Health inspection·May 28, 2024

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 and interview the facility failed to ensure food was stored in a manner to prevent food borne illness and failed to maintain a sanitary kitchen. This had the potential to affect all residents except Resident #34 who did not receive nutrition by mouth. Facility census was 38. Findings include: Observations of the kitchen on 05/28/24 at 8:10 A.M. revealed thawed raw boneless/skinless chicken breast in a bag lying in a bin in the refrigerator; the Ziplock bag holding the chicken breast was dated 05/19/24 and the juices from the chicken had leaked out filling the bottom of the bin. There was a bag of cooked barbeque chicken in a Ziplock bag that was dated 05/19/24 to 05/26/24, a carton of whole eggbeaters dated 05/06/24, two opened containers of beef base dated 11/27/23 and 01/05/24, and a carton of imitation vanilla was capped with aluminum foil dated 02/24. A large garbage can next to the stove was covered with a dirty lid. The microwave had dried food debris on the inside, there was loose miscellaneous debris covering the top the dishwasher, and the air vents in the ceiling located over the cooked food storage area were covered with a layer of blackish dust. Interview during the observations with the Dietary Manager verified the findings. Review of a dietary list provided by the facility revealed Resident #34 did not receive nutrition by mouth. This deficiency represents non-compliance investigated under Complaint Number OH00153987. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365370 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 05/28/2024 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)