Health inspection·November 8, 2023

F 0686 Level of Harm - Actual harm Residents Affected - Few was dependent on staff to assist with transfers, needed extensive assistance for bed mobility and dressing, and used a wheelchair for locomotion. The MDS assessment revealed the resident had bladder incontinence, was not a candidate for a toileting program, and had no pressure ulcers. Review of the wound progress note dated 10/09/23 identified Resident #33 developed an unstageable wound (intact or non-intact skin with localized area of persistent non- blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone/muscle interface.) on the left buttocks measuring 1.5 centimeters (cm) in length by 2 cm width with undetermined depth. Resident #33's physician orders noted on 10/09/23 to place a low air loss mattress on Resident #33's bed. Review of a nursing progress note dated 10/10/23 revealed Resident #33 was currently on a regular foam mattress. An interview with Wound Licensed Practical Nurse (WLPN) #125 on 11/02/23 at 7:33 A.M. revealed Resident #33 had a risk of developing pressure ulcers due to his obesity, diagnoses of diabetes mellitus, and his mobility problems. WLPN #125 stated Resident #33 was placed on a regular foam mattress upon admission and should have had a low air mattress in place on admission to prevent the development of pressure ulcers. WLPN #125 agreed Resident #33's pressure ulcer could have been prevented if the facility had obtained the low air loss mattress sooner. An interview on 11/01/23 at 8:03 A.M. Resident #33 stated he had developed a wound on his buttocks following his admission to the facility. Resident #33 stated the wound was painful and he was unsure if the wound was improving. Resident #33 stated he was admitted to the hospital with a COVID-19 infection and was very weak and unable to turn and reposition himself. Resident #33 stated the staff had encouraged him to change his position but stated he had been unable to without the assistance of staff. Resident #33 stated while he was in isolation for the COVID-19 infection the staff did not assist him out of bed or routinely assist him with frequently turning and repositioning. Resident #33 stated the facility changed his regular foam mattress to a low air loss mattress after the development of his pressure ulcer wound but was unable to remember the exact day the low air mattress was placed on his bed. An observation of Resident #33's wound treatment on 11/02/23 at 8:03 A.M. revealed the wound dressing was soiled with feces. WLPN #125 removed Resident #33's incontinence brief and noted the resident had been incontinent of liquid brown stool which soiled the left buttock wound treatment foam dressing. WLPN #125 notified State Tested Nursing Assistant (STNA) #126 Resident #33 was incontinent and needed changed. STNA #126 informed WLPN #125 the STNA, STNA #127, assigned to care for Resident #33 was late and would arrive for work at 8:10 A.M. On 11/02/23 at 8:35 A.M. Resident #33 received his meal tray and started eating breakfast and stated the staff had not provided incontinence care as of this time. On 11/02/23 at 8:45 A.M. an interview with STNA #127 revealed she was unaware Resident #33 needed incontinence care. STNA #127 stated she arrived to the facility after 8:00 A.M. and assisted the staff with passing meal trays and was not informed Resident #33 needed incontinence care. On 11/02/23 at 8:55 A.M. STNA #127 provided Resident #33 with incontinence care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 2 of 11 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 11/08/2023 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)

F 0686 Level of Harm - Actual harm Residents Affected - Few An interview on 11/02/23 at 10:15 A.M. with Licensed Practical Nurse (LPN) #124 revealed she was informed WLPN #125 was unable to perform Resident #33's wound treatment because she had to leave the facility for an appointment. LPN #124 stated she would perform the wound treatment after Resident #33 received his shower. Resident #33 completed his shower at 10:12 A.M. and was seated in a shower chair in his room awaiting staff to assist him back to bed. At 10:28 A.M. Resident #33 was assisted back to bed and the wound treatment performed. LPN #124 revealed Resident #33 had a left buttock wound the approximate size of a 50 cent coin. The wound had full thickness tissue loss with fatty tissue and yellow slough present in the wound base. An interview on 11/02/23 at 11:21 A.M. with Nurse Practitioner (NP) #123 revealed Resident #33 was bedridden, weak and unable to move himself. NP #123 stated she had completed an unavoidable development of pressure ulcer form dated 10/09/23 in error. NP #123 stated she felt Resident #33's pressure ulcer could have been prevented if the appropriate care and treatment was provided in a timely manner. A review of the facility policy and procedure titled Skin Condition Treatment, revised 02/20/12, revealed the policy was to reduce or eliminate causative factors for skin integrity alteration: pressure, shear, friction, moisture, circulatory impairment and neuropathy. Implement treatment of skin conditions. Provide systemic support for wound healing by providing nutritional and fluid support and control of systemic conditions affecting wound healing. Prevent further skin breakdown. The policy indicated to initiate appropriate pressure redistributing and/or prevention measures, including: Incontinence care every one to two hours and as needed and initiate pressure redistributing appliances as indicated by resident's functional mobility status. This deficiency is non-compliance discovered during the investigation of Complaint Number OH00147345. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 3 of 11 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 11/08/2023 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, power of attorney (POA) interview, resident interview, review of a Self -Reported Incident (SRI) and investigation, review of facility sign out sheets, and review of the facility policy for signing residents out, the facility failed to provide supervision and follow the facility policy for a resident signing out for a leave of absence (LOA) to ensure the whereabouts for one resident (Resident #87) who had left the facility after reporting she was leaving on a LOA. This resulted in Immediate Jeopardy and the potential for serious harm, injury or death, on 10/24/23 at approximately 4:30 P.M. when Resident #87, who had mild dementia and required supervision and assistance for activities of daily living, informed staff she was leaving with a friend for an LOA. The staff were unaware of the sign out procedure and did not have the resident sign out. The resident did not return to the facility and facility staff did not recognize she had not returned for over 42 hours. On 10/26/23 at 11:00 A.M. the resident was discovered alone at her home without food, utilities, or a means to call for assistance. The resident was transported to the hospital via emergency medical services and was admitted to the hospital for treatment of pneumonia. This affected one resident (#87) of one resident reviewed for being on a LOA. The facility census was 104. On 11/01/23 at 2:39 P.M., the Administrator and the Director of Nursing (DON), were notified Immediate Jeopardy began on 10/24/23 at approximately 4:30 P.M. when Resident #87 informed staff she was leaving the facility for a LOA with a friend. The facility staff were unaware of the sign out procedure, therefore the resident did not follow the sign out policy. The friend took Resident #87 to her home, which was without utilities, and left the resident alone without any food or means to call for assistance. The facility did not recognize Resident #87 had not returned to the facility from the LOA until 10/26/23 at 11:00 A.M., over 42 hours after she had left, when a staff member identified the resident as missing. Resident #87 was subsequently located at her home and transported to the hospital where she was admitted with pneumonia. The Immediate jeopardy was removed on 11/03/23 when the facility implemented the following corrective action: • On 10/26/23, at or around 12:00 P.M., Licensed Practical Nurse (LPN) #115, LPN #110, LPN #116, and Registered Nurse (RN) #117 completed a head count of all residents in the facility to ensure all were accounted for. No additional residents were identified to be missing. • On 10/26/23, LPN #110 completed an elopement risk assessment for residents on the affected unit (unit Resident #87 resided on) to ensure appropriate safety measures were in place. • On 10/26/23, the DON and the Administrator began educating all staff on LOA policies and procedures. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 4 of 11 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 11/08/2023 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 10/26/23, the facility updated Resident #87's plan of care to include a picture pf the resident at the nursing station with a notation stating Resident #87 could only leave the facility with her power of attorney (POA). • On 10/26/23, notifications were posted at exit doors reminding visitors and residents they were to enter/exit at the front entrance only by the reception desk. • On 10/26/23, a notice was posted at the internal elevator indicating that the use of the elevator was only for employees. • On 10/27/23, the Administrator began educating families on the directive to sign in and out of facility utilizing the front door as the only means of entering and exiting the facility. The education was completed for 129 residents and or resident family members using the Call Multiplier system which is a voice broadcasting and mass texting service. • On 10/27/23, the employee elevator was taken out of service so it could not potentially be used by visitors to reach an alternate exit that would bypass the reception desk and sign in/out area. • On 11/01/23, the Administrator educated the Social Worker on ensuring staff and the Interdisciplinary Team were updated when a change in LOA requests were made by the resident and/or responsible party. • On 11/01/23, the LOA policy was revised to include follow-up measures if a resident does not return from an LOA when they indicated they would return. • On 11/01/23, the DON began education with all nursing staff and agency staff on the new LOA policy and the missing person policy. New agency staff would be educated via an orientation binder at each desk that must be reviewed and signed before the staff member begins working. The facility implemented a plan for all nursing staff to be educated by 11/02/23. Staff not educated by 11/02/23 would not pe permitted to work until in-service education was completed. • On 11/2/2023, the Administrator posted a notice at entrance/exits; the reception desk, all nursing units, and the elevators reminding residents and/or visitors of the sign out/sign in policy. This (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 5 of 11 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 11/08/2023 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)

F 0689 notice was also given to residents who were capable of understanding. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On 11/02/23, and ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the DON, the Administrator, the charge nurse of the [NAME] Hall Unit, the Social Worker, the Medical Director, the Chief Operating Officer, and the Chief Nursing Officer to review and approve the facility action plan. • Beginning 11/03/23, the DON or designee will conduct audits of the LOA book to ensure residents are signing in/out as required and appropriate follow-up occurs by staff if the policy is not followed. The audits will be completed daily for two weeks and then three times a week for two weeks. The QAPI committee will monitor the results of the audits and follow-up as needed. • On 11/03/23, elopement risk assessments were completed on all facility residents to ensure appropriate safety measures are in place. • On 11/03/23 at 11:00 A.M. interviews with State Tested Nurse Aide (STNA) #120, STNA #121, and RN #122 revealed they were trained in the procedure for signing out residents who left the facility for a LOA. The staff were able to locate the LOA resident sign-out log and state the process for signing out a resident who was leaving the facility for a LOA. The Immediate Jeopardy was removed on 11/03/23, however the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #87 was admitted on [DATE] with diagnoses including dementia, vascular dementia, hypertensive chronic kidney disease, protein-calorie malnutrition, morbid obesity, chronic obstructive pulmonary disease, asthma, and cognitive communication deficit. Resident #87 had identified medical conditions which included muscle weakness, difficulty walking, and unspecified abnormalities of gait and mobility. Review of Resident #87's plan of care, initiated on 12/14/22 and revised on 06/27/23, revealed the resident had an activity of daily living self-care deficit related to impaired balance. Interventions on the plan of care included to provide extensive assistance of one staff member for transfers, toileting, and bathing. Resident #87 needed limited assistance of one staff member for bed mobility, dressing, and personal hygiene/oral care. Review of the Minimum Data Set (MDS) assessment, dated 10/26/23, revealed Resident #87 had moderately impaired cognition and needed (staff) supervision with bed mobility, dressing, personal hygiene, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 6 of 11 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 11/08/2023 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety transfers, and ambulation. Resident #87 used a wheelchair for locomotion and was occasionally incontinent of urine. Review of Resident #87's electronic clinical record included an undated special instruction located on the profile page of the record which stated Resident #87 was only to leave the facility with power of attorney (POA). Residents Affected - Few A review of the facility Self Repotered Incident (SRI), dated 10/26/23, revealed Resident #87 left the building without proper authorization on 10/24/23 at 4:00 P.M. The DON notified the Administrator Resident #87 was not in her room and had left the faciity on a LOA and had not returned to the community. Resident #87's family was notified and informed the facility Resident #87 was not with the family. The facility conducted an investigation and found a visitor had signed into the facility on [DATE] at 3:54 P.M. to visit with Resident #87. The visitor was a friend of Resident #87. Resident #87's friend was contacted, and he reported to the facility he had transported Resident #87 to her private home per the resident's request. The police were notified and found Resident #87 at her private residence. There was no documentation in Resident #87's medical record identifying the resident had left for a LOA on 10/24/23. There was no documentation the resident had not been at the facility from 10/24/23 through 10/26/23. An interview on 10/31/23 at 1:23 P.M. with Resident #87's POA revealed Resident #87 had dementia and was unable to care for herself. The POA stated Resident #87 was able to make some decisions with assistance due to her diagnosis of dementia. The facility had informed the POA Resident #87 was missing from the facility on 10/26/23 at approximately 11:30 A.M. The POA stated the facility had informed her a visitor had taken Resident #87 from the facility on 10/24/23 at approximately 4:00 P.M. The POA stated she had previously informed Social Service Designee (SSD) #111 Resident #87 should not leave the facility without family notification. The facility did not inform her of Resident #87's departure from the facility with a visitor until 10/26/23. The POA stated Resident #87 had called the visitor and asked him to take her home to her private residence. Resident #87's home had been vacant for an extended period of time and had all the utilities, including her phone line, turned off. Resident #87's private residence was in deplorable condition and Resident #87 was found lying on the couch complaining she was cold and hungry. The ambulance service was called and transported Resident #87 to the hospital where she was admitted with a diagnosis of pneumonia. An interview with Administrator on 10/31/23 at 3:57 P.M. revealed LPN #110 had informed her Resident #87 was not in the building on 10/26/23 at around 11:00 A.M. A search of the facility was conducted, and it was determined Resident #87 was not in the building. The facility notified the police and reported Resident #87 was missing. The facility contacted Resident #87's POA and was informed by the POA that Resident #87 was not with her family. The POA had informed the facility she was not notified of Resident #87's leave of absence. The Administrator stated State Tested Nursing Assistant (STNA) #112 was assigned to care for Resident #87 on 10/24/23. Resident #87 had informed STNA #112 she was leaving the facility with a visitor to see her house. STNA #112 informed LPN #113 Resident #87 was leaving the facility on a LOA. LPN #113 informed the nursing supervisor (LPN #114) of Resident #87's request to leave the facility. LPN #114 told LPN #113 it was okay for Resident #87 to leave the facility. The Administrator stated Resident #87 had exited the facility with the visitor via the side door of the facility, assisted Resident #87 to his vehicle, and left the facility with Resident #87. Resident #87 had not left via the front entrance of the facility and had not signed out of the facility at the time she left on the LOA. The Administrator stated the nursing staff had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 7 of 11 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 11/08/2023 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety communicated during shift report that Resident #87 had left for a few hours and had reported she was with her family. The nursing staff continued to communicate during shift-to-shift report that Resident #87 was out with her family therefore, the nursing staff did not identify Resident #87 was missing until 10/26/23. A review of the Resident Sign Out Sheet dated 10/01/23 to 10/31/23 had no documentation of Resident #87 leaving the facility for a LOA. Residents Affected - Few Interviews on 10/31/23 at 3:45 P.M. with STNA #118, LPN #110, LPN #119, and LPN #120 revealed they were unaware of where the LOA resident sign out sheet was located and thought it was located on a different nursing unit. An interview with LPN #116 on 10/31/23 at 4:00 P.M. verified there was no documentation of Resident #87 leaving the facility on the Resident Sign Out Log dated 10/01/23 to 10/31/23. An interview with the DON on 11/01/23 at 9:34 A.M. revealed on 10/26/23 LPN #110 was conducting a monthly assessment of the residents and had reported Resident #87 was not in her room. An interview with Resident #87 on 11/01/23 at 10:18 A.M. revealed she had called her friend to come to the facility and asked him to take her to see her private home. Resident #87 stated her friend dropped her off at her home. Resident #87 didn't realize the utilities had been turned off, including her phone line. She did not have a cellular phone and could not contact anyone to assist her with her daily needs. Resident #87 stated she did not have money or a way to call for food to be delivered and there was no food in the house. Resident #87 stated eventually an ambulance came and took her to the hospital where she was admitted with a diagnosis of pneumonia. Resident #87 could not remember how long she was at her home prior to the ambulance transporting her to the hospital or if she used the toilet. An interview on 11/01/23 at 10:33 A.M. with LPN #110 revealed on 10/26/23 at approximately 10:00 A.M. she had entered Resident #87's room to perform her monthly assessment and found Resident #87 was not in her room. LPN #110 stated she checked the LOA log and Resident #87's clinical record and could find documentation Resident #87 was signed out of the facility. LPN #110 stated there was no documentation of when Resident #87 had left the facility, who had taken Resident #87 out of the facility, where Resident #87 was transported, or when the facility should expect Resident #87 to return to the facility. LPN #110 stated residents were supposed to sign out on the LOA log on the nursing unit and before exiting the building at the front entrance of the facility. An interview on 11/01/23 at 10:47 A.M. with SSD #111 revealed early in the month of 08/2023 Resident #87's POA had met with him to discuss some financial issues. During the meeting the POA had informed SSD #111 Resident #87 should not leave the facility without informing the POA prior to leaving. The POA was worried that due to Resident #87's poor memory and diagnosis of dementia somebody in the community could take advantage of Resident #87. SSD #111 stated he had placed the special instruction in Resident #87's clinical record but did not communicate the information to the administrative or direct care staff. SSD #111 stated Resident #87's plan of care should have been updated to include the special instructions. SSD #11 verified he had not informed the nursing staff to revise the plan of care. An interview on 11/01/23 at 11:09 A.M. with STNA #112 revealed she was assigned to care for Resident #87 on 10/24/23. STNA #112 stated she saw Resident #87 preparing to leave the facility and asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 8 of 11 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 11/08/2023 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #87 who she planned to visit. Resident #87 informed her she was leaving to check on her private home. STNA #112 stated she informed LPN #113 of Resident #87 leaving the facility and LPN #113 told her Resident #87 had until 12:00 A.M. on 10/25/23 to return to the facility. Review of the facility policy titled Signing Residents Out, revised 08/2006, revealed all residents leaving the premises must be signed out. A sign-out register was located at each nurses' station. Registers must indicate the resident's expected time of return. Medication that must be administered while the resident is out will be given to the resident/person signing the resident out of the facility. Staff observing a resident leaving the facility and having doubts about the resident being properly signed out, should notify their supervisor. Restrictions on the resident's chart concerning who may not sign the resident out must be honored unless prohibited by facility policy or state/federal law governing such releases. If a resident chooses to go with an individual, the Director of Nursing services and/or Administrator must be contacted and informed of the situation. Residents must be signed back into the facility upon their return to the facility. This deficiency is non-compliance discovered during the investigation of Complaint Number OH00147846 and Complaint Number OH00147804. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 9 of 11 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 11/08/2023 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure incontinence care was provided in a timely manner to one (#33) out of three residents reviewed for bowel and bladder incontinence. The facility census was 104. Findings include: Record review revealed Resident #33 was admitted to the facility on [DATE] from the hospital with diagnoses including COVID-19 infection, diabetes mellitus with a right below the knee amputation, pulmonary embolism, high blood pressure, atherosclerotic heart disease, peripheral vascular disease, stroke, cognitive communication deficit, and morbid obesity. Resident #33 had medical conditions including generalized muscle weakness, difficulty walking and low back pain. Review of Resident #33's Minimum Data Set (MDS) assessment, dated 09/25/23, revealed he was dependent on staff to assist with transfers, had bladder incontinence, and was not a candidate for a toileting program. Resident 33's plan of care initiated on 09/22/23 revealed Resident #33 had bladder incontinence related to impaired mobility and medication side effects. Interventions on the plan of care included to check Resident #33 for incontinence every two hours and provide incontinence care when needed. Encourage fluids during the day and establish voiding patterns. An interview on 11/01/23 at 8:03 A.M. Resident #33 stated he was unable to use the toilet due to his weakness and needed routine assistance with incontinence care. An observation of Resident #33 on 11/02/23 at 8:03 A.M. with Wound Licensed Practical Nurse (WLPN) #125 revealed he was incontinent of liquid brown stool which soiled the left buttock wound treatment foam dressing. WLPN #125 notified State Tested Nursing Assistant (STNA) #126 that Resident #33 was incontinent and needed changed. STNA #126 informed WLPN #125 the STNA, STNA #127, assigned to care for Resident #33 was late and would arrive for work at 8:10 A.M. On 11/02/23 at 8:35 A.M. Resident #33 received his meal tray, started eating breakfast and stated the staff had not provided incontinence care. On 11/02/23 at 8:45 A.M. an interview with STNA #127 revealed she was unaware Resident #33 needed incontinence care. STNA #127 stated she arrived to the facility after 8:00 A.M., assisted the staff with passing meal trays, and was not informed Resident #33 needed incontinence care. On 11/02/23 at 8:55 A.M. STNA #127 provided Resident #33 with incontinence care. A review of the facility policy titled Urinary Continence and Incontinence - Assessment and Management, revised 08/2006, revealed the policy was for the staff and practitioner would appropriately screen for, and manage, individuals with urinary incontinence. The policy included care of residents who do not respond well to a toileting trial would use the check and change strategy. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices/garments. The primary goals were to maintain dignity and comfort and to protect the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 10 of 11 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 11/08/2023 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)

F 0690 skin. Level of Harm - Minimal harm or potential for actual harm An interview with Administrator and Director of Nursing on 11/02/23 at 1:15 P.M. verified the above findings. This deficiency is non-compliance discovered during the investigation of Complaint Number OH00147345. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 11 of 11