Health inspection·November 22, 2022

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected one (Resident #299) of one resident reviewed for funds conveyance. The facility census was 44. Residents Affected - Few Findings Include: Resident #299 was admitted to the facility on [DATE]. Resident #299 expired at the facility on [DATE] with diagnoses to include but not limited to hemiplegia and hemiparesis right side, dysphagia, diabetes mellitus, depression, and cerebral infarction. Review of the business records for Resident #299 revealed $974.48 were dispersed to the State Recovery of the United States on [DATE]. Interview on [DATE] at 9:46 A.M. with Human Resource Manager/Business Office Manager (HR/BOM) #255 revealed the corporate office sends her the check and then she sends it out right away. HR/BOM #255 verified that Resident #299's funds were conveyed outside of required timeframes (30 days). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 2 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, the facility failed to ensure mail was delivered to residents on Saturdays. This affected three residents (Residents #3, #10 and #29) of six reviewed who attended the resident council meeting and voiced concerns. The facility census was 44. Residents Affected - Many Findings include: 1. Review of medical record for Resident #3 revealed an admission date of 10/22/21. Diagnoses included cerebral infarction, hemiplegia affecting the right dominant side, bipolar type schizoaffective disorder, and diabetes mellitus with stage three diabetic chronic kidney disease. Review of the 10/16/22 Minimum Data Set (MDS) assessment revealed she was moderately cognitively impaired. Review of activities of daily living (ADLs) revealed Resident #3 required extensive assist of one staff for transfer, toileting, and personal hygiene. Interview during the resident council meeting conducted on 11/15/22 at 10:00 A.M. revealed Resident #3 stated mail was not received on Saturdays. 2. Review of medical record for Resident #10 revealed an admission date of 06/13/18. Diagnoses included schizophrenia, hypertensive heart disease with heart failure, depression, type two diabetes mellitus with neuropathy, and morbid obesity. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Activities of daily living (ADLs) revealed Resident #10 required extensive assist of one staff for bed mobility, transfer, transfer on and off the unit and toileting. Resident #10 required extensive assist of two staff for dressing and personal hygiene. Interview on 11/15/22 at 12:25 P.M. with Resident #10 revealed no mail was passed on the weekends. 3. Review of medical record for Resident #29 revealed an admission date of 08/25/22. Diagnoses included alcohol use with dementia, aortic aneurysm without rupture, bipolar disorder, adjustment disorder with mixed anxiety and depressed mood, type II diabetes mellitus with diabetic neuropathy, spondylolysis, hypothyroidism, chronic viral hepatitis C, post-traumatic stress disorder, and dementia with agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact. Resident #29 required limited assistance of one staff for bed mobility, transfer, walking in room and toileting and supervision for bathing, dressing, and eating meals. Interview on 11/15/22 at 12:15 P.M. with Res #29 confirmed he does not receive mail on Saturdays because the office was closed. Interview on 11/15/22 at 12:41 P.M. with Activities Supervisor #283 revealed there was no activities staff on the weekends, the Business Office Manager (BOM) picks up the mail and gives it to activities director or the Social Worker designee (SSD) to deliver Monday through Friday. Interview on 11/21/22 at 10:00 A.M. with the Administrator verified the facility does not have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 3 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0576 policy and was not specifically mentioned in the admission packet regarding receiving mail on the weekends, it is just part of their rights as a resident while living in the facility. Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 4 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #39) of one resident reviewed for advanced directives. The facility census was 44. Findings Include: Resident #39 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, schizophrenia, bipolar and systemic lupus erythematosus. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was moderate cognitively impairment and was independent for activities of daily living. Review of the physicians' orders for Resident #39 revealed an order dated [DATE] for do not resuscitate comfort care (DNRCC) a code status signifying cardiopulmonary resuscitative measures (CPR) was not to be conducted in case of cardiac or respiratory arrest. Review of the care plan dated [DATE] revealed the resident was a do not resuscitate comfort care- arrest (DNRCC-A) code status signifying medical interventions to maintain life up to the point of the heart or lungs stopping and CPR would not be performed on Resident #39. Review of the signed electronic documents section of Resident 39's medical record revealed no signed DNR was in the chart. Record review and interview on [DATE] at 5:14 P.M. with Licensed Practical Nurse (LPN) #256 revealed Resident # 39 's electronic medical record stated she was a DNRCC per the doctor's orders. The hard chart had no signed DNRCC document and on the outside of the hard chart was a sticker that stated Full Code meaning all life sustaining measures including CPR would be performed on Resident #39. This was verified by LPN #256 at time of the record review and LPN #256 stated the codes status should be the same throughout the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 5 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on medical record review, staff and family representative interview, and review of the facility policy, the facility failed to ensure a resident's family was notified following a change in status. This affected one (Resident #33) of three residents reviewed for notification of change in condition. The facility census was 44. Findings include: Review of the medical record for Resident #33 revealed an admission date of 11/07/17. Diagnoses included unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, chronic kidney disease stage three, hypertensive chronic kidney disease, type two diabetes mellitus, history of traumatic brain injury, schizoaffective disorder bipolar type, and chronic viral hepatitis C. Review of the 08/31/22 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #33 revealed a brief interview of mental status score of two which indicated severe cognitive impairment. Resident #33 was noted to be totally dependent upon one staff for toileting and bathing, required extensive assist of one staff for locomotion on and off the unit, dressing, eating and personal hygiene. Resident #33 required extensive assist of two staff for bed mobility and transfer. Resident #33 was noted to be incontinent of bowel and bladder. Review of facility self-reported incident (SRI) # 224007 dated 07/13/22 revealed Resident #33 called the local police with a concern of staff not taking care of him. The facility completed an investigation and was found to be unsubstantiated but failed to notify Resident #33's representative following the incident. Interview on 11/14/22 at 12:45 P.M. with Resident #33's representative confirmed she was not aware of any incident on 07/11/22 and had not been notified by the facility. Review of nursing progress note for Resident #33 dated 07/11/22 revealed Resident #33 called the police. Following the investigation by the police, Licensed Practical Nurse #277 notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON). Interview on 11/17/22 at 9:17A.M. with MDS #273 verified there was no documentation evidence Resident #33's representative had been notified timely of the incident. Review of undated facility policy called, Your Rights and Protections as a Nursing Home Resident revealed the facility must notify the doctor and legal representative or interested family member if your physical, mental, or psychosocial status starts to get worse. Review of undated facility policy called, Condition Change Policy and Procedure revealed notify physician and family and document the name of the family member documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 6 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents received showers as scheduled and per their preference. This affected three (Residents #2, #3, and #19) of three residents reviewed for showers. The facility had a census of 44 residents. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic obstructive pulmonary disease, chronic pain, and bed confinement. Review of Resident #2's Minimum Data Set Assessment (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition and required limited assistance of one staff member for hygiene. Bathing did not occur on this assessment. Review of Resident #2's care plan, dated 01/10/19, revealed he had self-care performance deficit related to morbid obesity, weakness and degenerative disc disease of the lower spine. Interventions included staff to provide extensive assistance for showering and bathing. Review of the shower log for Resident #2 revealed he was to receive his showers on Tuesdays and Fridays. Review of his shower sheets from 10/04/22 through 11/11/22, revealed he did not receive showers on 10/11/22, 10/15/22, 10/18/22, 10/25/22, 10/28/22, 11/01/22, 11/04/22, 11/08/22 and 11/11/22. There were no shower sheets or documentation in the electronic chart for Resident #2 for October 2022 or November 2022. Interview on 11/14/22 at 9:04 A.M. with Resident #2 revealed he does not get his showers as scheduled. He stated staff will put that he refused showers even though he did not. Interview on 11/15/22 at 03:00 P.M. Administrator confirmed nothing was documented under tasks in the electronic medical record for showers and confirmed no further shower sheets were available for this resident. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses included but not limited to acute cerebral infarction, type two diabetes, schizoaffective disorder, bipolar and chronic obstructive pulmonary disease. Review of this residents Minimum Data Set Assessment (MDS) 3.0 assessment, dated 10/16/22, revealed this resident had moderately impaired cognition and required extensive assistance of one staff for transfers, toilet use and personal hygiene. Review of this resident plan of care dated 07/21/21 revealed this resident had an Activities of Daily Living self-care performance deficit related to diagnoses. Interventions for this plan of care included to encourage a sponge bath when a full bath or shower cannot be tolerated. Interview on 11/14/22 at 11:32 A.M. with Resident #3 says she was told that she couldn't get a shower yesterday. Resident #3 didn't know what days her shower days were but wanted one yesterday. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 7 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of October 2022 shower sheets for Resident #3 revealed she received showers on 10/02/22 and 10/09/22 but refused showers on 10/11/22 and 10/13/22. There were no shower sheets or documentation in the electronic chart for Resident #3 for November 2022. Interview on 11/15/22 at 03:00 P.M. Administrator confirmed nothing is documented under tasks in the electronic medical record for showers and confirmed no further shower sheets were available after 10/16/22. 3. Review of the medical record for Resident #19 revealed an admission date of 06/04/19. Diagnoses included end stage renal disease, dependence upon dialysis, chronic atrial fibrillation, anxiety disorder, type II diabetes mellitus without complications, major depressive disorder, morbid obesity, and schizoaffective disorder. Review of the 10/02/22 Minimum Data Set (MDS) 3.0 assessment for Resident #19 revealed moderate cognitive impairment. Resident #19 required extensive assist of two for bed mobility, dressing, and toileting. Resident #19 required total dependence of two staff for transfer and bathing. Review of the facility shower logbook revealed Resident #19 was to receive showers during night shift on Tuesdays and Fridays. Review of shower sheets for Resident #19 revealed no showers given since 10/16/22 and no documentation since that date of refusals in the medical record. Interview on 11/15/22 at 3:00 P.M. with the Administrator confirmed nothing was document under the task tab in the electronic medical record for showers and confirmed no additional shower sheets were available after 10/16/22 for Resident #19. Review of 01/10/19 revised facility policy called Personal Care Needs revealed personal care and support provided to meet the needs of the residents includes bathing and showering to promote a healthy environment and prevent infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 8 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, review of job description, review of facility activity calendars, and policy review the facility failed to ensure activities to meet resident preferences and interests were offered on Saturdays. This affected two residents (Residents #10 and #29) of six residents reviewed for activities. The facility census was 44. Residents Affected - Few Findings include: 1. Review of medical record for Resident #10 revealed an admission date of 06/13/18. Diagnoses included schizophrenia, hypertensive heart disease with heart failure, depression, type II diabetes mellitus with neuropathy, and morbid obesity. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Activities of daily living (ADLs) revealed Resident #10 required extensive assist of one staff for bed mobility, transfer, transfer on and off the unit and toileting. Resident #10 required extensive assist of two staff for dressing and personal hygiene. Interview on 11/15/22 at 12:15 P.M. with Resident #10 confirmed there were no staff led activities on Saturdays to meet Resident #10's interests and preferences. 2. Review of medical record for Resident #29 revealed an admission date of 08/25/22. Diagnoses included alcohol use with dementia, aortic aneurysm without rupture, bipolar disorder, adjustment disorder with mixed anxiety and depressed mood, type two diabetes mellitus with diabetic neuropathy, spondylolysis, hypothyroidism, chronic viral hepatitis C, post-traumatic stress disorder, and dementia with agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact. Resident #29 required limited assistance of one staff for bed mobility, transfer, walking in room and toileting and supervision for bathing, dressing, and eating meals. Interview on 11/15/22 at 12:15 P.M. with Resident #29 confirmed there were no staff led activities on Saturdays to meet his interests and preferences. Interview on 11/15/22 at 12:41 P.M. with Social Services Designee (SSD) #283 revealed there were no activity staff on the weekends so a current events paper was delivered to the table in the activities room and laid on the table in the community area for residents to have access to that events paper. Residents could also start movies for themselves on Saturdays. SSD #283 stated she had never worked weekends while she was the activities director for three years, never had an assistant but occasionally a volunteer would come in on the weekends to provide an activity. Interview on 11/15/22 12:40 P.M. with Activities Director #202 confirmed there were no activity staff scheduled on the weekends and stated she was trying to make the residents more independent. Review of September, October and November 2022 activities calendars revealed no staff led activities on Saturdays. Review of undated facility Activity Director job description revealed the activity director will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 9 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0679 plan and implement evening and weekend functions as necessary. Level of Harm - Minimal harm or potential for actual harm Review of the undated facility policy titled, Your Rights and Protections as a Nursing Home Resident, revealed residents have a right to be treated with respect, participate in activities, and make complaints without fear of punishment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 10 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and policy review the facility failed to change an enteral tube feeding after 24 hours. This affected one resident (Resident #248) of two residents reviewed for tube feedings. The facility census was 44. Findings include: Review of medical record for Resident #248 revealed an admission date of 07/30/21. Diagnoses included severe dementia with agitation. chronic obstructive pulmonary disease, unspecified psychosis, pressure ulcer of left heel stage III, and unspecified severe protein-calorie malnutrition. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #248 was severely mentally impaired, required extensive assist for bed mobility, transfer, dressing and eating. Resident #248 was totally dependent upon staff for toileting, personal hygiene and bathing. Review of physician order dated 11/10/22 for Resident #248 revealed an order for an enteral feeding of Osmolite 1.2 at a rate of 60 milliliters per hour 24 hours a day with 150 cubic centimeter flush every four hours related to a diagnosis of severe protein-calorie malnutrition. Observation on 11/17/22 at 7:32 A.M. revealed Resident #248 sleeping in her bed, with the head of bed elevated. The Osmolite 1.2 container of enteral feeding hanging on the tube feeding pole was dated 11/15/22 with 04:00 ( 4:00 A.M.) written on the container underneath Resident #248's. Interview on 11/17/22 at 7:35 A.M. with Licensed Practical Nurse (LPN) #225 confirmed the enteral feeding container was dated 11/15/22 04:00 hours. LPN #225 stated she was unsure why the enteral feeding had not been changed, and it was to be changed every 24 hours. Review of January 2022 facility policy called, Enteral Feeding revealed tube feeding bag was to be changed every 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 11 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected two (Resident #2 and #4) of two residents reviewed for respiratory care. The facility had a census of 44 residents. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic obstructive pulmonary disease, chronic pain, bed confinement and anxiety. Review of Resident #2's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition and utilized oxygen. Review of Resident #2's care plan dated 01/10/19 revealed he had respiratory impairment related to chronic obstructive pulmonary disease and experienced shortness of breath while lying flat. He was noted to use oxygen frequently. Interventions included to administer medications as ordered. Review of the physician's order dated 11/07/19 revealed Resident #2's nasal cannula and oxygen tubing was to be replaced, initialed and dated weekly on night shift. Review of the physician's order dated 02/09/22 revealed Resident #2 was to have distilled water to humidify oxygen for nasal dryness every shift. Observation and interview on 11/14/22 at 9:04 A.M. with Resident #2 revealed he had oxygen on at two liters via a nasal cannula. Oxygen tubing and distilled water were noted to be undated. He stated he was unsure when the oxygen tubing and distilled water were changed last. Interview on 11/14/22 at 9:38 A.M. with Licensed Practical Nurse (LPN) #256 verified Resident #2's oxygen tubing and humidification bottle were undated. Review of the facility policy titled, Medication Administration, dated November 2021, revealed medications are to be administered in accordance with written orders of the prescriber. 2. Review of the medical record for Resident #4 revealed an admission date of 11/20/18 with diagnoses including Alzheimer's disease, emphysema, anxiety and a traumatic brain injury. Review of Resident #4's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had impaired cognition and utilized oxygen. Review of Resident #4's care plan dated 12/30/19 revealed he had altered respiratory status and difficulty breathing related to chronic obstructive pulmonary disease and experienced shortness of breath while lying flat and on exertion. He was noted to use supplemental oxygen. Interventions included to administer medications as ordered. Review of the physician's order dated 04/28/22 revealed Resident #4's oxygen was to be maintained at four liters to maintain oxygen level above 92%. There were no physician's orders for staff to change the nasal cannula and oxygen tubing. There was also no order for distilled water humidification to the oxygen concentrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 12 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the November 2022 Medication Administration Record and Treatment Administration Record for Resident #4 revealed nursing had administered oxygen daily at four liters on dayshift and nightshift. Observation and interview on 11/14/22 at 9:32 A.M. with Resident #4 revealed he had oxygen on at four liters via a nasal cannula. The oxygen tubing was noted to be undated. The oxygen concentrator had distilled water attached that was dated 10/06/22. He stated he did not know when the tubing or distilled water bottle were scheduled to be changed. Interview on 11/14/22 at 9:38 A.M. with Licensed Practical Nurse (LPN) #256 verified Resident #4's oxygen tubing was undated and the distilled water humidification bottle was dated 10/06/22. She verified there were no orders to change the oxygen tubing weekly or for him to have distilled water humidification to the oxygen concentrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 13 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure Resident #2's pain medication was administered as ordered. This affected one (Resident #2) of three residents reviewed for timely reordering of pain medications. The facility had a census of 44 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic pain and bed confinement. Review of the physician's orders for Resident #2, revealed an order for Methadone HCL tablet 10 milligrams (mg) (medication for pain), give 30 mg every 12 hours for pain dated 12/30/19. Review of the October 2022 Medication Administration Record, revealed Resident #2's Methadone was not administered at 9:00 A.M. and 9:00 P.M. on 10/24/22 and 10/29/22. Review of the Controlled Drug Records log for Resident #2, revealed there were no entries for narcotics given for the Methadone 10 mg tablets for the dates of 10/24/22 and 10/29/22. Interview on 11/14/22 at 9:04 A.M. with Resident #2 revealed there were times he did not receive his pain medications because the facility had not reordered the medication timely. He stated he was in pain when he did not receive the medication as ordered. Interview on 11/15/22 at 3:00 P.M. with the Administrator verified Resident #2's Methadone was not administered on the dates listed above. Review of the facility policy titled, Controlled Substance Prescriptions, dated November 2021, revealed re-orders for controlled medications should be made allowing for appropriate time for the pharmacy to obtain the prescription and to assurance an adequate supply is on hand. This deficiency represents non-compliance investigated under Complaint Number OH00133336. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 14 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of facility staffing schedules and staff interviews, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 44 residents currently residing in the facility. Findings include: Review of the nursing staff information and staff schedule for 11/5/22 revealed no RNs were present and working in the facility. Interview on 11/17/22 at 11:10 A.M. with Business Office Manager (BOM) #255 confirmed there was not an RN in the building on 11/5/22, the Director of Nursing (DON) #223 was scheduled on call. Interview on 11/17/22 at 11:22 A.M. with the Director of Nursing (DON) #223 confirmed she was on call but did not work in the facility on 11/5/22 and there was not an RN working. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 15 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review and interviews, the facility failed to ensure all narcotic medication accounting logs were maintained. This affected one (Resident #2) of three residents reviewed for documentation and accounting of narcotic medications. The facility had a census of 44 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic pain and bed confinement. Review of the physician's orders for Resident #2 revealed an order for Methadone HCL tablet 10 milligrams (mg) (medication for pain), give 30 mg every 12 hours for pain dated 12/30/19. Review of the October 2022 Medication Administration Record, revealed Resident #2 was administered Methadone 30 mg at 9:00 A.M. and 9:00 P.M. on 10/14/22, 10/15/22, 10/16/22, 10/17/22, 10/25/22, 10/26/22, 10/27/22 and 10/28/22. Review of the Controlled Drug Records log for Resident #2, revealed there were no entries for narcotics given for the Methadone 10 mg tablets for the dates of 10/14/22, 10/15/22, 10/16/22, 10/17/22, 10/25/22, 10/26/22, 10/27/22 and 10/28/22. Interview on 11/15/22 at 12:26 P.M. with the Administrator verified the controlled drug records for Resident #2's Methadone 10 mg tablets to be missing for the dates listed above. Review of the facility policy titled, Controlled Substance, dated November 2021, revealed accurate accountability of the inventory of all controlled drugs was to be maintained at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 16 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews and record review, the facility failed to ensure medications were properly stored and secured. This affected one (Resident #2) of one resident reviewed for improperly stored medications. The facility had a census of 44 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic obstructive pulmonary disease, chronic pain, bed confinement, anxiety and non-compliance with medications and treatment regimens. Review of the care plan dated 01/10/19 revealed Resident #2 had respiratory impairment related to chronic obstructive pulmonary disease with interventions including to administer medications per order. It was not care planned the resident could have medications at bedside and self administer. Review of the physician's orders for Resident #2 revealed an order for Advair Diskus Aeorosol Powder Breath Activated 250-50 micrograms (mcg) (medication for chronic obstructive pulmonary disease), one inhalation, orally every 12 hours for shortness of breath dated 06/26/22. There were no indications resident could keep the medication at bedside and self administer. Review of the November 2022 Medication Administration Record, revealed Advair 250-50 mcg was last administered on 11/15/22 at 9:00 P.M. Observation on 11/16/22 at 8:21 A.M. of Resident #2's room revealed Advair 250/50 mcg to be on the bedside tray table. Resident #2 stated when the nurse brought his inhaler to his room, he used it and then dropped it on the bed. Resident #2 stated he tried to find it on the bed but could not. He stated the nurse said she would come back later to retrieve the medication. Resident #2 could not state when the nurse had brought the Advair to the room or who the nurse was. Interview on 11/16/22 at 8:25 A.M. with Licensed Practical Nurse (LPN) #225, verified the Advair should not be left in Resident #2's room and she would remove it. Review of the facility policy titled, Medication Storage in the Facility, dated November 2021, revealed medications intended for internal use are to be stored in a medication cart or other designated area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 17 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview and record review, the facility failed to serve food in the proper portions to meet the nutritional needs of all residents in the facility ordered regular and therapeutic diets. This affected all 44 residents receiving meals from the kitchen, as no residents were identified by the facility as nothing by mouth (NPO). The facility census was 44. Findings include: Review of the facility's diet list revealed all residents received a variety of diet types including carbohydrate controlled diet (a therapeutic diet used to help control blood sugar levels in residents with diabetes), no added salt (NAS) diet, mechanically altered diet and regular diets with no restrictions. Review of the posted lunch menu for 11/15/22 revealed the meal being served to the residents included beef pot pie, broccoli, choice of bread and apricot crisp. Review of Resident Council meeting minutes for 04/27/22 revealed concerns with diet orders not being followed and the minutes for 10/19/22 revealed a concern with meal tickets not being followed and residents receiving the wrong foods. Review of the beef pot pie recipe revealed the following main ingredients should be included in the recipie: diced beef, sliced carrots and frozen peas. The serving size was eight ounces (oz). This was verified by DM #275 on 11/15/22 at 3:00 P.M. Observation on 11/15/22 at 11:25 A.M. of the lunch tray line meal service revealed beef pot pie, broccoli, and biscuits were being served for the resident meal. The beef pot pie did not have any vegetables in it, the beef appeared to be shredded not diced and the portion being served on the meal plates was one, four-ounce (oz.) spoodle. The broccoli portion being served was one, four oz. spoodle. The pureed beef pot pie had a green, #12 scoop to serve (which is equivalent to 3 oz), and pureed vegetables had a #16 scoop to serve (which is equivalent to two oz.). Dietary Manager (DM) #275 verified the portion sizes being served. Interview on 11/15/22 at 11:25 A.M. with DM #275 revealed a spreadsheet to guide the cooks on proper portions for each diet type could not be found for the lunch meal on 11/15/22 so no spreadsheet had been used as a guide for proper portion sizes for the meal. When the surveyor asked DM#275 to see the spreadsheet for the meal DM #275 pulled out a spreadsheet dated 06/06/21 and said to use this one. The menu on the spreadsheet for lunch was turkey pot roast 3.5 oz., one baked potato, 4 oz. carrots, choice of roll, one dessert choice and was dated Sunday 06/06/21. DM #275 verified the spreadsheet did not match the meal being served at lunch. Interview on 11/15/22 at 11:35 A.M. with DA #257 revealed DA #257 did not use spreadsheets to prepare desserts for the carbohydrate controlled diets. DA #257 stated a spreadsheet was not needed because the carbohydrate controlled diets always got the same foods as a regular diet. DA #257 said the dessert for the meal was gelatin cake, and the cake was made with diet gelatin. Interview on 11/16/22 at 10:00 A.M. with Registered Dietician (RD) #243 revealed he only did a tray line audit as needed, did not have access to the tray card system and did not sign off on any menus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 18 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0800 Level of Harm - Minimal harm or potential for actual harm or spreadsheets to certify the menus or spreadsheets met the nutritional requirements for all diet types for all residents in the facility. This deficiency represents non-compliance investigated under Complaint Number OH00136004 and OH00133336. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 19 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and interviews the facility did not ensure food was served at palatable temperatures. This had the potential to affect 44 residents receiving meals from the kitchen. No residents were identified as nothing by mouth (NPO). The facility census was 44. Residents Affected - Many Finding include: Observation on 11/15/22 at 11:25 A.M. of the lunch tray line revealed all hot food items on the steam table had temperatures over 165 degrees Fahrenheit (F) including beef and broccoli. There was no heat retention system being used in the kitchen to keep the food warm once it left the steam table besides thermal domes to cover the plates and enclosed meal delivery carts. The meal delivery cart carrying a test tray left the kitchen at 12:11 P.M. and arrived on the unit at 12:12 P.M. The test tray was the last tray served off the cart to Dietary Manager (DM) #275 who proceeded to take temperatures of the beef and broccoli on the test tray. The beef and broccoli did not reach 100 degrees Fahrenheit (F) as verified by DM #275 during the observation. DM #275 stated the food should be hotter. Interview on 11/16/22 at 10:00 A.M. with Registered Dietician (RD) #243 revealed he only conducted tray line audits on an as needed basis. Review of the resident Council minutes revealed cold food was a concern on 12/15/21, 01/19/22, 02/16/22, 03/23/22, and 10/19/22. Review of the facility policies and procedures dated 1/22/09 with a revision date of 08/08/22, titled, Dietary/Food Handling revealed that temperatures must be maintained for hot food at 135 degrees F or above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 20 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve food at the proper consistency to Resident #35. This affected one resident (Resident #35) of 44 residents receiving meals from the kitchen. No residents were identified by the facility as nothing by mouth (NPO). The facility census was 44. Findings include: Record review revealed Resident #35 was admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses that included but not limited to chronic obstructive pulmonary disease, vascular dementia with mood disturbance, dysphagia following cerebral infarction and aphasia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was severely cognitively impaired and required extensive assistance of one staff for eating. Review of the plan of care for Resident #35 dated 04/05/21 with a revision date of 10/14/22 revealed Resident #35 had a nutritional problem related to diagnoses and a history of difficulty chewing/swallowing. Interventions included but not limited to monitor, document and report to physician as needed for signs and symptoms of dysphagia to include pocketing, choking and several attempts of swallowing. Review of the physician's orders for November 2022 revealed orders for a regular diet with mechanical soft texture and pureed vegetables and thin liquids. Review of Resident #35's diet ticket revealed Resident #35 would receive a regular diet with mechanical soft texture and pureed vegetables at meals. Observation on 11/15/22 from 11:25 A.M. to 12:10 P.M. of the lunch tray line revealed Resident #35 was given regular vegetables instead of pureed vegetables. Interview on 11/15/22 at 11:45 A.M. with Dietary Aide #257 verified Resident #35 was given regular vegetables on her meal tray because Resident #35's boyfriend (another resident in the facility) feeds her and that made it ok to give her regular vegetables when the boyfriend feeds her. When asked by the surveyor where she got that information DA #257 stated that was what nursing told her. Additional review of the physician orders and care plan for Resident #35 revealed there were no orders or care plan to indicate it was ok for Resident #35's boyfriend to feed her regular vegetables that were not pureed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 21 of 22 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 365370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momentous Health at Richfield 4360 Brecksville Rd Richfield, OH 44286 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 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 observations, interview and record review, the facility failed to ensure the food was prepared, stored and served in a clean and sanitary manner. This had the potential to affect all 44 residents in the facility receiving meals from the kitchen, as there were no residents identified by the facility as nothing by mouth (NPO). The facility census was 44. Findings include: Observations during the initial tour of the kitchen on 11/14/22 from 8:15 A.M. to 8:30 A.M. revealed the walk-in freezer had a heavy ice build on the floor and reaching onto the bottom of the wire shelf and onto boxes of grilled chicken breasts, two cases of ground beef and one case of breaded fish sticks. Food splatter was on the wall behind the stove and wall near dishmachine. The microwave had dried food residue on the inside of the microwave. These observations were verified by Dietary Manager (DM) #275 at time of observation and DM #275 stated the dietary department had been short staffed recently as an explanation of the findings. Review of the facility policies and procedures dated 1/22/09 with a revision date of 08/08/22, titled, Dietary/Food Handling revealed guidelines for the safe food preparation, handling, and storage of perishable food included a clean kitchen environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 22 of 22