Health inspection·May 23, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure medical records were accurate and complete. This finding affected one (Resident #42) of nine resident records reviewed for accuracy. The facility census was 74. Findings include: Review of Resident #42's medical record revealed the resident was admitted on [DATE] with diagnoses including malignant neoplasm of the breast, neoplasm of the lung and primary osteoarthritis. Review of Resident #42's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #42's physician orders revealed an order dated 02/25/25 for oxycodone instant release (IR) 5 mg (milligrams) narcotic pain medication administer one tablet every two hours as needed for shortness of breath. Review of Resident #42's medication administration records (MAR) and narcotic flow records (NFR) from 03/01/25 to 03/31/25 revealed Licensed Practical Nurse (LPN) #813 documented on the NFR that she administered oxycodone 5 mg tablet on 03/04/25 at 7:50 A.M. and 03/04/25 at 10:27 A.M. The oxycodone medications were not documented on Resident #42's MAR indicating the medication was administered to the resident. Review of Resident #42's MAR and NFR from 03/01/25 to 03/31/25 revealed LPN #813 documented on the resident's MAR that she administered the oxycodone 5 mg tablet on 03/03/25 at 8:04 A.M. The medication was not documented on Resident #42's NFR. Review of Resident #42's MAR from 03/01/25 to 03/31/25 revealed LPN #816 had documented on the NFR that she administered oxycodone 5 mg to the resident on 03/04/25 at 3:10 A.M. The oxycodone medication was not documented on Resident #42's MAR indicating the medication was administered to the resident. Attempted interview on 05/21/25 at 11:39 A.M. with Resident #42 and the resident was unable to be interviewed. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365567 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 05/23/2025 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)