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and required extensive assistance from staff for eating. Review of Resident #324's baseline care plan dated 04/07/19 revealed the resident was on dysphagia II no added salt diet with nectar thick liquids with a goal to maintain adequate nutrition. Review of Resident #324's tray ticket under preferences revealed Resident #324 was to get ground meat, extra gray and sauces, pureed bread, nectar thick soup, nectar thick packet, nectar thick coffee, nectar thick milk and nectar thick juice. Observation on 04/22/19 at 12:54 P.M. revealed that Resident #324's tray had regular Italian wedding soup, pureed spaghetti, pureed meatballs, mashed potatoes, and pureed vegetables. This was verified by State Tested Nursing Assistant #121. Interview with the Director of Dining Services on 04/22/19 at 3:40 P.M. revealed the meat served to the resident should not have been pureed and he put on the diet ticket for ground meat for the staff. Review of facility's diet policy for Dysphagia II diet revealed protein foods should be chopped, or ground as tolerated, vegetables should be chopped or shredded but may be pureed, and pasta well cooked. Review of facility's spread sheet revealed residents on Dysphagia II diet should be served minced Italian wedding soup, spaghetti with meatballs minced, mashed potatoes, minced mixed vegetables with no corn, fruit cup minced, milk and coffee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 5 of 7 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 365567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slovene Home for the Aged 18621 Neff Rd Cleveland, OH 44119 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, food transportation carts were cleaned, food products were dated when opened and food/beverages were served in a manner to prevent contamination and/or food borne illness. This had the potential to affect all 125 residents who received meal trays from the kitchen. The facility identified two residents (Resident #31 and #73) who received nothing by mouth. The facility census was 127. Findings include: 1. Observations during the initial tour of the kitchen on 04/22/19 from 8:00 A.M. through 8:25 A.M. revealed the following: There were four of four garbage cans with trash in them were not covered with lids. The slicer had dried food on the blade and slicer guard, the floor mixer had food splatter on it and dried food was inside the mixing bowl, the table top mixer had food splatter on it, the wall behind the food processor had food splatter on it, the reach-in refrigerator had food splatter on the outside and inside of the door and there was a food residue on the clean side drain board of the dish machine. Observations of the walk-in refrigerator revealed there was salad mix, mozzarella cheese, shredded cheddar cheese, pureed desserts and tomato sauce that were not dated when opened. Interview with Director of Housekeeping #320 verified the findings on 04/23/19 at 8:25 A.M. 2. Observations during the tour of the pantries located in on all of the units on 04/22/19 from 8:40 A.M through 9:00 A.M. with Director of Dining Services #285 revealed four Cambro food transport containers that had food delivered to four serveries had food splatter on the outside and inside. Interview with Director of Dietary #285 on 04/23/19 at 10:31 A.M. revealed the dietary department had been short staffed lately and the kitchen could be cleaner. Review of the sanitation policies dated 2016 revealed that equipment and food contact surfaces would be sanitized. Cleaning instructions were provided for food carts, microwave oven, and slicer. 3. Observation of the lunch service on 04/22/19 at 12:20 P.M. revealed Dietary Staff (DS) #282 was wearing gloves as he served cups of juice and coffee. DS #282 was holding the cups around the top rim with his fingertips. DS #282 was observed pushing the beverage cart throughout the dining room as he continued to serve the beverages to Resident #2, #14, #18 #21, #32, #33, #37, #42, #56, #72 #76, #79, #81, #94, #99, #100, #110 and #422 without changing his gloves. DS #282 was observed at 12:25 P.M. entering the servery in the dining room to open the refrigerator and pour juice into cups, DS #282 continued to serve beverages without changing gloves. An interview with DS #282 at 12:30 P.M. revealed DS #282 stated his gloves were clean and that was why he did not change them. Observation of the lunch service on 04/22/19 at 12:35 P.M. revealed DS #273 was wearing gloves as the employee touched food scoops, trays and opened the refrigerator several times. DS #273 then began to plate food which included dinner rolls. DS #273 grabbed the dinner rolls for Resident #2, #14, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 6 of 7 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 365567 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slovene Home for the Aged 18621 Neff Rd Cleveland, OH 44119 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 #18 #21, #32, #33, #37, #42, #56, #72 #76, #79, #81, #94, #99, #100, #110 and #422 with the same gloves he had worn while touching the above items. An interview with DS #273 at 12:40 P.M. verified the employee failed to change gloves/complete hand hygiene after touching non-food items before using gloved hands to touch dinner rolls. Review of Staff Fundamentals for serving food policy, dated 2016 revealed staff were to change gloves when in contact of unclean surfaces, doors and/or equipment. Event ID: Facility ID: 365567 If continuation sheet Page 7 of 7