Health inspection·May 19, 2022

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure written bed hold notices were provided to residents or the resident representative when transferred to the hospital. This affected two residents (#27 and #73) of two residents reviewed for hospitalization. The facility census was 71. Findings include: Review of the medical record for Resident #27 revealed an admission date of 09/12/18. Diagnoses included hypertension, delirium due to known physiological condition, asthma, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severely impaired cognition, required supervision of one staff for bed mobility, transfers, and limited assistance of one staff for toilet use. Review of the Notice of Transfer or Discharge forms dated 11/04/21 and 03/03/22 revealed Resident #27 was transferred to the hospital on [DATE] and 03/03/22. Review of the closed medical record for Resident #73 revealed an admission date of 03/30/18 and a discharge date of 04/20/22. Diagnoses included dementia without behavioral disturbance, open wound of scrotum and testes, urogenital implants, and urinary catheter. Review of the quarterly MDS assessment dated [DATE] revealed Resident #73 had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, and toilet use and limited assistance of one staff for locomotion on and off the unit. Review of the Notice of Transfer or Discharge forms dated 04/13/22 revealed Resident #73 was transferred to the hospital on [DATE]. Interview on 05/18/22 at 4:52 P.M. with Social Services Director (SSD) #323 revealed the business office manager called the resident or resident representative and verbally informed them of their bed hold days and asked if they wanted to hold the bed. SSD #323 stated no written notices were provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 2 of 11 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 05/19/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the proper use of incontinence briefs and liners to prevent potential skin breakdown and infection. This affected three (#6, #31 and #68) of three residents observed for incontinence care. Findings include: 1. Review of Resident #6's medical records revealed an admission date of 10/15/19 with diagnoses that included Parkinson's disease, dementia and incontinence. Review of the care plan dated 04/20/22 revealed Resident #6 had self care deficits related to limited mobility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition and required total dependence with toileting. Observation of incontinence care on 05/16/22 at 9:38 A.M. with State Tested Nursing Assistant (STNA) #344 revealed Resident #6 was wearing two incontinence briefs. Interview with STNA #344 at time of observation revealed she had not provided care to Resident #6 previously on this shift and was not aware the resident was wearing two incontinence briefs. 2. Review of Resident #31's medical records revealed an admission date of 03/09/19 with diagnoses that included muscle weakness and difficulty walking. Review of the care plan dated 02/25/22 revealed Resident #31 had self care deficits related to limited mobility and was dependent on staff for toileting needs. Review of the MDS assessment dated [DATE] revealed Resident #31 had impaired cognition and was incontinent of bowel and bladder. Observation of incontinence care on 05/16/22 at 10:07 A.M. with STNA #303 revealed Resident #31 was wearing two incontinence briefs. Interview with STNA #303 at time of observation revealed she had not cared for Resident #31 since she began her shift at 6:00 A.M. and had not been aware the resident was wearing more than one incontinence brief. 3. Review of Resident #68's medical records revealed an admission date of 03/01/19 with diagnoses that included Alzheimer's disease, dementia, and overactive bladder. Review of the care plan dated 04/13/22 revealed Resident #68 had self-care deficits related to limited mobility and diminished awareness of bowel and bladder urges. Review of the MDS assessment dated [DATE] revealed Resident #68 had impaired cognition and required total dependence with toileting and was incontinent of bowel and bladder. Observation of incontinence care on 05/16/22 at 10:18 A.M. with STNA #344 revealed Resident #68 had an incontinence liner inside of her incontinence brief that was saturated with urine. Interview with STNA #344 at time of observation revealed she had not been aware the resident had more than one incontinence product in place. Review of facility policy titled Incontinence Care dated 10/2019 revealed only one incontinence brief was to be worn by residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 3 of 11 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 05/19/2022 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation and interview the facility failed to ensure expired medications were discarded timely. This affected two (Residents #35 and #65) of 32 residents whose medications were stored in the first floor medication cart. The facility census was 71. Findings include: Observation on 05/16/22 at 10:52 A.M. with Licensed Practical Nurse (LPN) #305 revealed the medication cart located on the first floor contained a bottle of Timolol (eye drops used to treat glaucoma) belonging to Resident #35 that had an open date of 04/10/22, and a vial of Humalog (insulin) belonging to Resident #65 with an open date of 04/05/22. Interview with LPN #305 at time of observation revealed eye drops were to be discarded 30 days after opening, and insulin should be discarded after 28 days. Review of the manufacturer guidelines dated 01/2020 revealed You can use Timolol for 28 days after first opening the bottle. Discard the opened bottle with any remaining solution after that time. Review of www.humalog.com revealed once opened Humalog vials should be thrown away after 28 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 4 of 11 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 05/19/2022 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 - Some 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 interview, the facility failed to ensure the menu was followed and appropriate food substitutions were provided. This affected five residents (#18, #42, #37, #55, and #67) of five residents observed during a breakfast meal and had the potential to affect all residents except Resident #53 who received nothing by mouth. The facility also failed to ensure therapeutic diets were followed as prescribed. This affected one resident (#42) of four residents (#37, #42, #50, and #67) reviewed for food concerns. The facility census was 71. Findings include: Review of the facility menu for breakfast on 05/18/22 revealed oatmeal, scrambled eggs, and cranberry muffin. 1. Observation on 05/18/22 at 8:58 A.M. of Resident #67's breakfast tray revealed a plain bagel with mandarin oranges on the same plate, a container of cream cheese, an eight-ounce container of fat free milk, a four-ounce container of grape juice, and a bowl of oatmeal. Interview with Resident #67 at the time of the observation revealed Resident #67 did not eat hot cereal and only drank cranberry juice. Interview on 05/18/22 at 9:02 A.M. with State Tested Nurse Aide (STNA) #327 verified the food items on Resident #67's tray. STNA #327 said although Resident #67 did not eat hot cereal it was often served to the resident. 2. Observation on 05/18/22 at 9:05 A.M. of Resident #42's breakfast tray revealed a plain bagel with mandarin oranges on the same plate, cream cheese, a four-ounce container of grape juice, an eight-ounce container of fat free milk, oatmeal, tea, and sugar. Interview at the time of observation with Resident #42 revealed I'll tell you what I didn't get and Resident #42 read off her meal tray ticket, no eggs, no bacon, no wheat toast, one sugar, no Health shake but got milk. Review of Resident #42's meal tray ticket revealed she was on a high calorie, high protein diet and was also supposed to receive eight ounces of whole milk. Interview on 05/18/22 at 9:06 A.M. with STNA #327 verified the food items on Resident #42's meal tray. STNA #327 stated since the new kitchen had taken over it had been like this, the kitchen sent whatever they wanted. Review of the medical record for Resident #42 revealed an admission date of 10/01/18. Diagnoses included hypertension, gastroesophageal reflux disease, and anxiety disorder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition and was independent with set up help only for eating. Review of the physician orders for May 2022 revealed orders for high calorie, high protein, regular diet with start date of 02/28/22 and four-ounce Health shake three times daily at meals with a start date of 02/23/22. Interview on 05/18/22 at 4:15 P.M. with Registered Dietitian (RD) #423 revealed Resident #42 had been on the high calorie, high protein diet when she started working at the facility in January 2022. RD #423 stated she believed Resident #42 was on the high calorie, high protein diet because her meal intakes varied but she liked and drank the Health shakes. RD #423 stated she heard about what (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 5 of 11 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 05/19/2022 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 - Some Resident #42 was served at breakfast and indicated Resident #42's dietary needs would not have been met at that meal. 3. Observation on 05/18/22 at 9:34 A.M. revealed Resident #55 had a breakfast ticket that specified super cereal, scrambled eggs, cottage cheese, whole milk, coffee, creamer, and sugar. Resident #55 received a breakfast tray containing super cereal, bagel, fruit, whole milk, coffee, and orange juice. 4. Observation on 05/18/22 at 9:38 A.M. revealed Resident #18 had a breakfast ticket that specified oatmeal, scrambled eggs, toast, jelly, margarine, brown sugar, yogurt, skim milk, and coffee. Resident #18 received a breakfast tray containing oatmeal, bagel, fruit, cream cheese, 2% milk, and orange juice. 5. Observation on 05/18/22 at 9:43 A.M. revealed Resident #37 had a breakfast ticket that specified oatmeal, scrambled eggs, 2% milk, tea, creamer, and sugar. Resident #37 received a breakfast tray containing oatmeal, bagel, fruit, 2 % milk, orange juice, and cream cheese. Interview on 05/18/22 at 11:42 A.M. with Dietary Manager #424 revealed if a planned protein was unavailable for breakfast than another protein should be substituted. Interview on 05/18/22 at 11:50 A.M. with Dining Services [NAME] #421 revealed Dining Services [NAME] #421 was late to work and substituted the protein of scrambled eggs with a bagel and fruit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 6 of 11 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 05/19/2022 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 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 serve food at a palatable temperature. This affected one (#55) of five residents reviewed for food concerns and had the potential to affect 70 of 71 residents (the facility identified Resident #53 as receiving no food from the kitchen). The facility census was 71. Residents Affected - Few Findings include: Review of the Resident Council Meeting Notes dated 02/15/22 revealed the residents had questions and comments about the food. The residents indicated the food could be hotter. In response to the residents, it was suggested to ask a staff member to warm their meals in the microwave. Interview with Resident #67 on 05/16/22 at 10:41 A.M. revealed sometimes the items on her food tray were cold when received. Interview with Resident #37 on 05/16/22 at 1:14 P.M. revealed mashed potatoes were served cold. Interview with Resident #50 on 05/17/22 at 11:17 A.M. revealed her breakfast tray arrived late and the food was cold. Observation on 05/18/22 at 9:35 A.M. revealed Resident #55's hot super cereal was recorded at 100 degrees Fahrenheit (F). State Tested Nursing Assistant #314 verified the hot super cereal temperature measured 100 degrees F. Review of the Menu Works Daily Service Temperature Log dated 07/12/21, revealed hot entrees were to be served at a temperature greater than 140 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 7 of 11 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 05/19/2022 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure resident food preferences were honored. This affected one resident (#67) of four residents (#37, #42, #50, and #67) reviewed for food concerns. The facility census was 71. Findings include: Review of the medical record for Resident #67 revealed an admission date of 03/28/16. Diagnoses included multiple sclerosis, Type two diabetes mellitus, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had intact cognition and required supervision of one staff for eating. Review of the quarterly nutrition assessment dated [DATE] and timed 10:57 A.M. revealed Registered Dietitian (RD) #423 suggested liberalizing Resident #67's diet to make food more enjoyable for her and to promote better intakes of nutrient-dense foods and balanced meals the resident was willing to try. The resident would like yogurt, milk, and coffee at all meals and would update preferences. RD #423 indicated she would follow-up on diet changes and education on making healthful dietary choices. Review of the physician orders for May 2022 revealed an order for regular house diet dated 01/19/22. Interview on 05/16/22 at 10:41 A.M. with Resident #67 revealed there were inconsistencies with food. Resident #67 stated every breakfast she was supposed to get [NAME] Krispie cereal, yogurt, and cranberry juice and that did not always happen. Observation on 05/18/22 at 8:58 A.M. of Resident #67's breakfast tray revealed a plain bagel, container of cream cheese, eight-ounce container of fat free milk, four-ounce container of grape juice, and bowl of oatmeal. Interview with Resident #67 at time of observation revealed she did not eat hot cereal and only drank cranberry juice. Review of Resident #67's meal tray ticket revealed the ticket listed oatmeal, bacon low sodium, bagel with cream cheese, fresh banana, creamer, yogurt, skim milk, coffee, and sugar. Interview on 05/18/22 at 9:02 A.M. with State Tested Nurse Aide (STNA) #327 verified the food items on Resident #67's meal tray and what was listed on the meal tray ticket. STNA #327 stated Resident #67 did not eat hot cereal and she often received hot cereal. Interview on 05/18/22 at 4:09 P.M. with RD #423 revealed she had updated Resident #67's preferences in their system. Resident #67 should be receiving bacon in the mornings, and a banana, skim milk, and yogurt with all three meals. RD #423 stated Resident #67 had not mentioned to her that she wanted cold cereal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 8 of 11 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 05/19/2022 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 and staff interview, the facility failed to ensure the kitchen area was maintained in a clean and sanitary condition. This had the potential to affect 70 of 71 residents receiving food from the kitchen (the facility identified Resident #53 as receiving no food from the facility kitchen). The facility census was 71. Findings include: Initial kitchen tour conducted on 05/16/22 between 8:35 A.M. and 8:55 A.M. revealed the following: 1. Observation of the hood suppression system above the stove area in the kitchen revealed a considerable amount of dust, dirt, and other unknown debris above the stove top area where food was prepared. 2. Observation of the walk-in freezer revealed one open box of bread left open to air. The bread was very hard and showed signs of freezer burn. 3. Observation of the walk-in cooler revealed dust, dirt, and various debris located on the floor and within the cooling fan. Fresh strawberries stored in the walk in cooler had a moderate amount of green mold. 4. Observation of the dry storage area revealed honey barbeque sauce had a label indicating opened on 02/10/22 and an expiration date of 03/10/22; hot barbeque sauce had a label dated opened on 02/04/22 and an expiration date of 03/04/2, and an opened bag of pudding mix with a blank label affixed without a date. Interview with Dining Services [NAME] #421 at 8:55 A.M. on 05/16/22 verified all of the above observations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 9 of 11 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 05/19/2022 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview the facility failed to ensure the dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 71. Residents Affected - Many Findings include: Observation of the dumpster area on 05/16/22 between 8:45 A.M. and 9:00 A.M. revealed the following: 1. Numerous bags of garbage outside and around the dumpster. 2. Numerous loose articles on the ground including food scraps, personal protective equipment (gloves and masks) and other debris. 3. A trash cart filled with approximately ten to twelve red bio-hazard bags was noted outside the dumpster in the area directly behind the dumpster. Cook #421 verified the condition of the dumpster area in an interview on 05/19/22 at 9:00 A.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 10 of 11 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 05/19/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview the facility failed to properly dispose of red biohazard bags. This had the potential to affect all residents. The facility census was 71. Residents Affected - Many Findings include: Observation 05/16/22 at 9:20 A.M. of the outside dumpster area revealed a gray colored trash cart overflowing with red biohazard bags and biohazard bags on the ground around it. Interview on 05/16/22 at 9:20 A.M. with Infection Control Preventionist (ICP) #385 verified the observation and stated there was a process for biohazard bag disposal. ICP #385 explained they had a contracted company that picked up the biohazard bags. The biohazard bags were normally boxed up and locked in a shed; ICP #385 pointed to the area the biohazard bags were to be stored. The area ICP #385 pointed to was a large garage with a garage door that was closed located next to the dumpster area. Review of the facility policy titled The Policy of Disposal of Hazardous Waste for Slovene Home dated January 2022 revealed waste would be collected daily by maintenance staff, placed in transport biohazard waste boxes, and placed in the locked shed until picked up by disposal company. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 11 of 11