Inspection·November 30, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to ensure proper sanitation was maintained during food preparation, failed to ensure dishes were adequately cleaned, and failed to ensure the dishwasher was maintained in optimal condition to properly clean dishes, eating utensils, and food preparation utensils. This had the potential to affect all 98 residents who the facility identified as receiving food from the kitchen. The facility identified two (#55 and #207) residents who do not eat food prepared in the kitchen. The facility census was 100. Findings include: 1. During the initial tour of the kitchen on 11/27/23 between 8:45 A.M. and 9:30 A.M., with the Regional Kitchen Manager (RKM) #699, revealed the high temperature dishwashing machine's wash cycle had a reading of 150 degrees Fahrenheit (F), and the rinse cycle had a reading of 120 degrees F after multiple cycles. Further observation revealed the dishwashing machine's booster heater was in the off position. Interview with RKM #699 during the observation of the dishwasher on 11/27/23 between 8:45 A.M. and 9:30 A.M. verified the booster heater was off, and stated the dishwasher should reach a minimum of 150 degrees F during the wash cycle and 180 degrees F during the rinse cycle. RKM #699 revealed the dishwashing machine was a recent purchase within the last two to three weeks. 2. Observation of the kitchen on 11/27/23 between 11:30 A.M. and 12:00 P.M. with RKM #699 revealed Dietary [NAME] (DC) #965 was wearing personal protective equipment (PPE) that included a surgical mask and gloves. DC #965 was observed slicing roast beef by using one hand to slice the meat and the other to hold the meat in place. DC #965 then proceeded to reach up and pull down his surgical mask, adjust it, and continued to slice the roast beef. Interview with RKM #699 on 11/27/23 between 11:30 A.M. and 12:00 P.M. verified DC #965 was not handling food in a sanitary manner while slicing the roast beef during the observation of food preparation. 3. Observation on 11/28/23 at 3:23 P.M. of the Memory Care Unit (MCU) dining area revealed 14 maroon colored coffee mugs and bowls placed on the countertop to be utilized. Further observation revealed multiple stains throughout the coffee mugs and bowls. Interview and observation on 11/28/23 at 3:23 P.M. with State Tested Nurse Aide (STNA) #716 revealed the coffee mugs and bowls were brought from the kitchen to be used by residents and were visibly stained with dark black and brown residue. STNA #716 revealed the coffee mugs and bowls were considered cleaned and scheduled to be used for the dinner meal. Demonstration of the cleanliness of the coffee mugs and bowls with Kitchen Staff (KS) #788 and KS #893 on 11/28/23, following confirmation by STNA #716 of the residue on the mugs and bowls, revealed a white napkin was used to wipe around the inside of the mugs and bowls and produced dark black and brown residue. Demonstration revealed the stains were able to be removed by wiping with the napkin. Interview with KS #788 and KS #893 at the time of the demonstration confirmed and verified the findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 2 of 4 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 11/30/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Review of the facility document titled, Sanitation Inspection, dated June 2023, revealed the facility had a policy in place that staff would inspect dishwasher temperatures daily. Review of the document revealed the facility did not implement the policy. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 3 of 4 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 11/30/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of email correspondence, review of infection control tracking documents, staff interview, and review of facility policies, the facility failed to maintain an infection surveillance program which adequately tracked location, organisms, antibiotic use, and other metrics to determine infection trends. Additionally, the facility failed to ensure staff had means to sanitize their hands in the laundry room. This had the potential to affect all 100 residents in the facility. The census was 100. Residents Affected - Many Findings include: 1. Review of the facility's infection tracking information revealed a 2023 report sheet which only identified the total number of infections in different categories and where they were acquired each month. The facility could only furnish monthly tracking forms from September to November 2023, which only documented the room number, resident initials, and general infection category for each case. Interview with the Administrator on 11/30/23 at 2:36 P.M. confirmed the above findings regarding the facility's infection tracking information. The Administrator stated the previous administration only reviewed infection tracking in meetings without any formal tracking documentation. The facility was aware more information should be tracked than what was on the forms they furnished and were working on implementing a new system. Review of the undated infection surveillance policy revealed the purpose of surveillance was to identify individual cases and trends to guide appropriate interventions and prevent future infections. Surveillance data was to include laboratory records, infection control rounds, antibiotic review, and other metrics. 2. Observation of the laundry room with Maintenance Director #854 on 11/28/23 at 1:44 P.M. revealed there were no means for staff to cleanse their hands including available hand sanitizer, soap, sinks, or paper towels in the soiled laundry room. Interview with Maintenance Director #854 on 11/28/23 at 1:50 P.M. confirmed the above findings. Review of an email sent by the Administrator on 11/29/23 revealed the facility was supposed to have hand sanitizer posted in the soiled linen room and acknowledged the hand sanitizer was not present in the past week. Further review of the email also acknowledged there was no handwashing sink available in the soiled laundry room. Review of the standard precautions policy dated 09/2022 revealed hand hygiene was to be done with soap and water when the hands were visibly soiled, after contact with contaminated surfaces, and after caring for residents with C. difficile infection. Hand hygiene was to be done immediately after removing gloves to avoid transfer of microorganisms to other environments. Soiled linens were to be handled in a manner that prevents exposure and avoids transfer of microorganisms to other residents and environments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366335 If continuation sheet Page 4 of 4