Inspection·December 16, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of facility investigation documents, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were free from abuse. This affected one (Resident #10) of three residents reviewed for abuse. The facility census was 88 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 10/09/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction. diabetes with diabetic neuropathy, and repeated falls. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 11/05/24 revealed the resident had intact cognition. Review of the SRI and facility investigation for Resident #10 dated 11/19/24 revealed Resident #10 made an allegation of abuse to the Director of Nursing (DON) regarding Certified Nursing Assistant (CNA) #427. Resident #10 reported when CNA #427 came into her room the aide was upset that she had to change the resident. Resident #10 alleged CNA #427 pushed her toward the wall and hit the resident in the head. Resident #10 stated she had not reported the incident to anyone at the time, and she waited until the morning and called her daughter. Further review of the SRI revealed the facility substantiated abuse had occurred and CNA #427 was terminated. Review of a written statement regarding Resident #10 dated 11/19/24 revealed Licensed Practical Nurse (LPN) # 302 brought CNA#427 to Resident #10's room and the resident identified the CNA as the person who hit her. Review of the written statement regarding Resident #10 dated 11/19/24 revealed CNA #427 denied ever pushing, hitting, or yelling at Resident #10. Interview on 12/12/24 at 9:58 A.M. with Resident #10 confirmed the staff treated her well except for an aide that had yelled at her and hit her. Resident #10 confirmed the facility staff told her the aide was fired and there had been no problems since then. Interview on 12/12/24 at 12:04 P.M. with the DON and the Administrator confirmed the facility had (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 5 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 12/16/2024 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)