Slovene Home for the Aged

In the surveyor’s words

From the most serious findings on record at Slovene Home for the Aged, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 18, 2026

  Based on record review, interview, review of facility investigation documents, observation of web-cam video, and policy review, the facility failed to ensure a resident received adequate supervision and assistance to prevent a fall with major injury during incontinence care.Actual harm occurred on 03/09/26 when Resident #56, who had hemiplegia and hemiparesis of the non-dominant left side, and required maximum assistance with toileting hygiene, was provided incontinence care by one staff person, resulting in the resident rolling out of bed and falling to the floor. Resident #56 experienced rib pain and was sent to the hospital, sustaining broken ribs. […]

• No harm, potential for more than minimal, widespreadF804Aug 20, 2025

  Based on observation, interviews and record review the facility failed to provide food at appetizing temperatures. This had the potential to affect 189 of 196 facility residents. The facility identified seven residents (Residents #119, #120, #126, #149, #155, #166, #186) as receiving nothing by mouth (NPO). The facility census was 196.Findings include:An observation on 08/18/25 at 08:20 A.M. of tray line revealed a test tray was prepared and placed on the food cart at 8:23 A.M. and transported by dietary staff to the [NAME] North unit where it arrived at 8:26 A.M. The test tray remained on the cart in view of the surveyor, until all other trays were distributed to residents. The test tray was removed from the cart at 8:42 A.M. […]

• No harm, potential for more than minimal, widespreadF804Sep 26, 2024

  Based on observation and interviews, and facility policy, the facility failed to serve hot and palatable foods. This had the potential to affect all residents, except resident #54 and #56 who received no food by mouth (NPO). The facility census was 83. Findings include: Interview on 09/23/24 at 9:46 A.M. with Resident #21 revealed food from the kitchen was not good and was always served late. Interview on 09/23/24 at 9:49 A.M. with Resident #179 revealed food from the kitchen was very cold and always had to be warmed up by staff. Interview on 09/23/24 at 10:45 A.M. with Resident #47 revealed food from the kitchen was bland and had no seasoning. Interview on 09/23/24 at 12:17 P.M. […]

• No harm, potential for more than minimal, widespreadF812Sep 26, 2024

  Based on observations, interviews, and facility policies, the facility failed to ensure food was prepared and served under sanitary conditions. This had the potential to affect all residents, except resident #54 and #56 who received no food by mouth (NPO). The facility census was 83. Findings include: Observation and interview on 09/23/24 at 8:30 A.M. during the tour of the kitchen revealed a box of hairnets available at the entrance of the kitchen. Observation revealed Kitchen Aide (KA) #603 was observed to be without a hairnet in place while preparing the breakfast meal. KA #603 confirmed and verified she was without a hairnet. Observation and interview on 09/23/24 at 12:30 P.M. […]

• No harm, potential for more than minimal, widespreadF812Jun 15, 2023

  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. […]