Health inspection·June 4, 2021

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, revealed the facility failed to ensure Resident #301 who had an order to test her stool for occult blood (a test to check for hidden blood in the stool) was completed as ordered and/ or the physician or nurse practitioner was notified the ordered test was not completed. This affected one resident (Resident #301) out of one resident (Resident #301) reviewed for change in condition. The facility census was 93. Residents Affected - Few Finding include: Review of medical record for Resident #301 revealed an admission date of 05/06/21 and diagnoses included gastro-esophageal reflux, diabetes, cerebral infarction, repeated falls, dementia, and heart failure. Review of lab report dated 05/10/21 revealed Resident #301 had a complete blood count (CBC) completed that showed a hemoglobin level of 11.8 which was within normal limits and a low hematocrit of 35.4. Review of bowel pattern per point click documentation revealed Resident #301 had a large bowel movement on 05/11/21, large bowel movement on 05/14/21, large bowel movement on 05/16/21, medium bowel movement on 05/17/21, medium bowel movement on 05/18/21, large bowel movement on 05/20/21, and a large and medium bowel movement on 05/21/21. The documentation revealed no documentation for bowel movements from 05/23/21 to 06/03/21. Review of Medicare five-day Minimum Data Set (MDS) dated 05/12/ 21 revealed Resident #301 had impaired cognition. She required extensive assist of two person assist with bed mobility, transfers, and toileting. She was always incontinent of bowel. Review of Nurse Practitioner #900 progress note dated 05/17/21 at 1:40 P.M. revealed she reviewed Resident #301 lab work and noted her hemoglobin and hematocrit was trending down and she ordered her stool to be tested for occult blood and to repeat lab work of a CBC on 05/20/21. Review of physician order dated 05/17/21 revealed Resident #301 had an order to check for occult blood in her stool times three and report results to the physician. Review of nursing notes and lab reports for Resident #301 dated 05/17/21 to 06/02/21 revealed no documentation Resident #301's stool was checked for occult blood per physician order or the physician or nurse practitioner was notified of unable to complete at ordered. (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 3 Event ID: 366335 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 366335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Snf-the Villa at Marymount 5200 Marymount Village Drive Garfield Heights, OH 44125 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)