Health inspection·June 15, 2023

F 0689 resident representative were notified. Level of Harm - Minimal harm or potential for actual harm Interview on 06/08/23 at 3:07 P.M. with State Tested Nurse Aide (STNA) #477 via phone revealed she was not assigned to Resident #66 on 05/31/23. STNA #477 had the back assignment on the unit. STNA #477 was not aware Resident #66 was not in the building until after Resident #66 was found. STNA #477 did not hear an alarm or know which door Resident #66 had exited. Residents Affected - Few Observation and interview during a tour of the area where Resident #66 was found, on 06/12/23 from 9:45 A.M. to 10:01 A.M., with Laundry Aide (LA) #498 revealed she was not working when she found Resident #66 outside of the facility. LA #498 was walking home after visiting a relative's house around 7:00 P.M., it was still daylight and it was warm outside. LA #498 saw Resident #66 sitting in a wheelchair outside of the facility on a short walkway just beyond the St. [NAME] unit exit door. The short walkway lead to a larger sidewalk. LA #498 did not recall hearing an alarm at this time; she was focused on Resident #66. LA #498 stated the St. [NAME] unit door was shut and locked. LA #498 asked Resident #66 what she was doing outside, and Resident #66 responded she was just out there. LA #498 took Resident #66 back into the facility via the front doors and informed the nurse and nurse supervisor. LA #498 stated inside the facility, the alarm of the exit door on the St. [NAME] unit was going off but they couldn't hear it until they were on St. [NAME] unit. The St. [NAME] unit was unoccupied/closed. Observation of the emergency exit door on the St. [NAME] unit revealed it was located near room [ROOM NUMBER]. Further observation revealed upon exiting this door there was a choice of taking a stairwell or walking a short distance to another door which lead directly outside. Walking from the St. [NAME] unit to the unit where Resident #66 resided at the time she exited the building took approximately two minutes. Interview on 06/12/23 at 10:02 A.M. with Licensed Practical Nurse (LPN) #515 revealed it was around 7:30 P.M. to 8:00 P.M. when she observed LA #498 bringing Resident #66 into the building. LPN #515 stated she filled out an incident report and completed a body audit and found no injuries. LPN #515 stated Resident #66 was confused and would frequently exit seek. LPN #515 last saw Resident #66 in the solarium with her head down falling asleep. There were two other residents in the solarium with Resident #66. While LPN #515 was doing her medication pass the aide assigned to Resident #66 informed her, she was going on her lunch; this left two other STNAs on the floor, STNA 409 and STNA #477. STNA #477 was showering a resident. About 10 minutes into her medication pass LA #498 brought Resident #66 into the facility via the resident's wheelchair. LPN #515 had no idea Resident #66 had been outside of the facility. LPN #515 said Resident #66 used a wheelchair to get around and was pretty good about self-propelling. LPN #515 also said Resident #66 could be sneaky but was pleasant and delusional. LPN #515 explained when Resident #515 was exit seeking she was usually trying to find her parents; LPN #515 would call Resident #66's daughter and after Resident #66 talked to her daughter she would settle down. LPN #515 stated she did not hear the alarm on the emergency exit door on St. [NAME] unit until she went down that hall. LPN #515 stated Resident #66 was wearing a WanderGuard bracelet but did not think the emergency exit door which Resident #66 had exited had a WanderGuard sensor. LPN #515 stated if there was a WanderGuard alarm at that exit door, she would have heard the alarm on her unit. Interview on 06/12/23 at 10:18 A.M. with STNA #409 revealed she did not know Resident #66 had exited the facility until she was informed by the nurse. STNA #409 was providing resident care in room [ROOM NUMBER] at that time. STNA #409 was not aware Resident #66's aide had gone on lunch. STNA #409 stated it was not unusual for Resident #66 to exit seek and she required redirection. STNA #409 stated between 7:00 P.M. and 8:00 P.M. they were busy providing resident care and getting residents to bed. STNA #409 last saw Resident #66 at dinner. STNA #409 did not hear an alarm sounding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 2 of 13 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 06/15/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility policy titled Elopement Protocol, revised April 2020, revealed each resident would be kept safe and within the facility. The Elopement Protocol would be initiated by a physician's order immediately when a resident was found to be a risk for wandering or elopement. Wandering was defined as disoriented wandering about the facility grounds. Elopement was defined as leaving the building/grounds purposely. The policy indicated staff were to redirect those residents that wandered from exits. All staff were to be aware of all potential wanderers/elopers. Safe areas for residents to walk included hallways in the facility, supervised by nursing staff. If door or exit alarm sounded, the nearest personnel were to respond immediately. This deficiency represents non-compliance investigated under Control number OH00143474. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 3 of 13 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 06/15/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to ensure timely staff response to resident calls for assistance. This affected three of three residents (#27, #52, #60) reviewed for staff response to call lights and four residents identified through random interviews (#13, #39, #51, #69) The facility census was 73. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 10/16/17. Diagnoses included osteoporosis, anemia, intestinal obstruction, congestive heart failure, cognitive communication deficit, diverticulosis, Paget's disease, and chronic gastritis with bleeding. Review of the Medicare Annual Minimum Data Set (MDS) assessment, dated 04/16/23, revealed Resident #27 had moderately impaired cognition. Resident #27 required supervision of one staff assistance for bed mobility, dressing, toileting, and personal hygiene and was independent with no assistance for transfers, ambulation, and bathing. The assessment indicated Resident #27 was occasionally incontinent of bladder and always continent of bowel. Review of the Call Light Audit Report from 06/01/23 to 06/08/23 revealed Resident #27 utilized call light and was identified by room number. Resident #27 utilized call light six times from 06/01/23 to 06/08/23. Three of six occurrences of call light use were over 30-minute wait time. - Activated call light on 06/05/23 at 9:05 A.M. Call light turned off at 4:00 P.M. Total of six hours 55 minutes. - Activated call light on 06/07/23 at 11:11 A.M. Call light turned off at 12:05 P.M. Total of 54 minutes. - Activated call light on 06/07/23 at 1:12 P.M. Call light turned off at 2:20 P.M. Total of one hour and eight minutes. 2. Review of the medical record for Resident #52 revealed an admission date of 04/24/23. Diagnoses included adult failure to thrive, hypertension, rhabdomyolysis, history of falling, mild cognitive impairment, and localized bilateral edema. Review of the Medicare admission Minimum Data Set (MDS) assessment, dated 05/01/23, revealed Resident #52 had intact cognition. Resident #52 required extensive two staff assistance for bed mobility, extensive one staff assistance for dressing, toileting, and personal hygiene, total two staff assistance for transfers, and total one staff assistance for bathing. The assessment indicated Resident #52 was frequently incontinent of bowel and bladder. Review of the Call Light Audit Report from 06/01/23 to 06/08/23 revealed Resident #52 utilized call light and was identified by room number. Resident #52 utilized call light 12 times from 06/01/23 to 06/08/23. Seven of 12 occurrences of call light use were over 30-minute wait time. - Activated call light on 06/02/23 at 8:24 P.M. Call light turned off at 9:08 P.M. Total of 44 minutes. - Activated call light on 06/03/23 at 9:14 P.M. Call light turned off at 10:03 P.M. Total of 49 minutes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 4 of 13 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 06/15/2023 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 0725 - Activated call light on 06/05/23 at 8:31 P.M. Call light turned off at 9:04 P.M. Total of 33 minutes. Level of Harm - Minimal harm or potential for actual harm - Activated call light on 06/06/23 at 7:26 P.M. Call light turned off at 8:49 P.M. Total of one hour and 23 minutes. Residents Affected - Some - Activated call light on 06/07/23 at 1:08 P.M. Call light turned off at 1:52 P.M. Total of 44 minutes. - Activated call light on 06/07/23 at 1:52 P.M. Call light turned off at 2:52 P.M. Total of one hour. - Activated call light on 06/07/23 at 5:27 P.M. Call light turned off at 7:15 P.M. Total of one hour and 48 minutes. 3. Review of the medical record for Resident #60 revealed an admission date of 05/30/23. Diagnoses included fracture of right hip, fracture of right pubis, osteopenia, repeated falls, prostate cancer, legal blindness, hearing loss, and essential tremor. Resident #60 was on hospice services. Review of Medicare admission Minimum Data Set (MDS) assessment, dated 06/05/23, revealed Resident #60 had moderately impaired cognition. Resident #60 required limited one staff assistance for bed mobility, transfers, and locomotion on unit, extensive one staff assistance for dressing, toileting, and personal hygiene, and physical help of one staff for bathing. The assessment indicated Resident #60 had indwelling urinary catheter and was always incontinent of bowel. Review of the Call Light Audit Report from 06/01/23 to 06/08/23 revealed Resident #60 utilized call light and was identified by room number. Resident #60 utilized call light 32 times from 06/01/23 to 06/08/23. Nine of 32 occurrences of call light use were over 30-minute wait time. - Activated call light on 06/01/23 at 6:38 P.M. Call light turned off at 7:14 P.M. Total of 36 minutes. - Activated call light on 06/01/23 at 7:15 P.M. Call light turned off at 9:34 P.M. Total of two hours and 19 minutes. - Activated call light on 06/02/23 at 7:02 P.M. Call light turned off at 7:51 P.M. Total of 49 minutes. - Activated call light on 06/03/23 at 8:07 A.M. Call light turned off at 11:36 A.M. Total of three hours and 29 minutes. - Activated call light on 06/05/23 at 4:54 A.M. Call light turned off at 5:49 A.M. Total of 55 minutes. - Activated call light on 06/05/23 at 7:11 P.M. Call light turned off at 8:33 P.M. Total of one hour and 22 minutes. - Activated call light on 06/05/23 at 8:34 P.M. Call light turned off at 9:58 P.M. Total of one hour and 24 minutes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 5 of 13 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 06/15/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Activated call light on 06/07/23 at 8:04 A.M. Call light turned off at 9:09 A.M. Total of one hour and five minutes. - Activated call light on 06/07/23 at 9:18 A.M. Call light turned off at 10:11 A.M. Total of 53 minutes. Interview on 06/08/23 at 1:36 P.M. with Resident #13 revealed she had experienced long call light wait times of up to one hour. Interview on 06/08/23 at 1:53 P.M. with Resident #52 revealed call light wait times were long. Resident #52 noted one occurrence she waited for an aide to return for three hours. Resident #52 noted some staff rushed through care. Interview on 06/08/23 at 2:05 P.M. with Resident #39 revealed she sometimes had to wait a long time for staff to answer her call light. Resident #39 indicated the times varied to get staff assistance. Interview on 06/08/23 at 3:32 P.M. with Resident #51 revealed she had experienced long call light wait times. Observation on 06/12/23 at 9:15 A.M. revealed no visible call light indicators above resident doors or in hallways. Interview on 06/12/23 at 1:44 P.M. with Resident #69 and Responsible Party (RP) for Resident #60 revealed call light wait times would often be as high as one to two hours. The RP for Resident #60 reported Resident #60 was actively dying so the RP often sat with Resident #60. The RP indicated when they activated the call light the staff did not answer timely. The RP indicated they often had to look for a staff member to get assistance. Interview on 06/12/23 at 2:05 P.M. with State Tested Nursing Assistant (STNA) #437 revealed there were not lights above resident doors to alert staff a call light was activated, the call lights rang to pagers kept by staff. Interview on 06/13/23 at 10:39 A.M. with STNA #401 and STNA #502 revealed day shift did not have enough staff. STNA #401 and #502 indicated they felt rushed when providing care and often fell behind on assignment. STNA #401 and #502 indicated it was difficult to answer call lights timely due to others needing assistance and broken pagers. STNA #502 noted there were times when she was busy and would forget to answer call lights. Interview on 06/13/23 at 11:46 P.M. with Maintenance Director #413 indicated he was responsible for monitoring call light audit reports and would report patterns of long wait times to the Director of Nursing (DON). Maintenance Director #413 indicated he would look for times over 30 minutes to report. Interview on 06/13/23 at 11:57 P.M. with the DON revealed Maintenance Director #413 reviewed call light audit reports and notified her with any abnormalities. The DON indicated 15 to 20 minutes was acceptable call light wait times and anything over 30 minutes would be a concern. The DON indicated she was unaware of any complaints of long call light wait times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 6 of 13 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 06/15/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 06/13/23 at 12:52 P.M. with Clinical Coordinator #447 revealed she had confirmed each nurse had a pager on their medication cart. Clinical Coordinator #447 indicated nurses were responsible for monitoring the STNAs and call light wait times. Review of facility policy, Resident Call Light Response, dated 03/21/21 revealed all call lights were to be answered in a timely manner. The policy indicated each nursing staff member would carry a pager to alert them to resident calling for assistance. This deficiency represents non-compliance investigated under Complaint Numbers OH00143123 and OH00142939. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 7 of 13 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 06/15/2023 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, interview, and record review the facility failed to ensure the correct serving size was used when serving the main entrée and failed to follow the recipe when preparing green beans. This affected 27 residents (#21, #22, #23, #24, #25, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #47, #48, #49, and #50) that resided on the [NAME] unit. The facility census was 73. Findings include: Review of the lunch menu for 06/13/23 revealed tomato soup, Kansas chicken casserole, cornbread, green beans, and peanut butter cookie. Observation on 06/13/23 at 12:45 P.M. revealed Dietary Staff (DS) #603 plating the meals trays for 10 residents in the [NAME] dining room and seven residents who were served meal trays in their rooms on the [NAME] unit (Residents #21, #22, #23, #24, #25, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #47, #48, #49, and #50). DS #603 served the Kansas chicken casserole using a gray handled scoop, one scoop per plate and one scoop of green beans using a green handled ladle with four ounces imprinted on the ladle. DS #603 used her gloved hand to serve the corn bread. Interview with DS #603 at the time of the observation revealed the serving size for the gray handled scoop for the Kansas chicken casserole had no indicator on it as to what serving it provided. DS #603 did not know what the gray handled scoop serving size was but stated there was a color coded chart in the kitchen which indicated the color scoop and the serving size it provided. Interview on 06/13/23 at 1:00 P.M. with Regional Director of Dining Services (RDDS) #606 revealed typically the gray handled scoop provided four ounces but there was a color coded chart in the kitchen that provide that information. RDDS #607 provided the recipe for the green beans. Review of recipe indicated whole green beans, frozen. Cooking instructions included: preheat steamer, steam green beans until tender. There was no indication of any seasonings. There was nothing it the recipe which would indicate why the observed liquid in the green beans was red in color. Interview on 06/13/23 at 1:14 P.M. with RDDS #607 revealed he would check to see if there was another recipe that was used. Follow up interview on 06/13/23 at 1:17 P.M. with RDDS #606 revealed the seasoning of the green beans made the liquid the green beans were sitting in red in color. RDDS #606 tasted the green beans and stated it tasted like paprika. RDDS #606 said he would get the recipe the cook used. Another follow-up interview on 06/13/23 at 2:35 P.M. with RDDS #606 verified the gray handled scoop used to serve the Kansas chicken casserole at lunch provided four ounces and the menu spread sheet called for six ounce servings. RDDS #606 also stated they were unable to identify the recipe the cook used to prepare the green beans. RDDS #606 stated they removed all the spicy items from the kitchen except for back pepper when it was brought to their attention that residents complained the food was too spicy. This deficiency represents non-compliance investigated under Complaint numbers OH00139859, OH00143123, and OH00142939. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 8 of 13 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 06/15/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure palatable meals were served. This had the potential to affect 29 residents (#21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, and #50) that received food from the kitchen and resided on the [NAME] unit. The facility census was 73. Residents Affected - Some Finding include: Observation on 06/13/23 at 12:31 P.M. of tray line temperatures being obtained in the kitchenette on the first floor by Dietary Staff (DS) #603 revealed the tomato soup measured 165 degrees Fahrenheit (F), Kansas chicken casserole measured 160 degrees F, and green beans measured 165 degrees F. There was also corn bread, as listed on the menu. Interview at this time with DS #603 revealed there were three residents on the unit that received a pureed diet. DS #603 stated the pureed meals were pre-plated, covered with foil and were sitting on a tray on top of a heated two-well unit filled with water. DS #603 stated she did not take the temperature of the pureed food. DS #603 then pulled the foil off one the three pureed plates to reveal runny globs of two tan colored items and one green colored item which all ran together. DS #603 was unable to identify which glob of food was the pureed Kansas chicken casserole and what glob was the pureed corn bread. DS #603 obtained the temperature of one of the tan colored globs which measured 117 degrees F. DS #603 then obtained the temperature of the food on another plate that appeared the same as the first, with runny tan and green colored globs which measured 119 degrees F then immediately dropped to 118 degrees F. DS #603 verified the temperatures were low and stated the food needed to be in containers to be kept warm. DS #603 also verified the pureed foods were runny. DS #603 and DS #604 stated they had heard complaints from residents that the soups were too spicy so they stopped using seasoning. DS #603 stated that had been a while ago and the facility recently hired a new cook who had been working for two weeks. Both staff stated they had not heard any recent food complaints. Observation on 06/13/23 at 1:23 P.M. revealed the last meal cart arriving on the [NAME] unit. At 1:27 P.M., Stated Tested Nurse Aide (STNA) #411 started passing the hall trays. At 1:37 P.M. the last tray was served, and a test tray was completed with RDDS #606. The Kansas chicken casserole measured 98.1 degrees F, green beans measured 92 degrees F, tomato soup measured 140 degrees F, coffee measured 143 degree F, and the milk measured 49 degrees F. The Kansas chicken casserole tasted very good but was cold and the green beans were spicy and cold. RDDS #606 verified the findings and stated he also thought the green were a little spicy. Interview on 06/13/23 at 1:45 P.M. with Resident #41 stated her meal was cold when it was served which was a consistent issue. Resident #41 stated she thought the green beans were okay; she indicated they did not taste spicy to her. Interview on 06/13/23 at 1:50 P.M. with Resident #36 revealed she had eaten most of the green beans and some of the soup. Resident #36 stated she thought the meal as a whole was okay but she did not like the chicken casserole and thought the green beans were spicy. Interview on 06/13/23 at 2:09 P.M. with STNA #411, who was observed picking up meal trays, revealed STNA #411 assisted Resident #27 with lunch. Resident #27 ate about 50% of the green beans and the chicken casserole and consumed all the soup. Resident #27 had complained the green beans were too spicy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 9 of 13 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 06/15/2023 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 Level of Harm - Minimal harm or potential for actual harm Interview on 06/13/23 at 2:35 P.M. with Regional Director of Dining Services (RDDS) #606 revealed they were unable to identify the recipe the cook used to prepare the green beans. RDDS #606 stated they had removed all the spicy items such as cayenne pepper and everything considered spicy out of kitchen except for black pepper. RDDS #606 stated he was not sure when the spicy items were removed but it was after it was brought to their attention the residents were complaining the food was too spicy. Residents Affected - Some Interview on 06/13/23 at 4:50 P.M. with the Director of Nursing (DON) revealed she had heard complaints about the food from residents. The DON stated they had a cook that over did it with the spiciness. Review of Resident Council meeting minutes for 03/16/23, 04/18/23, and 05/23/23 revealed on 03/16/23 food related comments included temperature of food and absence of small creamers and on 04/18/23 food related comments and concerns included resident wanted to see other options on the menu and have the spicier meals discontinued. Review of a policy titled Meal Quality and Temperature, revised January 2023, revealed food and drinks were palatable, attractive, and served at a safe and appetizing temperature to ensure resident satisfaction and to meet nutrition and hydration needs. This deficiency represents non-compliance investigated under Complaint numbers OH00143123, OH00142939, and OH00139859. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 10 of 13 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 06/15/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and interview, the facility failed to ensure the puree meals were the appropriate consistency. This affected four residents (#26, #31, #46, and #53) who received pureed diets and two residents (#21 and #28) who received pureed vegetables. The facility census was 73. Findings include: Observation on the purred process on 06/13/23 at 11:19 A.M. with Dietary [NAME] (DC) #605 revealed DC #605 placing four scoops of cooked Kansas chicken casserole into a small pan then adding the casserole to the blender. Next DC #605 added water from a spout near the stove to the blender, enough water was added to cover the casserole. At 11:29 A.M. DC #605 started the blender to puree the Kansas chicken casserole. DC #605 added thickener multiple times and then indicated it was done. here was no recipe observed. Dietary Manager (DM) #601 stated they had a recipe book and would get the recipe for the puree Kansas chicken casserole. Observation of the finished puree casserole revealed it was soupy. Taste test at this time with DM #601 revealed the casserole tasted good and seasoned, but the texture was like a thick and creamy soup. DM #601 verified the findings. Interview on 06/13/23 at 12:21 P.M. with DM #601 revealed they did not have a recipe for the pureed entrée. Observation and interview with DS #603 during tray line on 06/13/23 at 12:31 P.M. revealed the pureed meals were pre-plated, covered with foil and sitting on a tray that was sitting on top of a heated two-well unit filled with water. DS #603 pulled the foil off one the three pureed plates revealing runny globs of two tan colored items and one green colored item which all ran together. DS #603 was unable to identify which glob was the pureed Kansas chicken casserole and which glob was the pureed corn bread. DS #603 verified the pureed meals were runny. This deficiency represents non-compliance investigated under Complaint numbers OH00143123, OH00142939 and OH00139859. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 11 of 13 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 06/15/2023 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 observations and interview, the facility failed to maintain the kitchen in a clean and sanitary manner, failed to ensure food was properly stored, and failed to serve ready to eat food in a sanitary manner. This affected all residents except one resident (#35) who received nothing by mouth. The facility census was 73. Findings include: Tour of the kitchen on 06/12/23 from 2:17 P.M. to 2:36 P.M. with Dietary Manager (DM) #601 revealed the ice cream and popsicles containers stored in the white deep freezer had various food stains and what appeared to be cookie or cookie dough was noted on the bottom of the freezer. The bulk bread crumb container had a small Styrofoam bowl stored in the breadcrumbs and the clear lid was in disrepair. In walk-in cooler there was a cart that had two large pans of cooked cut up potatoes that were not covered. DM #601 stated the potatoes were in the cooler to cool down and they should have been covered. Underneath the table with the coffee machine there was an area of large dark brownish/black spillage on the floor. The inside of the table next to the coffee machine which housed a tray of coffee cups had various food splatters. Observation of the deep fryer revealed various food splatters, the standing mixer next to the deep fryer had various food splatters and was coated with grease, and the wall behind the mixer and deep fryer had various food splatters. A brownish tinged puddle was observed on the floor behind the mixer and around the mixer feet were heavy rust stains. All the findings were verified with DM #601 during the tour. Observation on 06/13/23 at 11:19 A.M. with Dietary [NAME] (DC) #605 of the pureed process revealed the blender base had dried food splatter and the blender top was stained a brownish color. Interview on 06/13/23 at 11:25 A.M. with DM #601 verified the observation of the blender and stated she had tried to clean the brownish stain and it did not come out. Observation on 06/13/23 at 11:40 A.M. of the hot box where DC #605 was observed putting covered cooked food revealed the inside bottom of the hot box had stains that were dried and brownish in color. An empty pan that sat down into the bottom of the hot box also had dried, brownish stains. Observation of two silver carts with the cart doors opened revealed they were unclean. One cart was holding trays, scoop plates, a tray of cookies on plates that were uncovered; the grooves of the meal cart where the trays slid in were rusted and covered with whitish stains, possibly hard water as well as on the back and bottom of the inside of the cart. The second cart held a tray of coffee mugs, a tray of cookies on plates covered with plastic wrap, and thermal lids. The groves where the trays slid in on this cart also had rust and whitish debris on them on the inside back and on the bottom of the cart. Interview on 06/13/23 at 11:43 A.M. with DM #601 verified the observations of the two carts and the hot box. DM #601 stated the carts were cleaned after each meal and she thought the carts were just old. Observation on 06/13/23 at 12:45 P.M. revealed Dietary Staff (DS) #603 wash and glove hands and begin meal service. DS #603 was observed serving the Kansas chicken casserole using a gray handled scoop, green beans using a green handled ladle and corn bread using her gloved hands. DS #603 also used her gloved hands to pick up trays, plates, and meal tickets throughout the meal service without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 12 of 13 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 06/15/2023 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 washing her hands or changing her gloves while continuing to use her gloved hand to put the corn bread on each plate. Interview on 06/13/23 at 1:19 P.M. with Regional Director of Dining Services #606 revealed during meal service tongs should be used to serve the corn bread not gloved hands. At this time DS #603 revealed she forgot to bring the tongs from the kitchen. This deficiency represents non-compliance investigated under Complaint numbers OH00143123, OH00142939 and OH00139859. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 13 of 13