Health inspection·September 26, 2023

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 review, interview, and facility policy review the facility failed to ensure proper mouth care was provided for Resident #43. This affected one resident (#43) out of three residents reviewed for assistance with activities of daily living. The facility census was 39. Residents Affected - Few Findings include: Review of the medical record for Resident #43 revealed and admission date of [DATE] with diagnoses including unspecified dementia severe with psychotic disturbance, paranoid schizophrenia, and chronic obstructive pulmonary disease. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 required extensive assistance of two or more staff members for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. Review of the physician orders for Resident #43 revealed an order dated [DATE] to admit to hospice services. Further review of physician orders for Resident #43 revealed no orders for mouth care. Review of Plan of Care tasks for Resident #43 revealed assistance with personal hygiene tasks such as combing hair, brushing teeth, shaving, and washing face and hands was charted as completed on [DATE] at 6:32 P.M. Review of hospice documentation revealed a progress note dated [DATE] 3:19 A.M. that stated that during inspection or Resident #43's mouth cavity revealed copious amounts of green debris with white spots and mouth care was immediately provided by Hospice Registered Nurse (RN). Review of Plan of Care tasks for Resident #43 revealed assistance with personal hygiene tasks such as combing hair, brushing teeth, shaving, and washing face and hands was not documented as completed again until [DATE] at 6:26 P.M., more than 15 hours later. Review of the progress notes for Resident #43 revealed a nurses note dated [DATE] at 10:49 P.M. that stated Resident #43 had expired at 7:24 P.M. Interview on [DATE] at 3:20 P.M. with Licensed Practical Nurse (LPN) #309 revealed Resident #43 had a history of becoming combative with hands on care but prior to Resident #43's passing, he had become calm and hands on care was able to be given without resistance. Review of the policy titled Resident Activity of Daily Living (ADL) Care, dated [DATE], revealed all residents were expected to maintain acceptable standards of oral hygiene and mouth care to be provided, when necessary, at intervals appropriate to resident's needs. This deficiency represents non-compliance investigated under Complaint Number OH00146402. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 2 of 15 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 09/26/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, policy and procedure review and interview, the facility failed to timely identify, provide timely medical intervention and notify Resident #42's physician and power of attorney (POA) of an acute change in condition/altered mental status. This affected one resident (#42) of three residents reviewed for change of condition. The facility census was 39. Residents Affected - Few Actual Harm occurred beginning on 08/27/23 at 1:46 A.M. when facility staff failed to timely identify and provide medical intervention for an acute change in condition (including lethargy, pain, decreased oxygen level) for Resident #42. The resident was noted to have a change in condition with no evidence, from 08/27/23 through 08/31/23 the resident's physician or power of attorney (POA) were notified. On 08/31/23 at 9:36 P.M. per family request, 911 was called and Resident #42 was transported via Emergency Medical Services (EMS) to the local Emergency Department. Resident #42 was admitted to the hospital with a urinary tract infection and possible sepsis. The resident did not return to the facility. Findings include: Review of Resident #42's medical record revealed an admission date of 06/28/23 with diagnoses including malignant neoplasm of meninges, malignant neoplasm of prostate, and displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with malunion, and anemia in neoplastic disease. Resident #42 was transported to the hospital Emergency Department on 08/31/23, admitted to the hospital and was discharged from the hospital on [DATE] to a different Skilled Nursing Facility. Review of Resident #42's Clinical admission Evaluation dated 06/29/23 included Resident #42 obeyed commands, and denied weakness, tremors, numbness, or tingling. Resident #42's mood was pleasant, and no unwanted behaviors were witnessed. Resident #42 was confused, speech was clear, had the ability to understand others, and made himself understood. Review of Resident #42's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 required extensive assistance of two staff for bed mobility, transfers, and required total dependence of two staff for toilet use. Resident #42 was always incontinent of urine and bowel. Resident #42 required limited assistance of staff for eating. Review of Resident #42's care plan dated 07/09/23 included Resident #42's power of attorney (POA) consented for all physician recommended medical or surgical treatments. Resident #42's POA's wishes would be honored through the next review date. Interventions included to communicate any change of condition with Resident #42 and his POA, explain any medical or surgical treatments being recommended by the physician and how they pertain to Resident #42's quality of life, report any change of condition to the nurse or social worker. Review of Resident #42's progress notes dated 08/26/23 at 10:28 P.M. revealed Resident #42 was congested, had thick mucus coming from his nose, and had a moist cough. Vital signs included a temperature of 98.2 degrees Fahrenheit, respirations 22 per minute, blood pressure 111/54, pulse 70 beats per minute, and 93 percent oxygen saturation level on room air. Resident #42 was administered Levsin (gut antispasmodic) for secretions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 3 of 15 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 09/26/2023 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 0684 Level of Harm - Actual harm Residents Affected - Few Review of Resident #42's progress noted dated 08/27/23 at 1:46 A.M. revealed hospice was notified and arrived at the facility to evaluate Resident #42. As a result of the visit, the facility nurse was told to monitor Resident #42 and if any changes took place to call hospice. Review of Resident #42's Hospice Assessment notes dated 08/27/23 at 2:20 A.M. revealed an unidentified facility nurse called and reported Resident #42 was congested with a moist cough, thick mucus, and secretions. Respirations were 24 per minute with no shortness of breath or labored breathing. The medication Levsin used for secretions was effective. The facility nurse was advised to call the hospice agency if Resident #42 had a change in status. Review of Resident #42's progress notes from 08/27/23 at 1:46 A.M. through 08/30/23 at 9:31 P.M. revealed no documented evidence Resident #42 was monitored for a change of condition. There was no documented evidence Resident #42's mental status or vital signs were checked during this time period. There was no documented evidence Resident #42's POA, the hospice nurse, or Resident #42's physician were notified of any issues for Resident #42's during this time period. Review of Resident #42's progress notes dated 08/30/23 at 6:44 A.M. revealed the anti-anxiety medication, Ativan 0.5 milligrams (mg) (which could be administered every four hours as needed for anxiety) was administered. Review of Resident #42's progress notes dated 08/30/23 at 6:48 A.M. revealed Morphine sulfate oral solution (opioid pain medication) 10 mg/5 milliliter (ml), 0.5 ml (which could be administered every two hours as needed for pain and shortness of breath) was administered for the resident crying and screaming. Review of Resident #42's Hospice Assessment note dated 08/30/23 at 8:31 P.M. revealed an emergent visit for lethargy noted by family. Family stated this was not Resident #42's baseline and he was found by them freezing, cold, and unresponsive. Family stated Resident #42 was cold due to anemia and they encouraged the facility to put extra layers on him. At the time of the visit, Resident #42 was cool to touch, pulses were palpable, and skin was pale. Resident #42 was minimally responsive to verbal and painful stimuli. Per facility nurse Resident #42 was restless and crying out in pain and was medicated with Roxanol (Morphine) and Ativan at 6:50 A.M. and since then Resident #42 was minimally responsive. The plan was to hold pain medication and hope Resident #42's lethargy wore off and was due to poor excretion due to age and body. The facility nurses were instructed to hold nighttime antipsychotic medication and all as needed medications until morning and the hospice nurse could reassess Resident #42's level of consciousness. Family and facility nurses agreeable to the plan. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 10:21 A.M. revealed emergent visit for lethargy noted by family. Resident #42 was curled on his right side in bed. Resident #42 was oriented to self, was minimally verbal with garbled speech, and followed commands. Resident #42's skin was warm, dry, with no edema and not mottling. Resident #42 had left over food in his mouth which was gently removed. Resident #42 was changed to a pureed diet. The resident's lungs were clear to auscultation, respirations shallow from pain, no shortness of breath. Resident #42 was notably lethargic and had not been out of bed since 08/30/23. Coordinated care with facility staff, educated facility nurse to give as needed Morphine for pain. Resident #42 was to be a daily watch at this time. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 11:11 A.M. included Hospice Nurse (HN) #318 spoke with POA #340, and POA #340 was very upset regarding Resident #42's care at the facility. POA #340 stated she did not believe Resident #42 was declining, rather she believed there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 4 of 15 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 09/26/2023 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 0684 Level of Harm - Actual harm Residents Affected - Few was something wrong that needs to be treated. POA #340 demanded a laboratory testing (a complete blood count (CBC) and Depakote level draw and wants everything to find out what's wrong. POA #340 was educated on limitations of treatment, tests when a resident was on hospice and Resident #42 could be discharged from hospice for seeking treatment. POA #340 stated she wanted hospitalization and treatment for Resident #42 until cardiac arrest. POA #340 verbalized understanding about possible discharge from hospice. CBC and Depakote draw requested from the hospice physician at this time. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 2:33 P.M. revealed POA #340 called HN #318 and expressed concern about Resident #42's hydration status. POA #340 stated Resident #42 got dehydrated and developed urinary tract infections (UTIs) frequently and wanted him tested for a UTI and specific gravity. Permission was given for a urine test for infection, but a specific gravity would not be covered. POA #340 verbalized understanding but still wanted a urine test for infection and a specific gravity. POA #340 and HN #318 discussed hospitalization for fluid resuscitation, and HN #318 reminded POA #340 hospice patients could not be admitted to the hospital for treatment or they would be discharged from services. POA #340 verbalized understanding. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 2:42 P.M. revealed the facility was called and Resident #42's lab order was placed with Licensed Practical Nurse (LPN) #309. Review of Resident #42's progress notes dated 08/31/23 at 6:59 P.M. written by LPN #309 revealed new orders for STAT (immediate) labs from Hospice Nurse #318 for a CBC, Depakote level, urine culture and sensitivity and specific gravity would be passed onto oncoming nurse. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 9:15 P.M. included POA #340 called and was very upset and wished for Resident #42 to be sent to the hospital. POA #340 reported Resident #42's oxygen saturation level was 85 percent and he was pocketing food. POA #340 indicated she went to the facility on [DATE] and Resident #42 was sitting in his wheelchair underneath an air conditioner in the hall. POA #42 stated Resident #42 was very lethargic, his temperature was 95 degrees Fahrenheit, and she warmed him up with blankets. POA #340 stated she requested lab work and a urinalysis for culture and sensitivity earlier in the day (08/31/23) because she believed Resident #42 was anemic and possibly dehydrated with a UTI. POA #340 stated the facility left these labs for the night nurse and the results would not be back until next week due to the holiday weekend. POA #340 demanded Resident #42 to be transported via squad to the local hospital Emergency Department. Hospice Nurse (HN) #341 advised POA #340 she would contact the facility for more information. Review of Resident #42's Pre-hospital Care Report Summary dated 08/31/23 included a call was received on 08/31/23 at 9:36 P.M. and Emergency Medical Services (EMS) were on scene at 9:40 P.M. The dispatch reason was respiratory distress. At 9:59 P.M. Resident #42's oxygen saturation level was 88 percent and oxygen was initiated at four liters nasal cannula. The POA told the facility to withhold all comfort care medications and to run diagnostic testing for illness. The POA requested transport to the Emergency Department for more diagnostic procedures. Patient contact was delayed due to fire department consultation with Med Control. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 9:39 P.M. included HN #341 spoke with the facility and was told POA #340 demanded Resident #42 be transported to the local hospital. HN #341 stated it was POA #340's wish that Resident #42 was transported to the local Emergency Department and the wishes must be followed. Review of Resident #42's progress note dated 08/31/23 at 11:21 P.M. written by Licensed Practical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 5 of 15 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 09/26/2023 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 0684 Level of Harm - Actual harm Residents Affected - Few Nurse (LPN) #313 included when LPN #313 arrived for work it was reported to her Resident #42 needed STAT (immediate) labs and a urine test completed. Lab work was ordered, and Resident #42 was catheterized to obtain a urine specimen. When LPN #313 entered Resident #42's room to administer bedtime medications she observed Resident #42 grimacing in pain and white thick secretions coming from his mouth. Resident #42's temperature was 98.7 degrees Fahrenheit, respirations were 16 per minute, pulse was 75, blood pressure was 148/55, and oxygen saturation level was 86 percent on room air. LPN #313 informed POA #340 of Resident #42's condition and that she would keep Resident #42 comfortable and administer oxygen to assist with his oxygen saturation level. POA #340 wanted Resident #42 to be sent to the Emergency Department to be evaluated. POA #340 stated she understood this could revoke Resident #42's hospice order. POA #340 wanted Resident #42 sent to the Emergency Department via 911 and Emergency Medical Services (EMS). LPN #313 called 911 and Resident #42 was transported to the local Emergency Department. Resident #42's POA, Director of Nursing, and the hospice nurse were updated. Review of Resident #42's progress note dated 09/01/23 at 1:15 A.M. included Resident #42 was admitted to the local hospital with a diagnosis of UTI with possible sepsis. Resident #42 was removed from hospice status. Interview on 09/20/23 at 11:29 A.M. with Resident #42's POA #340 revealed she wanted all life saving measures done for Resident #42 up until extreme measures would be implemented like intubation, chest compressions. POA #340 stated if Resident #42 needed medicine she wanted him to have it. POA #340 stated Resident #42 had a fractured right hip, surgery was not recommended due to his brain tumor, and he started receiving hospice services in 07/2023. POA #340 stated the main reason Resident #42 started receiving hospice services was because it was not known how fast his brain tumor would progress and communication with the facility was challenging due to new owners and administration. POA #340 stated she did not receive a call from the facility informing her Resident #42's mental status changed and when she came in for a visit on 08/30/23 and found him cold and freezing and not responding well. POA #340 stated the nurse and State Tested Nursing Assistant (STNA) #315 assigned to care for Resident #42 were regular facility staff, knew Resident #42 and should have known his baseline and realized something was off. POA #340 stated she told Hospice Nurse #318 that Resident #42 had a UTI, as she could almost guarantee it. POA #340 stated Resident #42 needed medicine to clear his infection, and she wanted him to have fluids and antibiotics. POA #340 stated she wanted Resident #42 to have blood work and a urine test, and Hospice Nurse (HN) #318 requested a urine test and blood work through the facility. POA #340 stated on 08/31/23 at 9:00 P.M. she received a call from the resident's facility nurse, she did not remember her name, and the nurse told her she was preparing to have Resident #42's urine test completed and blood work drawn. POA #340 stated she thought the facility nurse was calling to give her the results because the urine test and blood work should have been done in the morning. The nurse also told POA #340 Resident #42's oxygen saturation was 85 percent, and POA #340 indicated she insisted Resident #42 was sent to the hospital via a 911 call and transported by EMS. POA #340 stated Resident #42 laid in bed all day on 08/31/23 and was not responsive. Interview on 09/20/23 at 3:31 P.M. of LPN #309 revealed she had just started working at the facility around 08/31/23 and did not remember Resident #42 or any details regarding his care. Interview on 09/20/23 at 4:02 P.M. with LPN #313 revealed when she arrived for work on 08/31/23 at 6:30 P.M., LPN #309 reported to her Resident #42 needed a urine sample and blood work drawn STAT. LPN #313 stated Registered Nurse (RN) #316 assisted her, placed a Foley catheter to obtain the urine specimen, and checked Resident #42's vital signs. LPN #313 stated Resident #42 did not look well and was grimacing in pain. LPN #313 stated she called POA #340 and informed her of Resident #42's low oxygen level, and she could make Resident #42 comfortable with oxygen and pain medication. LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 6 of 15 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 09/26/2023 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 0684 Level of Harm - Actual harm Residents Affected - Few #313 indicated POA #340 wanted Resident #42 sent to the hospital and asked if Resident #42's STAT labs and urine test were back because the order was written early in the day. LPN #313 indicated a urine specimen was collected and placed in the specimen area but would not be picked up until the morning. LPN #313 stated the urine specimen was not sent and blood work was not drawn because Resident #42 was transported to the Emergency Department. Interview on 09/20/23 at 4:14 P.M. with RN #316 revealed on 08/31/23 Resident #42 was lethargic and she thought he was passing. RN #316 stated she obtained Resident #42's urine specimen via a Foley catheter, and it was supposed to be sent the next morning, but he was sent to the hospital and the urine was not sent. RN #316 stated Resident #42's urine was orange in color and was darker than it should have been. RN #316 stated she did not know why the urine and lab work were not done on the day shift. RN #316 stated Resident #42 was usually alert, but the day he was sent to the hospital he was lethargic, sleeping a lot, and it was a change from how he usually was. Interview on 09/21/23 at 8:15 A.M. with STNA #315 revealed Resident #42 could answer questions and say things like good morning, and how are you, but could not carry-on long conversations. STNA #315 stated Resident #42's nurse told him the day before he went to the hospital that Resident #42 was in pain and trying to get out of his chair and she gave him something to calm down and help him relax. STNA #315 stated after Resident #42 received the medication he was less sleepy and talkative. STNA #315 stated the resident was a lot sleepy the day he went to the hospital, and STNA #315 thought it was because Resident #42 did not sleep well. The nurse told me Resident #42's family was concerned because he was not his normal self which was alert. Interview on 09/21/23 at 8:29 A.M. with STNA #317 revealed Resident #42 was generally alert and not sleepy or lethargic. Interview on 09/21/23 at 1:23 P.M. with Hospice Nurse (HN) #318 and Hospice Supervisor (HS) #320 revealed HN #318 visited Resident #42 once a week, but the last few days he was lethargic and he was visited two days in a row. Resident #42 received a hospice emergent visit for lethargy on 08/30/23 (Hospice Nurse #342) and 08/31/23. HN #318 stated on 08/31/23 Resident #42 was lethargic and POA #340 was concerned about the lethargy, concerned because Resident #42 was not eating and POA #340 was also worried the resident might have a UTI. HN #318 stated she had not visited Resident #42 since 08/23/23 but did not receive any calls 08/27/23 through 08/31/23 from the facility regarding Resident #42's status. HN #318 stated on 08/27/23 the facility called to let the hospice nurses know they were using Levsin for secretions. HS #320 stated they would expect to get a call if Resident #42 was lethargic or had a change in condition in case they needed to make a visit to make Resident #42 more comfortable. HN #318 stated she called LPN #309 on 08/31/23 at 2:42 P.M. and gave orders for lab work and a urine specimen to be completed for Resident #42. HN #318 stated Resident #42 had lethargy and increased pain on 08/31/23 and this was a change from 08/23/23. Interview on 09/21/23 at 2:57 P.M. with the Director of Nursing (DON) revealed an actual physician order was not written on 08/31/23 for the urine specimen and lab work to be completed per hospice. The DON also stated even with the resident's advance directives for Do Not Resuscitate (regardless of a DNRCCA or DNR no intubation) would require staff to perform all life saving measures to be done for Resident #42 up until the point of cardiac respiratory arrest. Review of the facility policy titled Change in Condition Monitoring, dated 05/01/22, revealed the facility should promptly notify the resident, his or her attending physician, and the family, guardian, POA of changes in the resident's medical, mental condition and, or status. The nurse would notify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 7 of 15 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 09/26/2023 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 0684 Level of Harm - Actual harm Residents Affected - Few the resident's attending physician or physician on call when there had been a significant change in the resident's physical, emotional, or mental condition. A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacted more than one area of the resident's health status, and required interdisciplinary review and or revision to the care plan. Prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider. Unless otherwise instructed by the resident a nurse would notify the resident's representative when there was a significant change in the resident's physical, mental or psychosocial status. Except in medical emergencies, notifications would be made within twenty-four hours of a change occurring in the resident's medical, mental, condition or status. The nurse would record in the resident's medical record information relative to changes in the resident's medical, mental condition or status. This deficiency represents non-compliance investigated under Complaint Numbers OH00146368 and OH00146399. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 8 of 15 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 09/26/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview, the facility failed to ensure routine ongoing skin assessments were completed to timely identify and/or prevent pressure ulcer development. This affected three residents (#7, #20 and #43) of four residents reviewed for skin assessments/pressure ulcer care and treatment. Residents Affected - Few Findings include: 1. Review of Resident #7's medical record revealed an admission date of 08/28/18 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, heart failure, major depressive disorder, and vascular dementia. Review of Resident #7's physician orders dated 07/31/20 revealed weekly skin checks by licensed nurse, every day shift, every Tuesday for weekly skin check. Review of Resident #7's medical record including assessments dated 12/19/21 through 09/21/23 revealed on 12/19/21 Resident #7's Braden Scale for Predicting Pressure Ulcer Risk noted he was high risk for developing a pressure ulcer, injury. Further review did not reveal documented evidence Resident #7 had another Braden Scale assessment completed. Review of Resident #7's care plan revised 04/07/23 included Resident #7 had an ADL (activity of daily living) self-care performance deficit related to diagnoses. Resident #7 would maintain his current level of function in self-care performance through the review date. Interventions included Resident #7 needed two staff members to be pulled up, centered on bed, and could make small changes in position using the half bed rails. Resident #7 needed weight bearing help with significant position changes. Resident #7 was totally dependent for incontinence care. Resident #7 needed weekly skin assessments by a registered nurse. Review of Resident #7's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had severe cognitive impairment. Resident #7 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #7 was always incontinent of urine and bowel. Review of Resident #7's medical record including progress notes and assessments dated 09/05/23 through 09/19/23 did not reveal documentation weekly skin checks were completed. Interview on 09/21/23 at 3:01 P.M. with the Director of Nursing (DON) revealed weekly skin checks should be documented in the resident medical record under the assessment tab. The DON confirmed Resident #7 did not have weekly skin checks documented for 09/05/23, 09/12/23, or 09/19/23. The DON confirmed Resident #7 did not have a Braden Scale for Predicting Pressure Ulcer Risk completed since 12/19/21. The DON stated the facility had new ownership starting 07/2023 and when the systems merged some of the information might not have carried over. Review of the facility policy titled Wound Care, dated 05/01/22, included the nursing staff and attending physician would assess and document an individual's significant risk factors for developing pressure sores, for example, immobility, recent weight loss and a history of pressure ulcers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 9 of 15 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 09/26/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #20 revealed an admission date of 06/30/23 with diagnoses including cellulitis of right and left lower limb, and chronic diastolic congestive heart failure. Review of Resident #20's physician's orders revealed an order for head-to-toe skin check to be completed one time a day every Tuesday. Residents Affected - Few Review of Resident #20's assessments revealed no Braden Risk Assessment tool was completed since admission on [DATE] and only one weekly skin check was completed on 09/05/23. Review of Resident #20's care plan dated 06/30/23 revealed Resident #20 had potential and actual impairment to skin integrity, 09/13/23 wound to left thigh treatment per physician orders. Interventions included to apply protective barrier cream after each incontinence and with A.M. and P.M. care, avoid friction and shearing, use turn sheet for repositioning, daily skin inspection during hands on care, follow facility protocols for treatment of injury, Resident #20 needed pressure relieving and reducing mattress, pillows, sheepskin padding to protect the skin while up in the chair, and to keep skin clean and dry. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #20 was at risk of developing pressure ulcer injuries and no formal assessment tool such as the Braden scale was used. Observation of wound care for Resident #20 on 09/21/23 at 9:00 A.M. with Nurse Practitioner #322 revealed all prevention measures were in place at the time of the observation. Interview with the DON on 09/21/23 at 3:45 P.M. confirmed that a Braden Risk Assessment tool was not completed and only one weekly skin check was completed on 09/05/23 for Resident #20. The DON further revealed that per company policy, residents were to have a Braden Risk Assessment completed quarterly and annually. 3. Review of the medical record for Resident #43 revealed and admission date of 01/29/22 with diagnoses including unspecified dementia severe with psychotic disturbance, paranoid schizophrenia, and chronic obstructive pulmonary disease. Review of Resident #43's assessments revealed the most current Braden Risk Assessment was completed on 02/06/22. Review of Resident #43's care plan dated 01/03/23 revealed Resident #43 had an actual alteration in skin integrity related to chronic vascular wound to the left lower leg, diabetic neuropathic foot ulcer to the left second toe, and frequently refused dressing changes and would remove completed dressings. Interventions included administering treatments as ordered, assessing, recording, and monitoring wound healing if wounds were present, encourage mobility, monitor nutritional status, and to provide incontinence care if soiled to reduce exposure to moisture. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #43 was at risk for developing pressure ulcers and no formal tool such as a Braden Risk Assessment was utilized. Interview with the DON on 09/21/23 at 3:45 P.M. confirmed that a Braden Risk Assessment tool was not completed since 02/06/22 and further revealed that per company policy, residents were to have a Braden Risk Assessment completed quarterly and annually. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 10 of 15 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 09/26/2023 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 0686 This deficiency represents non-compliance investigated under Complaint Numbers OH00146402, OH00146368 and OH00146399. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 11 of 15 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 09/26/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #41 revealed an admission date of 07/03/23 with diagnoses including cerebral infarction, aphasia, hemiplegia, and hemiparesis right dominant side, bipolar disorder, paranoid schizophrenia, behavioral and emotional disorders, impulse disorder, restlessness, and agitation. The resident was transferred to the hospital 09/02/23 and had not returned. Review of the admission MDS assessment dated [DATE] revealed Resident #41 had intact cognition. The assessment had not identified the resident to have behaviors of wandering. The resident was independent for ambulation. Review of the elopement risk assessment dated [DATE] revealed Resident #41 was at low risk for elopement. Review of the care plan dated 07/11/23 stated Resident #41 was an elopement risk. The intervention was to keep the resident's picture in the elopement book. Review of the physician orders for September 2023 identified order that Resident #41 may go out on Leave of Absence (LOA), with medication, dated 07/10/2023. The resident was moved to the locked unit on 08/12/23. Review of the Physician Progress Note dated 07/08/23 at 7:55 A.M. revealed Resident #41 occasionally signed and went out to eat with family. Review of the nurses note dated 07/09/23 at 7:12 P.M. revealed Resident #41 was educated on making sure he signed out when he is going out on a LOA with his family or staff. The resident had an order for his supervised LOA with medications. There was no note in the medical record regarding Resident #41 having left the faciity on his own without signing out. Interview 09/19/23 at 4:01 P.M. with the Administrator and Chief Commercial Officer (CCO) #300 revealed the facility had a soft file on the incident of Resident #41 leaving the facility without signing out on 07/09/23. They felt the incident was not an elopement due to the fact that Resident #41 was cognitively intact and had an order for LOA that did not include supervision. Review of the soft file included a summary of the incident dated 07/09/23. The summary stated Resident #41 was admitted [DATE], was [AGE] years old with a Brief Interview for Mental Status (BIMS) of 15, indicating the resident was cognitively intact. The resident had no Power of Attorney (POA) or guardian. The resident had diagnosis of aphasia and Moyamoya (a rare, progressive cerebrovascular disorder caused by blocked arteries at the base of the brain). The facility holds all smoking material and the resident thought he did not have any cigarettes. He walked to the gas station on Sunday, 07/09/23, to get a pack of cigarettes. He was educated to sign out and alert staff when he wanted to go out. The resident's mother agreed he could go out; however, also educated the resident to ask her or the staff when he wanted/needed something. He expressed understanding. A Quality Assurance and Performance Improvement (QAPI) was put in place covering new smoking assessments, smoking agreements, smoking care plans, LOA policy, LOA order, ensure LOA sign out book visible at each nurse's station (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 12 of 15 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 09/26/2023 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 0842 and front desk. Level of Harm - Minimal harm or potential for actual harm Interview 09/19/23 at 4:01 P.M. with the Administrator and COO #300 verified there was no note in Resident #41's medical record regarding him leaving the facility on 07/09/23. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00146368. Based on record review, interview, and observation the facility failed to ensure documentation was accurate for two residents (#20, and #41) out of four resident records reviewed for accurate documentation. The facility census was 39. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 06/30/23 with diagnoses including cellulitis of right and left lower limb, and chronic diastolic congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 required extensive assistance of two or more staff members for bed mobility and dressing. Resident #20 required total dependance of two or more staff members for transfers, toilet use, and personal hygiene. Review of physician orders for Resident #20 revealed an order dated 09/13/23 for left lower thigh posterior, medial area, to cleanse with normal saline, pat dry, pack wound with alginate silver, and cover with absorbent dressing to be completed one time a day and as needed. Observation of wound care for Resident #20 on 09/21/23 at 9:00 A.M. with Nurse Practitioner (NP) #322 revealed soiled dressing that was removed had a date of 09/19/23. Interview on 09/21/23 at 10:27 A.M. with NP #322 revealed soiled dressing that was removed during wound care observation was dated 09/19/23 and the current order was for dressing to be completed daily. Review of Resident #20's Treatment Administration Record (TAR) for September 2023 revealed that on 09/20/23 the left lower thigh posterior medial area wound dressing was signed as completed. Further review of Resident #20's TAR for August 2023 revealed an order for left lower thigh dressing to be completed twice a day at 9:00 A.M. and 9:00 P.M. Dressing changes were not signed as completed for 9:00 P.M. on 08/05/23 and 08/14/23 and 9:00 A.M. on 08/08/23 and 08/19/23. Interview on 09/21/23 at 3:45 P.M. with the Director of Nursing (DON) confirmed dressings were not signed as completed on Resident #20's TAR for 08/05/23, 08/08/23, 08/14/23 and 08/19/23. The DON also confirmed that the dressing order was signed as completed on 09/20/23 even though soiled dressing that was removed during wound care observation was dated 09/19/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 13 of 15 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 09/26/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment in resident rooms. This affected seven of twelve rooms on the locked unit, the residents who used the East hallway, and had the potential to affect all 39 residents currently residing in the facility. Findings include: During the initial tour was conducted on 09/18/23 from 10:18 A.M. to 12:20 P.M. the following was observed. • room [ROOM NUMBER] had a sticky floor. • room [ROOM NUMBER] floors needed cleaning, they had spills and sticky areas. • room [ROOM NUMBER] had sticky floors. • room [ROOM NUMBER] had no paper towels. The floor and paper and crumbs. • room [ROOM NUMBER] had no soap in the in the soap dispenser. • room [ROOM NUMBER] had no soap in the in the soap dispenser. • room [ROOM NUMBER] the paper towel dispenser was not working and there was a spill on the floor. The above observations were verified by State Tested Nurse Aide (STNA) #301 at the time of the observations. Interviews on 09/18/23 from 11:09 A.M. through 4:02 P.M. and on 09/19/23 at 11:14 A.M. with five alert and oriented residents (#3, #7, #19, #23, #35) revealed they felt the facility was kept somewhat clean; some housekeepers were much more thorough than others. Interview on 09/18/23 from 11:16 A.M. through 4:17 P.M. with staff revealed the facility had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 14 of 15 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 09/26/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some housekeeping issues. They stated there was often no soap and paper towels, the floors were sometimes dirty. At least one of the two housekeepers had called off that morning. The facility had been through a lot of cleaning staff. The cleaning people didn't show up sometimes. Observation on 09/18/23 at 11:24 A.M. revealed the dining room on the locked unit had not been swept after breakfast. There were crumbs and other food debris under the tables. The dining room tables had not been wiped down. There were spills and liquids on the tables. This was verified by Licensed Practical Nurse (LPN) #302 who quickly began to sweep the floor and wipe the tables. No housekeeping staff were observed on the East unit on 09/18/23. Observations on 09/19/23 at 11:21 A.M. revealed the East hallway was sticky. It was observed that the staff's shoes would stick to the floor. If someone stood still for a minute their shoes stuck enough to almost pull them off. The floor was also dirty in areas. These observations were verified by STNA #303 at the time of the observation. Observations on 09/21/23 at 10:38 A.M. with Maintenance/Housekeeping Director #310 revealed the following: • The doors inside the locked unit entrance were peeling. • room [ROOM NUMBER] wall at the doorway was peeling. • The molding was peeling away at the entrance door to the locked unit from the East unit. • room [ROOM NUMBER] didn't have paint above the lights and part of the wall appeared damaged. Interview on 09/21/23 at 10:50 A.M. Maintenance/Housekeeping Director #310 verified the findings and revealed there had been issues with housekeeping. The facility lost some housekeeping staff and was working on getting good housekeeping staff. Rooms were to be deep cleaned after a resident left and before a new resident was moved into a room. Interview on 9/21/23 at 5:03 with the Director of Nursing (DON) verified the facility was struggling with finding good reliable housekeepers. This deficiency represents non-compliance investigated under Complaint Numbers OH00146402, OH00146399, and OH00146368. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365370 If continuation sheet Page 15 of 15