Health inspection·July 20, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of Radiology Reports from 07/07/23 for bilateral knees and bilateral femurs revealed Resident #60 had no acute fractures or dislocation. Noted right knee replacement with no hardware complication. Review of Nursing Assignment Sheet dated 07/07/23 revealed Resident #60 required wheelchair with staff assistance for mobility and mechanical lift with two staff assistance. Residents Affected - Few Review of facility Self-Reported Incident (SRI) #236856 dated 07/08/23 revealed on 07/07/23 Former STNA #806 transferred Resident #60 from bed to wheelchair without using stand up lift or two-person transfer resulting in fall for Resident #60. Former STNA #806 attempted pivot transfer without following physician orders or specific instructions on assignment sheet. Former STNA #806 did not request assistance from other staff for transfer. Review of statement dated 07/14/23 written by Former STNA #806 revealed on 07/07/23 at 11:45 A.M. she entered Resident #60's room to prepare her for day. Former STNA #806 indicated Resident #60 was still in bed, so she helped her get legs over edge of bed and come to edge of bed in seated position. Former STNA #806 indicated she positioned the wheelchair and helped Resident #60 to stand like normal and once on her feet instructed Resident #60 to turn. Former STNA #806 indicated Resident #60 flopped down onto the chair and caught the edge of chair and fell out onto floor landing on bottom. Former STNA #806 indicated she fell backwards with the wheelchair into roommate's bed. Review of statement dated 07/14/23 for STNA #805 revealed she was not asked by Former STNA #806 for assistance to transfer Resident #60 on 07/07/23. Review of statement dated 07/16/23 for LPN #803 revealed she was not asked by Former STNA #806 for assistance to transfer Resident #60 on 07/07/23. Review of STNA Competency Skills Review dated 12/19/22 for Former STNA #806 was signed off for demonstrating proper use of mechanical lift with two persons. Interview on 07/19/23 at 1:40 P.M. with LPN #803 revealed on 07/07/23 she was the nurse on duty assigned to Resident #60. LPN #803 indicated she was called to Resident #60's room by Former STNA #806 when Resident #60 had a fall. LPN #803 confirmed Former STNA #806 was not using stand up lift while transferring as ordered. LPN #803 indicated there was an assignment book for the STNAs with information on each resident and the type of services they require. LPN #803 indicated had Resident #60 been transferred correctly there would not have been a fall. Interview on 07/19/23 at 1:51 P.M. with Resident #60 revealed she used a stand up lift for transfers. Resident #60 indicated most times staff used the stand up lift. Resident #60 indicated about one week prior the aide did not use the stand up lift and she fell. Resident #60 indicated she did not get hurt. Resident #60 was unable to provide additional details when asked further questions about fall. Interview on 07/20/23 at 7:43 A.M. with Registered Nurse (RN) Clinical Coordinator revealed on 07/07/23 LPN #803 called to notify her of Resident #60's witnessed fall with no visible injuries. RN Clinical Coordinator notified family and physician. RN Clinical Coordinator indicated Resident #60's daughter called and reported she had video footage of the fall from camera family had placed in room. Daughter of Resident #60 was noted to be very upset by the footage and indicated RN Clinical Coordinator needed to review it with her. RN Clinical Coordinator indicated due to the daughter's concern (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 2 of 3 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 07/20/2023 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 Former STNA #806 was sent home pending investigation. RN Clinical Coordinator indicated herself and Administrator viewed the video with Daughter of Resident #60 and confirmed Former STNA #806 had failed to perform transfer for Resident #60 as ordered causing the fall. RN Clinical Coordinator indicated she had verified each STNA assignment sheet was up to date and found no discrepancies. Interview on 07/20/23 at 10:21 A.M. with STNA #805 revealed she was working on the other side of Newburgh unit on 07/07/23 and was not assigned to Resident #60. STNA #805 indicated Former STNA #806 was assigned to Resident #60. STNA #805 indicated she was sitting at nursing station completing charting when she heard Former STNA #806 shout down hallway for help. STNA #805 indicated herself and LPN #803 went down hall and found Resident #60 on floor in room. STNA #805 indicated Resident #60 required a stand up lift for transfers and the lift was not seen in room. STNA #805 indicated she was not asked for assistance to transfer Resident #60 by Former STNA #806. STNA #805 indicated two staff were required for use of stand up lift. STNA #805 indicated there was an nurse aide assignment book available to all staff. The book gave information on all residents and what care/services they required. Observation on 07/20/23 at 10:49 A.M. of a two minute and four second video dated 07/07/23 at 11:50 A.M. with Assistant Administrator present revealed Former STNA #806 standing to left side of wheelchair positioned by foot of Resident #60's bed. Resident #60 was observed to be sitting in the middle of her bed with legs partially dangling over edge. Former STNA #806 instructed Resident #60 to scoot further to edge of bed and Resident #60 attempted to scoot however was unsuccessful. Former STNA #806 moved bedside table out of way and grabbed onto Resident #60's left bicep and pulled her to edge of bed. Former STNA #806 stood back by wheelchair and instructed Resident #60 to get into chair. Resident #60 observed to struggle to get self to feet and stand slightly bent forward at waist. Resident #60 was observed with hands reached out and appeared to be attempting to stabilize herself. At no time did Former STNA #806 reach for Resident #60 to stabilize or assist. Resident #60 was observed to attempt to pivot and abruptly sat back into wheelchair. Resident #60 missed the chair and fell to ground between wheelchair and foot of bed. When Resident #60 fell it caused the wheelchair to push away and knock Former STNA #806 onto footboard of roommate's bed. Former STNA #806 was noted to be holding her back. Resident #60 remained on floor holding onto wheelchair and footboard of bed. Former STNA #806 walked to doorway of room and was seen calling down hallway for help when the video ended. At no time was it evident Former STNA #806 checked on Resident #60's condition or ensured safety/comfort. There was no evidence of use of stand up lift or two staff assistance for transfer as ordered. The lock did not appear to be engaged on wheelchair to prevent it from moving during transfer. Interview on 07/20/23 at 10:54 A.M. with Assistant Administrator confirmed video showed Former STNA #806 and Resident #60. Assistant Administrator confirmed Former STNA #806 had not used stand up lift or two staff assistance as ordered nor had she locked brakes of wheelchair. Review of facility policy, Fall Risk Reduction Protocol, dated March 2021, revealed residents would ambulate and transfer with appropriate devices to reduce risks for falls. Review of facility policy, Mechanical Lift, dated May 2020 revealed a mechanical lift would require at least two people were present during transfer. This deficiency represents non-compliance investigated under Complaint Number OH00144413 and is an example of continued non-compliance from survey ending 06/15/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365567 If continuation sheet Page 3 of 3