Inspection visit
Health inspection
41 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 41 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0567
Honor the resident's right to manage his or her financial affairs.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure resident authorized the facility to manage
their personal funds and the authorization was witnessed by a third party. This affected two (Residents #30
and #207) of six residents reviewed for personal funds. The facility census was 54.
Residents Affected - Few
Findings include:
1. Review of the closed medical record for Resident #30 revealed an admission date of 07/23/24 with
diagnoses including heart disease, anxiety and dementia. He was discharged on 02/15/25.
Review of the Resident Fund Management Service (RFMS), undated, for Resident #30 revealed
handwriting at the top of the form stating Human Resources Director (HR) #343 had opened the account.
She had explained to the resident and over the course of a month he would not sign and stated he needed
to read the form over.
Review of the RFMS trial balance list dated 03/10/25 revealed Resident #30 had a balance of $2,000.29.
Interview on 03/18/25 at 8:43 A.M. with HR #343 verified Resident #30 passed away on 02/15/25. She
stated he had a guardian for financial decisions. She stated she had attempted to have Resident #30 sign
the RFMS authorization, however, he wanted to read the form and then refused to sign. HR #343 stated the
money he had in his account came from another facility and was deposited in the RFMS account on
10/15/24. She verified Resident #30 had a financial guardian and she had not reached out to them for
authorization.
2. Review of the closed medical record for Resident #207 revealed an admission date of 03/19/20 with
diagnoses including dementia and depression. She was discharged on 05/24/24.
Review of the RFMS, dated 06/04/20, for Resident #207 revealed the resident had not signed the form nor
her representative. The form was also not witnessed by a third party.
Review of the RFMS trial balance list dated 03/10/25 revealed Resident #207 had a balance of $5,239.68.
Interview on 03/18/25 at 8:43 A.M. with HR #343 verified Resident #207 passed away on 05/24/24. She
verified the form was not signed or witnessed.
Review of the facility policy titled, Resident Funds, dated 05/01/22, revealed the facility would
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 116
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
03/31/2025
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 0567
Level of Harm - Minimal harm
or potential for actual harm
establish uniform guidelines to protect personal funds managed by the facility on behalf of its residents.
However, it did not state the process of having residents or their representatives sign for an RFMS account
of have it witnessed by a third party.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 2 of116
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
03/31/2025
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 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
Based on interview, record review, and facility policy review, the facility failed to ensure resident personal
funds were disbursed to the resident's estate within 30 days. This affected two (Residents #30 and #207) of
two residents reviewed for personal funds after death. The facility census was 54.
Residents Affected - Few
Findings include:
1. Review of the closed medical record for Resident #30 revealed an admission date of 07/23/24 with
diagnoses including heart disease, anxiety and dementia. He passed away on 02/15/25.
Review of the Resident Fund Management Service (RFMS) trial balance list dated 03/10/25 revealed
Resident #30 had a balance of $2,000.29.
Interview on 03/18/25 at 8:43 A.M. with Human Resource Director (HR) #343 verified Resident #30 passed
away on 02/15/25. She stated he had a guardian for financial decisions who she had attempted to contact.
She was unaware of the required time frame to disperse the funds to his estate.
2. Review of the closed medical record for Resident #207 revealed an admission date of 03/19/20 with
diagnoses including dementia and depression. Resident #207 passed away on 05/24/24.
Review of the RFMS trial balance list dated 03/10/25 revealed Resident #207 had a balance of $5,239.68.
Interview on 03/18/25 at 8:43 A.M. with HR #343 verified Resident #207 passed away on 05/24/24. She
stated Resident #207 had a financial power-of-attorney. She was unaware of the required time frame to
disperse the funds to her estate.
Review of the facility policy titled, Resident Funds, dated 05/01/22, revealed the facility would establish
uniform guidelines to protect personal funds managed by the facility on behalf of its residents. However, it
did not state the process of funds being disbursed after a resident had passed away.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 3 of116
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
03/31/2025
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 - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure residents were able to use the phone
when requested and in private. This affected one (Resident #206) of one resident reviewed for facility phone
usage. The facility census was 54.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #206 revealed an admission date of 02/27/25 with diagnoses
including bipolar disorder (mental health condition that causes mood swings), anxiety and hypertension.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident
#206 had adequate hearing, clear speech, understood others and was able to be understood. He had
impaired cognition. It was noted under section F for preferences for routines and activities that it was very
important for him to use a phone in private.
Interview on 03/18/25 at 7:40 A.M. with Licensed Practical Nurse (LPN) #325 revealed residents had
access to a phone but would have to use the corded phone at the nurse's station. The phone number would
be dialed and then handed through a hole in the plastic that sat on top of the nursing station counter. The
resident would then have to use the phone in the hallway. She stated she was unaware of other private
phones for the residents to utilize.
Observation and interview on 03/18/25 at 4:50 P.M. of Resident #206 revealed he wanted to use the phone
at the west nursing station. He stated to LPN #325 that he needed to call someone and asked to use the
phone. LPN #325 stated he could not use the phone as she had two admissions. Resident #206 then left
the nursing station. LPN #325 stated Resident #206 had asked her six times to use the phone already and
she was busy with admissions. She verified she had refused to allow him to use the phone.
Interview on 03/19/25 at 8:10 A.M. with Resident #206 verified he did eventually get to use the phone on
03/18/25. He stated there was no privacy with phone use as the nursing staff handed a corded phone out
and he had to talk on the phone in the hallway.
The facility was unable to provide a policy on phone use or resident privacy with phone calls.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 4 of116
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
03/31/2025
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 - Some
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, interview and facility policy review, the facility failed to ensure advance directive orders were
consistent across electronic and paper medical records. This affected five residents (#7, #15, #20, #25 and
#34) out of 24 resident records reviewed. The facility census was 54.
Findings include:
1. Review of Resident #7's medical record revealed an admission date of [DATE] and diagnoses including
schizoaffective disorder, hypertension, insomnia, muscle weakness and diabetes.
Review of Resident #7's electronic medical record (EMR) revealed he had an advance directive of Do Not
Resuscitate Comfort Care Arrest (DNRCCA) (indicating no life-sustaining interventions would be attempted
in the event of cardiac or respiratory arrest).
Review of Resident #7's paper medical record revealed he had an advance directive of full code, indicating
life-sustaining interventions, including cardiopulmonary resuscitation (CPR) would be attempted in the
event of cardiac or respiratory arrest).
Interview on [DATE] at 3:34 P.M. with Social Service Designee (SSD) #355 indicated she was
knowledgeable on many residents' advance directives due to conducting plan of care meetings. SSD #355
verified Resident #7's paper medical record was not accurate as he did not have an advance directive of full
code.
2. Review of Resident #15's medical record revealed an admission date of [DATE] and diagnoses including
dementia with agitation, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety
disorder, paranoid personality disorder and delusional disorders.
Review of Resident #15's EMR revealed he had an advance directive of DNRCCA.
Review of Resident #15's paper medical record revealed he had an advance directive of full code. No
signed Do Not Resuscitate (DNR) form was available in the resident's record.
Interview on [DATE] at 3:34 P.M. with SSD #355 verified Resident #15's paper medical record was not
accurate and did not match the EMR as Resident #15 did not have an advance directive of full code and no
signed DNR was available in his chart.
3. Review of Resident #20's medical record revealed an admission date of [DATE] and diagnoses including
type two diabetes, chronic kidney disease, traumatic brain injury, dementia with agitation and generalized
anxiety disorder.
Review of Resident #20's EMR revealed he had an advance directive of DNRCCA.
Review of Resident #20's paper medical record revealed he had an advance directive of full code. No
signed DNR form was available in his record.
Interview on [DATE] at 3:34 P.M. with SSD #355 verified Resident #20's paper medical record was not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 5 of116
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
03/31/2025
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 - Some
accurate and did not match the EMR as Resident #20 did not have an advance directive of full code and no
signed DNR form was available in his chart.
4. Review of Resident #25's medical record revealed an admission date of [DATE] and diagnoses including
traumatic brain injury, insomnia, protein-calorie malnutrition, vascular dementia with other behavioral
disturbance, anxiety and depression.
Review of Resident #25's EMR revealed he had an advance directive of DNRCCA.
Review of Individual #25's paper medical record revealed a face sheet stating he had an advance directive
of DNRCCA, but no signed DNR form was available in his record.
Interview on [DATE] at 3:34 P.M. with SSD #355 verified Resident #25's paper medical record was not
complete as no signed DNR form was available in his chart.
5. Review of Resident #34's medical record revealed an admission date of [DATE] and diagnoses including
vascular dementia with psychotic disturbance, paranoid personality disorder, violent behavior, osteoarthritis
and depression.
Review of Resident #34's EMR revealed he had an advance directive of DNRCCA.
Review of Individual #34's paper medical record he had an advance directive of full code. No signed DNR
form was available in his record.
Interview on [DATE] at 3:34 P.M. with SSD #355 revealed the previous DON responsible for ensuring
residents had advance directives in place but the facility had a new DON at this time. SSD #355 indicated
she was knowledgeable on many residents' advance directives due to conducting plan of care meetings.
SSD #355 verified Resident #34's paper medical record was not accurate and did not match the EMR as
Resident #34 did not have an advance directive of full code and no signed DNR was available in his chart.
Review of the facility policy, Advance Directives, dated [DATE] revealed upon admission the social worker
and/or admission director will furnish information on advance directives. When a social worker is not
available the Registered Nurse (RN) supervisor will give and review advance directive information and
document in the medical record. A Do Not Resuscitate order is honored upon admission after reviewed with
the individual/family member or surrogate by the social worker/or admission RN when they arrive to the
facility to ensure continuation. Residents with DNR orders will be identified on the face sheet and in the
resident's medical record Resident's advance directives will be reviewed upon admission, re-admission
from the hospital, quarterly and annually by the social worker. Staff with direct care responsibilities will be
knowledgeable of the location of resident's resuscitative status information throughout the facility. All facility
staff including non direct care employees and temporary agency staff will be aware of facility procedure if
they encounter a resident's arrest.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 6 of116
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
03/31/2025
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observations, staff and resident interviews, and facility policy review, the facility failed to ensure a
safe, clean, homelike environment by ensuring water temperatures reached appropriate and homelike
temperatures, and blinds, ceiling tiles, walls, door frames, and hand rails were without the need for repair.
This affected all residents residing in the facility. The facility census was 54.
Findings include:
1. Interview on 03/10/25 at 10:01 A.M. with Resident #48 revealed the water was cold and the water
pressure was low. Resident #48 indicated the shower room was broken.
Interview on 03/10/25 at 10:29 A.M. with Resident #203 revealed the shower was broken and he had been
unable to get a shower.
Observation and interview on 03/10/25 at 10:29 A.M. with Resident #23 revealed her toilet had not been
working for a week and Resident #23 reported the shower room was broken. Observation of Resident #23's
toilet revealed it was not secured to the floor. Resident #23 reported hot water was also an issue, stating it
was either too hot or too cold.
Observation and interview on 03/10/25 at 12:01 P.M. with Resident #27 revealed the resident had asked
where she could use the bathroom and stated her toilet did not work. Housekeeper #311 was nearby and
indicated she could use the one in her room. Housekeeper #311 went into Resident #27's bathroom in her
room and confirmed the toilet was not secured to the floor and was not working appropriately. The
bathroom was shared between two rooms, including Resident #23. Resident #27 was assisted by staff to a
bathroom down the hall.
Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed a sign on the west side shower room
indicating Do not use shower. Out of order.
Interview on 03/10/25 at 12:22 P.M. with Resident #22 revealed the shower room had not been working all
weekend and he was unable to get a shower. Resident #22 stated the backed up water leaked out into the
hallway.
Interview on 03/10/25 at 12:49 P.M. with Resident #44 revealed she could get showers, but the water was
cold.
Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with the Administrator revealed the shower room had
been fixed and it had been out of order since 03/07/25.
Interview on 03/11/25 at 1:08 P.M. with the Administrator revealed she was unable to find any logged water
temperatures or maintenance records for the last 12 months.
Follow up tour on 03/12/25 from 9:45 A.M. to 10:05 A.M. with Housekeeping and Maintenance Supervisor
(HMS) #306 revealed most residents shared a bathroom between two rooms, but there were a few with
private bathrooms. HMS #306 indicated there were no showers in resident rooms, and there were two
shower rooms in the facility.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 7 of116
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
03/31/2025
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 0584
Observation of water temperatures on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 using the
facility's digital thermometer revealed the following:
Level of Harm - Minimal harm
or potential for actual harm
•
Residents Affected - Many
Resident #18's sink water temperature was 101.5 degrees Fahrenheit (F).
•
Resident #49's sink water temperature was 99.1 degrees F.
•
Resident #48 and #203's sink water temperature was 101.9 degrees F.
•
Resident #31 and Resident #45's sink water temperature was 96.1 degrees F.
•
Resident #20's sink water temperature was 77.0 degrees F.
•
Resident #5's sink water temperature was 90.5 degrees F.
•
Resident #15's sink water temperature was 102.6 degrees F.
•
Resident #14's sink water temperature was 98.4 degrees F.
•
Resident #104's sink water temperature was 101.5 degrees F.
•
Resident #205's sink water temperature was 81.7 degrees F.
•
The [NAME] side shower room shower was 81.0 degrees F.
•
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 8 of116
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
03/31/2025
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 0584
The East side shower room shower was 97.3 degrees F.
Level of Harm - Minimal harm
or potential for actual harm
Interview during the observation of water temperatures on 03/12/25 from 11:16 A.M. to 12:19 P.M. with
Resident #49 revealed the water was never hot.
Residents Affected - Many
Interview during the observation of water temperatures on 03/12/25 from 11:16 A.M. to 12:19 P.M. with
Resident #5 revealed the water did not get hot no matter how long it ran.
Interview on 03/12/25 at 11:42 A.M. with HMS #306 confirmed the water temperatures throughout the
building were not within a comfortable range. HMS #306 indicated he had recently taken over the
maintenance supervisor position and was unsure how to adjust the water temperatures. HMS #306
indicated the water was heated by a boiler system. HMS #306 indicated this was the first time he had taken
water temperatures.
Review of the facility policy titled Water Temperature dated 05/01/22 revealed maintenance was responsible
for checking temperature controls of water in the facility and recording the checks in a maintenance log.
Water temperatures would be no more than 120 degrees.
2. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed Resident #8, Resident #34 and
Resident #46 were observed with broken blinds in their rooms.
Interview on 03/10/25 at 12:50 P.M. with Resident #46 revealed the blinds in his room had been broken
since he moved in.
Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with the Administrator confirmed the environmental
findings for Resident #8, #34, and #46.
Follow up interview and tour on 03/12/25 from 9:45 A.M. to 10:05 A.M. with HMS #306 revealed Resident
#38's room had broken mini blinds. The observations were confirmed with HMS #306 at the time of the
observation.
Observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 revealed Resident #104's mini
blinds were broken in their room and Resident #5's mini blinds were broken in their room.
Interview during the observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 confirmed
findings in Resident #5's room and Resident #104's room.
3. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed multiple discolored ceiling tiles
observed across from the west side nursing station, in the hallway outside Resident #21 and Resident
#15's room, in the east side shower room, and in hallway outside Resident #14's room. There were multiple
patched and unpainted dents in walls on the memory care unit. The paint was chipped on the door frame
leading to the 100 hallway, and there was paint chipped off the doors of Resident #37, Resident #33,
Resident #8, Resident #1, Resident #23, and Resident #19's rooms. Resident #38's room had dented and
paint chipped walls. There was a piece of plywood leaning against the wall in the occupied room. Resident
#40's room had numerous white unpainted patches on the walls and there was blue painters' tape around
cabinets, door frames, and lights.
Interview on 03/10/25 at 12:45 P.M. with Certified Nursing Assistant (CNA) #317 reported there was not a
maintenance person currently and there was no one to report issues to. CNA #317 indicated if
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 9 of116
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
03/31/2025
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 0584
there was some kind of emergency she would report it to housekeeping.
Level of Harm - Minimal harm
or potential for actual harm
Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with the Administrator confirmed the above
environmental findings. The Administrator indicated there were some ceiling leaks when the ice was melting
with the temperature changes.
Residents Affected - Many
Interview on 03/11/25 at 1:08 P.M. with the Administrator revealed she was unable to find any maintenance
records for the last 12 months, including maintenance records regarding the discolored ceiling tiles, dents
on the memory care walls, paint chipping from the doorway in the 100 hall, and paint chipping from the
residents doors.
Follow up tour on 03/12/25 from 9:45 A.M. to 10:05 A.M. with HMS #306 revealed Resident #38's room also
had two discolored and sagging ceiling tiles. Resident #1 and Resident #23's shared room was observed
with a vanity with a missing drawer and mirror and it had two cabinet doors hanging off the hinges. The
observations were confirmed with HMS #306 at the time of the observation.
Observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 revealed large holes were observed
in the wall behind Resident #5's headboard.
Interview during the observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 confirmed the
findings in Resident #5's room.
4. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed the handrail extending between rooms
#13 and #14 was loose on the wall, the handrail extending between rooms #36 and #37 was loose on the
wall, and the handrail extending from the east side shower room door to the corner of the wall was loose.
Interview on 03/10/25 at 12:45 P.M. with Certified Nursing Assistant (CNA) #317 reported there was not a
maintenance person currently and there was no one to report issues to. CNA #317 indicated if there was
some kind of emergency she would report it to housekeeping.
Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with Administrator confirmed the above findings.
Interview on 03/11/25 at 1:08 P.M. with Administrator revealed she was unable to find any maintenance
records for the last 12 months.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 10 of116
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
03/31/2025
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility
failed to prevent resident-to-resident physical abuse. This affected one resident (#23) out of five residents
reviewed for abuse. Facility census was 54.
Findings include:
Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses including
lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder. Resident #23 was her
own responsible party.
Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a
brief interview for mental status (BIMS) score of 14, indicating she was cognitively intact and displayed
other behaviors one to three days of the seven-day look-back period.
Review of Resident #23's plan of care dated 09/18/24 and revised 12/19/24 revealed Resident #23 had
delusions, behavior problems and could attempt to manipulate with physical aggression, verbal aggression
and emotional outbursts and was also noted to make false accusations.
Review of a nurses' note dated 09/29/24 at 8:00 P.M. and authored by Licensed Practical Nurse (LPN) #327
revealed this nurse was notified of incident regarding this resident and co-resident. Resident #23 states that
co-resident threw water at her, hit her with a wet floor sign, and a shoe. Resident #23 was observed sitting
in wheelchair, wet and sobbing. Vitals taken, and resident skin assessed. This nurse noticed a small skin
tear near Resident #23's heel. Resident #23 also complained of being sore after incident. This nurse
escorted Resident #23 to bed and administered as-needed (PRN) pain medication along with before bed
medications. Resident #23 was in compliance with neuro-checks and every 15-minute (Q15) safety checks.
Resident #23 was in bed meditating, call light within reach and safety maintained. Physician and Director of
Nursing (DON) notified.
Review of an interdisciplinary team note dated 09/30/24 at 4:46 P.M. and authored by Registered Nurse
(RN) #313, who was the facility's DON at the time of the resident-to-resident altercation, revealed upon
investigating physical altercation that occurred with male resident, Resident #23 alleges that male resident
attacked her while coming from smoke break. Resident #23 alleges that he rode up in his motorized
wheelchair, threw up a cup of water at her then proceeded to hit her in the head with wet floor sign.
Resident #23 also alleges that Resident #10 hit her repeatedly with his house-shoe. Resident #23 states
that altercation was unprovoked and denies any verbal exchange proceeding incident. This DON and
Assisted Director of Nursing (ADON)/LPN #368 conducted interviews with nursing staff and residents
present at time of altercation. Statements conclude that Resident #23 was being followed by male resident
and that he ran up against her in motorized wheelchair. He then hit Resident #23 several times with
house-shoe at the back of her head. While turning around to defend herself Resident #23 lost balance
falling out of wheelchair onto her back and buttocks. Resident #23 does report complaints of headache,
neck, and upper back soreness rated 8/10. PRN pain medications administered and effective with pain
complaints at this time. Resident #23 was asked if she felt she needed emergency evaluation, resident
states, No I should be fine. Resident educated by this nurse during assessment to notify nursing staff of
increased pain. Neuro-checks and fall follow-up initiated at time of incident. Skin assessment completed by
this nurse. Skin clear and intact at this time, with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 11 of116
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
03/31/2025
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
exception to a small skin tear of 0.2 centimeters (cm) by 0.1 cm to posterior ankle which is now scabbed
over. No signs or symptoms of infection present at this time. Area is to be left open to air and monitored by
nursing staff. Physician notified of altercation, resident who responsible for self is currently stable and 15
minute-checks in place for safety intervention at this time.
Review of Resident #10's closed medical record revealed an admission date of 03/29/24 and diagnoses
including schizoaffective disorder, type two diabetes, depression, dysphagia and aphonia. Resident #10
was his own responsible party. Resident #10 discharged to an assisted living facility on 03/12/25.
Review of a quarterly MDS assessment dated [DATE] revealed Resident #10 had a BIMS score of 14,
indicating he was cognitively intact. Resident #10 displayed verbal behaviors four to six days out of the
seven-day look-back period.
Review of Resident #10's plan of care dated 04/10/24 and revised 10/02/24 revealed Resident #10 had
impaired mood coupled with behaviors. Resident #10 had a history of being verbally aggressive and
antagonist as well as physically aggressive with recent incidents on 09/25[/2024] and 09/29[/2024].
Review of a nurse's note dated 09/29/24 at 9:54 P.M. and authored by RN #348 revealed at approximately
8:00 P.M. this nurse was called to for incident involving Resident #10 and a co-Resident. Resident #10
stated that co-Resident struck him with an umbrella and Resident #10 retaliated by hitting her with his shoe.
Resident #10 was assessed and obtained no injuries from altercation. Vitals were within normal limits and
no complaints of pain were voiced. Resident is aware and in agreement of 15-minute checks for the next 48
hours as Resident #10 is his own responsible party. Physician and DON notified.
Review of a facility SRI dated 09/29/24 revealed an allegation of physical abuse between Resident #10 and
Resident #23. Resident #10 initiated physical altercation with Resident #23 during smoke break and hit
Resident #23 with a house-shoe. Interviews, assessments and notifications were completed and the facility
substantiated the allegation of resident-to-resident physical abuse.
Review of a witness statement dated 09/29/24 and authored by Certified Nursing Assistant (CNA) #353
revealed the following information: I was on the patio [with] the smoking residents at 7:35 P.M. At 7:45 P.M.
Resident #23 was finished smoking and went into the building and stopped in the hallway to talk to two
other residents. Resident #10 came down the hall and behind Resident #23's wheelchair and started hitting
Resident #23 in the back of her head from behind with his blue tennis shoe. Resident #23 started
screaming and turned around to try to defend herself resulting in her wheelchair tipping backwards and
Resident #23 falling out of her wheelchair. Resident #10 took off back down the hallway. I notified the nurse
(not identified) and spoke to the DON.
Review of a witness statement dated 09/29/24 and authored by LPN #327 revealed the following
information: I was not around to witness this incident. After the incident occurred I did witness Resident #23
sobbing and wet in her wheelchair.
Review of a witness statement dated 09/29/24 and authored by RN #313 on behalf of Resident #31
revealed the following information: I was sitting down next to Resident (not fully identified) and we were
ordering chicken wings. Resident #23 comes around the corner screaming for her life and Resident #10
comes behind Resident #23 and hits her repeatedly in the back of her head with his shoe. Resident #23
turned around to defend herself and fell out of her wheelchair. The CNA (not identified)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 12 of116
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
03/31/2025
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 0600
Level of Harm - Minimal harm
or potential for actual harm
called for some back-up to help her. Resident #10 went around the corner and fled the scene. I did not see
Resident #23 hit Resident #10 with anything.
Interview on 03/10/25 at 10:29 A.M. with Resident #23 reported she had past issues with Resident #10,
including being hit with his shoe.
Residents Affected - Few
Interview on 03/19/25 at 11:13 A.M. with Chief Operating Officer (COO) #300 verified the content of the
above SRI investigation between Resident #10 and Resident #23 on 09/29/24 and confirmed it was
substantiated for resident-to-resident physical abuse.
Review of the facility policy, Abuse Prevention, dated 08/20/21 revealed the facility would not tolerate
abuse, neglect, exploitation of its residents or misappropriation of resident property. The facility would
complete the assessment, care planning and monitoring of residents with needs and behaviors which might
lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have
behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with
communication disorders and those that require heavy nursing care and/or are totally dependent on staff as
part of its abuse prevention and identification interventions. The policy did not have specific response
protocols for instances of resident-to-resident abuse.
This deficiency represents noncompliance investigated under Complaint Number OH00162361.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 13 of116
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
03/31/2025
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility
failed to timely report allegations of misappropriation and injury of unknown origin. This affected two
residents (#18 and #23) out of five residents reviewed for abuse. Facility census was 54.
Findings include:
1. Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses
including lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder. Resident
#23 was her own responsible party.
Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a
brief interview for mental status (BIMS) score of 14, indicating she was cognitively intact and displayed
other behaviors one to three days of the seven-day lookback period.
Review of Resident #23's plan of care dated 09/18/24 and revised 12/19/24 revealed Resident #23 had
delusions, behavior problems and could attempt to manipulate with physical aggression, verbal aggression
and emotional outbursts and was also noted to make false accusations.
Review of a SRI dated 01/06/25 at 5:08 P.M. revealed Resident #23 reported to Registered Nurse (RN)
#313, the Director of Nursing (DON) at the time of the allegation, that her tablet was missing. Resident #23
stated a Certified Nursing Assistant (CNA) who was taking care of her removed her dinner tray that the
tablet was on. The time of the occurrence was identified as 01/06/25 at 3:07 P.M. An alleged perpetrator
was listed as CNA #329. A search was completed for the tablet and the tablet was not found. Resident #23
was offered a lock box which she declined. The facility determined the allegation of misappropriation to be
unsubstantiated.
Review of the facility's investigation for the SRI on 01/06/25 revealed two sheets of paper including a
statement from Social Service Designee (SSD) #355 and a statement from CNA #353. No further evidence
of investigation was available for review.
Review of the statement dated 01/07/25 and authored by SSD #355 revealed the following information: I
interviewed Resident #23 on 01/07/25 and she stated she had an iPad (tablet) that was missing. Resident
#23 stated she has two iPads, one with a purple and blue case and another Amazon iPad with a black case
that had googly eyes and the words do not touch on the front of it. Resident #23 stated the iPad was on her
tray table on top of her food tray and that it was removed by a CNA and never returned. An addendum was
located at the bottom of SSD #355's statement which indicated on 01/10/25 Resident #23 found her
missing iPad but no further information was available.
Review of the statement dated 01/09/25 and authored by CNA #353 revealed she had no knowledge of
Resident #23's tablet.
Review of the facility's grievance and self-report tracking log for January 2025 revealed on 01/04/25,
Resident #23 had reported her missing iPad. Under the 'Resolution' header, there was a notation the iPad
was found on 01/10/25.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 14 of116
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
03/31/2025
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 03/12/25 at 11:09 A.M. with Resident #23 revealed in January 2025, her tablet was laying on
her meal tray. Resident #23 identified her tablet as an Amazon Fire tablet, which she showed the surveyor
during the interview. This tablet had a black cover with white writing with Resident #23's initials and the
phrase don't touch my tablet on it. Resident #23 stated CNA #329 picked up her meal tray and took the
tablet, then sold her tablet to Resident #10 for $100.00. She was able to activate an alarm on her tablet
from her cell phone, which she found in Resident #10's room. Resident #23 could not state how much time
had elapsed from when the tablet was observed gone to the time she found it in Resident #10's room.
Resident #23 shared she had two Amazon Fire tablets, a 9-inch one and an 11-inch one and indicated the
9-inch one was the one that had been reported missing. Resident #23 verified the facility did not interview
her regarding her allegation of misappropriation or have her write a witness statement.
Interview on 03/12/25 at 11:22 A.M. with CNA #329 revealed she was angry she was suspended over the
allegation of misappropriation regarding Resident #23's missing tablet. CNA #329 stated she worked on
01/05/25 and did not have Resident #23 as her resident that date. CNA #329 reported Resident #23 made
the complaint at lunch regarding her missing tablet, so she told Licensed Practical Nurse (LPN) #329 and
CNA #353. CNA #353 had went into the kitchen to look through the trash for Resident #23's tablet and an
agency nurse (not identified) was also aware of the missing tablet. On 01/06/25, the previous Director of
Nursing (DON), RN #313 and previous Assistant Director of Nursing (ADON)/LPN #368 told her she was
being suspended over the theft of Resident #23's tablet. CNA #329 stated she was not interviewed and the
facility did not have her write a witness statement. CNA #329 stated they had her come in on 01/08/25 as
the facility had found Resident #23's tablet as SSD #355 observed Resident #23 on the tablet and Resident
#23 stated at that time CNA #329 had stole the tablet, sold it to Resident #10 then got her tablet back.
Interview on 03/12/25 at 11:38 A.M. with LPN #354 revealed she did not recall Resident #23's missing iPad
and shared Resident #23 was always on an iPad in her room.
Interview on 03/12/25 at 11:45 A.M. with CNA #353 revealed she was aware of the allegation of
misappropriation regarding Resident #23 and confirmed she had to write a witness statement. First,
Resident #23 said a resident stole her iPad and she hit an alarm on it and it went off. Then, Resident #23
stated a kitchen staff had stolen her iPad and then she accused CNA #329 of stealing the iPad. CNA #353
stated the iPad was missing maybe four or five days, then it reappeared.
Interview on 03/12/25 at 11:53 A.M. with SSD #355 revealed she was in charge of keeping the facility's
grievance and self-report tracking log. SSD #355 recalled someone (name not provided) had told her about
the allegation and stated a CNA had taken Resident #23's meal tray which had her tablet on it and
Resident #23 had thought someone had sold it to Resident #10. SSD #355 stated Resident #23 later found
her tablet in Resident #10's room. When asked about the facility's grievance and self-report tracking log and
the date of 01/04/25 regarding Resident #23's concern with her missing tablet, SSD #355 verified the date
of 01/04/25 was accurate and was the date she was first made aware of Resident #23's missing tablet.
During an interview on 03/12/25 at 12:12 P.M. the Chief Operating Officer (COO) #300 was notified the
allegation of misappropriation regarding Resident #23's missing tablet was first reported to SSD #355 on
01/04/25, but the facility failed to file a SRI regarding the misappropriation until 01/06/25. COO #300
verified the SRI was not reported timely as required per facility policy and procedure.2. Review of the
medical record for Resident #18 revealed an admission date of 05/30/18 with diagnoses including
Parkinson's disease, age-related osteoporosis, dementia, generalized muscle weakness,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 15 of116
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
03/31/2025
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 0609
and dependence on wheelchair. Resident #18 was hospitalized from [DATE] to 01/20/25.
Level of Harm - Minimal harm
or potential for actual harm
Review of a nurse's note dated 01/03/25 at 7:35 A.M. revealed Resident #18 was found on floor by nurse
aide lying flat on her back. Nurse and aide picked Resident #18 up off the floor and into her wheelchair.
Resident #18 was taken to the dining room for breakfast. Resident #18 stated she got up from her recliner
chair to pick something up off the floor and fell backwards. It was noted Resident #18 claimed she didn't hit
her head and had no complaints of pain at this time.
Residents Affected - Few
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident
#18 had severely impaired cognition and was dependent on staff for activities of daily living (ADLs).
Review of a nurse's note dated 01/18/25 at 9:55 A.M. revealed Resident #18's was sent to hospital for
evaluation related to abdominal pain and suspicious x-ray of abdomen.
Review of a Hospital Medicine History and Physical dated 01/18/25 revealed Resident #18 presented to
hospital for concern of bowel obstruction. While in the emergency department (ED) a cat (CT) scan was
completed, and Resident #18 was noted to have a fracture of the pelvis. CT results showed acute fractures
of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left
acetabulum. Orthopedics were following; however, the fracture was nonsurgical. Resident #18's sister was
present at hospital and reported on 01/03/25 Resident #18 had a fall and had been complaining of pain to
left hip since. Physical examination showed edema to right lower extremity and trace edema to left hip.
Resident #18 had pain to the left hip inguinal fold area and when laying on side.
Review of the Hospital Discharge summary dated [DATE] revealed diagnoses including closed
nondisplaced fracture of pelvis, chronic constipation, and cellulitis of extremity.
Review of a nurse's note dated 01/20/25 at 3:29 P.M. revealed the hospital reported Resident #18 had
pelvic fracture with no surgical interventions. Resident #18 would return to facility weight bearing as
tolerated.
Review of a nurse's note dated 01/20/25 at 6:30 P.M. revealed Resident #18 returned to the facility from the
hospital.
Review of a NP progress note dated 01/21/25 revealed Resident #18 re-admitted to facility from hospital
with diagnoses of left pelvic fracture. The NP noted prior to admission Resident #18 was totally dependent
on staff for ADL care needs.
Interview on 03/18/25 at 8:00 A.M. with Resident #18's sister revealed she had made an allegation of
neglect in January 2025 and had provided videos as supporting evidence to facility staff. During the
interview, the resident's sister also shared Resident #18 had a fall at the beginning of January 2025. An
x-ray was completed that did not show a fracture; however, Resident #18 was in pain following the incident
and was unable to advocate for herself. The resident's sister revealed around the middle of January 2025
Resident #18's stomach was hard and full for a few days and she was having edema. The sister indicated
while at the hospital Resident #18 was found to have a hip fracture.
Review of a family provided two minute and one second video dated 01/04/25 at 9:08 A.M. revealed
Resident #18 was receiving incontinence care while in bed from Nurse Aide #329 and Nurse Aide #353.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 16 of116
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
03/31/2025
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident #18 could be heard groaning when turned by the staff. During turning at the one minute and 39
second mark Resident #18 could be heard saying ouch and says ow again at the one minute and 57
second mark while staff were attempting to re-dress the resident.
Review of a family provided one minute and 28 second video dated 01/04/25 at 11:20 A.M. revealed
Resident #18 was being prepared for transfer using sit to stand lift by Nurse Aide #329 and Nurse Aide
#353. At the 34 second mark Nurse Aide #329 pulls Resident #18's legs to edge of bed and the resident
could be heard groaning (in pain) out loudly.
Review of an email provided by Resident #18's sister dated 01/05/25 timed 8:35 P.M. revealed Resident
#18's sister contacted the former Administrator, former DON, Social Services Designee (SSD) #355, and
Ombudsman with her concerns. In the email, Resident #18's sister noted the resident fell on [DATE] and
hurt her left hip and leg. The sister indicated an x-ray was taken about 6:00 P.M. on 01/03/25; however, she
did not receive notification of results until 01/04/25 at 9:45 A.M. The sister indicated it was apparent
Resident #18 was in pain; however, she was not made aware of a treatment plan in place. The sister stated
Resident #18 was unable to request pain medications. The sister included a series of videos in the email
from a camera in Resident #18's room. The sister indicated on video Nurse Aide #329 was not gentle and
did not appear to be knowledgeable of Resident #18's potentially broken left hip. The sister shared
additional unrelated concerns related to the care of Resident #18 in the email.
Review of a facility Self-Reported Incident (SRI) dated 01/06/25 at 9:30 A.M. revealed Resident #18's sister
made an allegation Nurse Aide #329 was rough during incontinence care. The resident's recent fall with
pain was not included on the SRI investigation.
Further review revealed there was no evidence of SRI filed for Resident #18's 01/18/25 pelvic fracture to
rule out potential abuse.
During an interview on 03/18/25 at 2:04 P.M. with the Administrator and Chief Operating Officer (COO)
#300, Resident #18's fall on 01/03/25, SRI on 01/06/25, and pelvic fracture on 01/18/25 were reviewed.
COO #300 indicated she was unable to remember any details of Resident #18's fall. COO #300 and the
Administrator confirmed they were unable to provide any additional details related to Resident #18's fall and
subsequent fracture including interventions, investigation, interdisciplinary review, or root cause analysis.
COO #300 confirmed there was no reporting of injury of unknown origin to rule out abuse for Resident #18.
Review of facility policy Abuse Prevention dated 08/20/21 revealed the facility would investigate all alleged
violations involving abuse including injuries of unknown origin. An injury of unknown origin is classified
when the source of injury was not observed or could be explained by the resident and the injury is
suspicious due to extent/location/number of injuries or injuries over time. Serious bodily injuries should be
reported to Ohio Department of Health (ODH) immediately or no later than 2 hours after alleged incident.
Follow up was required for injuries of unknown source to make necessary changes in resident's plan of
care to protect against occurrence of another similar injury.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 17 of116
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
03/31/2025
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 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of a self-reported incident, review of the facility policy, record review and interview, the facility failed
to thoroughly investigate allegations of misappropriation and injury of unknown origin. This affected two
residents (#18 and #23) out of five residents reviewed for abuse Facility census was 54.
Residents Affected - Few
Findings include:
1. Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses
including lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder. Resident
#23 was her own responsible party.
Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a
brief interview for mental status (BIMS) score of 14, indicating she was cognitively intact and displayed
other behaviors one to three days of the seven-day lookback period.
Review of Resident #23's plan of care dated 09/18/24 and revised 12/19/24 revealed Resident #23 had
delusions, behavior problems and could attempt to manipulate with physical aggression, verbal aggression
and emotional outbursts and was also noted to make false accusations.
Review of a SRI dated 01/06/25 at 5:08 P.M. revealed Resident #23 reported to Registered Nurse (RN)
#313, the Director of Nursing (DON) at the time of the allegation, that her tablet was missing. Resident #23
stated a Certified Nursing Assistant (CNA) who was taking care of her had removed her dinner tray that the
tablet was on. The time of the occurrence was identified as 01/06/25 at 3:07 P.M. An alleged perpetrator
was listed as CNA #329. A search was completed for the tablet and the tablet was not found. Resident #23
was offered a lock box which she declined. The facility determined the allegation of misappropriation to be
unsubstantiated.
Review of the facility's investigation for the SRI on 01/06/25 revealed two sheets of paper including a
statement from Social Service Designee (SSD) #355 and a statement from CNA #353. No further evidence
of investigation was available for review.
Review of the statement dated 01/07/25 and authored by SSD #355 revealed the following information: I
interviewed Resident #23 on 01/07/25 and she stated she had an iPad (tablet) that was missing. Resident
#23 stated she has two iPads, one with a purple and blue case and another Amazon iPad with a black case
that had googly eyes and the words do not touch on the front of it. Resident #23 stated the iPad was on her
tray table on top of her food tray and that it was removed by a CNA and never returned. An addendum was
located at the bottom of SSD #355's statement which indicated on 01/10/25 Resident #23 found her
missing iPad but no further information was available.
Review of the statement dated 01/09/25 and authored by CNA #353 revealed she had no knowledge of
Resident #23's tablet.
Review of the facility's grievance and self-report tracking log for January 2025 revealed on 01/04/25,
Resident #23 had reported her missing iPad. Under the 'Resolution' header, there was a notation the iPad
was found on 01/10/25.
Interview on 03/12/25 at 11:09 A.M. with Resident #23 revealed in January 2025, her tablet was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 18 of116
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
03/31/2025
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 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
laying on her meal tray. Resident #23 identified her tablet as an Amazon Fire tablet, which she showed the
surveyor during the interview. This tablet had a black cover with white writing with Resident #23's initials
and the phrase don't touch my tablet on it. Resident #23 stated CNA #329 picked up her meal tray and took
the tablet, then sold her tablet to Resident #10 for $100.00. She was able to activate an alarm on her tablet
from her cell phone, which she found in Resident #10's room. Resident #23 could not state how much time
had elapsed from when the tablet was observed gone to the time she found it in Resident #10's room.
Resident #23 shared she had two Amazon Fire tablets, a 9-inch one and an 11-inch one and indicated the
9-inch one was the one that had been reported missing. Resident #23 verified the facility did not interview
her regarding her allegation of misappropriation or have her write a witness statement.
Interview on 03/12/25 at 11:22 A.M. with CNA #329 revealed she was angry she was suspended over the
allegation of misappropriation regarding Resident #23's missing tablet. CNA #329 stated she worked on
01/05/25 and did not have Resident #23 as her resident that date. CNA #329 reported Resident #23 made
the complaint at lunch regarding her missing tablet, so she told Licensed Practical Nurse (LPN) #329 and
CNA #353. CNA #353 had went into the kitchen to look through the trash for Resident #23's tablet and an
agency nurse (not identified) was also aware of the missing tablet. On 01/06/25, the previous Director of
Nursing (DON), RN #313 and previous Assistant Director of Nursing (ADON)/LPN #368 told her she was
being suspended over the theft of Resident #23's tablet. CNA #329 stated she was not interviewed and the
facility did not have her write a witness statement. CNA #329 stated they had her come in on 01/08/25 as
the facility had found Resident #23's tablet as SSD #355 observed Resident #23 on the tablet and Resident
#23 had stated at that time CNA #329 had stole the tablet, sold it to Resident #10 then got her tablet back.
Interview on 03/12/25 at 11:38 A.M. with LPN #354 revealed she did not recall Resident #23's missing iPad
and shared Resident #23 was always on an iPad in her room.
Interview on 03/12/25 at 11:45 A.M. with CNA #353 revealed she was aware of the allegation of
misappropriation regarding Resident #23 and confirmed she had to write a witness statement. First,
Resident #23 said a resident stole her iPad and she hit an alarm on it and it went off. Then, Resident #23
stated a kitchen staff had stolen her iPad and then she accused CNA #329 of stealing the iPad. CNA #353
stated the iPad was missing maybe four or five days, then it reappeared.
Interview on 03/12/25 at 11:53 A.M. with SSD #355 revealed she was in charge of keeping the facility's
grievance and self-report tracking log. SSD #355 recalled someone (name not provided) had told her about
the allegation and stated a CNA had taken Resident #23's meal tray which had her tablet on it and
Resident #23 had thought someone had sold it to Resident #10. SSD #355 stated Resident #23 later found
her tablet in Resident #10's room. When asked about the facility's grievance and self-report tracking log and
the date of 01/04/25 regarding Resident #23's concern with her missing tablet, SSD #355 verified the date
of 01/04/25 was accurate and was the date she was first made aware of Resident #23's missing tablet.
During an interview on 03/12/25 at 12:12 P.M. the Chief Operating Officer (COO) #300 was notified the SRI
and subsequent investigation regarding Resident #23's missing tablet was an insufficient investigation as it
lacked resident interviews, additional staff interviews and an interview with the alleged perpetrator (CNA
#329) and she did not agree or disagree.
Follow-up interview on 03/12/25 at 12:19 P.M. with COO #300, the Administrator and CNA #329 revealed
CNA #329 was asked questions by facility staff regarding the allegation of misappropriation, but
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 19 of116
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
03/31/2025
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 0610
Level of Harm - Minimal harm
or potential for actual harm
again no record of this was available for surveyor review. CNA #329 reiterated she was not asked to
complete a written witness statement as a result of the allegation. 2. Review of the medical record for
Resident #18 revealed an admission date of 05/30/18 with diagnoses including Parkinson's disease,
age-related osteoporosis, dementia, generalized muscle weakness, and dependence on wheelchair.
Resident #18 was hospitalized from [DATE] to 01/20/25.
Residents Affected - Few
Review of a nurse's note dated 01/03/25 at 7:35 A.M. revealed Resident #18 was found on floor by nurse
aide lying flat on her back. Nurse and aide picked Resident #18 up off the floor and into her wheelchair.
Resident #18 was taken to the dining room for breakfast. Resident #18 stated she got up from her recliner
chair to pick something up off the floor and fell backwards. It was noted Resident #18 claimed she didn't hit
her head and had no complaints of pain at this time.
Review of progress notes, nurse practitioner noted, and therapy notes from 01/03/25 to 01/18/25 revealed
Resident #18 had complaints of pain to left hip and pelvic area. Resident #18 was medicated for pain
throughout this time.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident
#18 had severely impaired cognition and was dependent on staff for activities of daily living (ADLs).
Review of a nurse's note dated 01/18/25 at 9:55 A.M. revealed Resident #18's was sent to hospital for
evaluation related to abdominal pain and suspicious x-ray of abdomen.
Review of a Hospital Medicine History and Physical dated 01/18/25 revealed Resident #18 presented to
hospital for concern of bowel obstruction. While in the emergency department (ED) a cat (CT) scan was
completed, and Resident #18 was noted to have a fracture of the pelvis. CT results showed acute fractures
of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left
acetabulum. Orthopedics were following; however, the fracture was nonsurgical. Resident #18's sister was
present at hospital and reported on 01/03/25 Resident #18 had a fall and had been complaining of pain to
left hip since. Physical examination showed edema to right lower extremity and trace edema to left hip.
Resident #18 had pain to the left hip inguinal fold area and when laying on side.
Review of the Hospital Discharge summary dated [DATE] revealed diagnoses including closed
nondisplaced fracture of pelvis, chronic constipation, and cellulitis of extremity.
Interview on 03/18/25 at 8:00 A.M. with Resident #18's sister revealed she had made an allegation of
neglect in January 2025 and had provided videos as supporting evidence to facility staff. During the
interview, the resident's sister also shared Resident #18 had a fall at the beginning of January 2025. An
x-ray was completed that did not show a fracture; however, Resident #18 was in pain following the incident
and was unable to advocate for herself. The resident's sister revealed around the middle of January 2025
Resident #18's stomach was hard and full for a few days and she was having edema. The sister indicated
while at the hospital Resident #18 was found to have a hip fracture.
Review of a family provided one minute and 48 second video dated 01/04/25 at 7:57 A.M. revealed
Resident #18 was sitting in a recliner chair for breakfast. Nurse Aide #329 was sitting in a chair next to
Resident #18. Nurse Aide #329 appeared distracted during the video.
Review of a family provided two minute and three second video dated 01/04/25 at 8:00 A.M. revealed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 20 of116
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
03/31/2025
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 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident #18 was sitting in recliner chair for breakfast. Nurse Aide #329 was sitting in a chair next to
Resident #18. Nurse Aide #329 appeared distracted during the video and at the 15 second mark stood in
the hallway before returning to sit next to Resident #18.
Review of a family provided two minute and one second video dated 01/04/25 at 9:08 A.M. revealed
Resident #18 was receiving incontinence care while in bed from Nurse Aide #329 and Nurse Aide #353.
Resident #18 could be heard groaning when turned by the staff. During turning at the one minute and 39
second mark Resident #18 could be heard saying ouch and says ow again at the one minute and 57
second mark while staff were attempting to re-dress the resident.
Review of a family provided one minute and 28 second video dated 01/04/25 at 11:20 A.M. revealed
Resident #18 was being prepared for transfer using sit to stand lift by Nurse Aide #329 and Nurse Aide
#353. At the 34 second mark Nurse Aide #329 pulls Resident #18's legs to edge of bed and the resident
could be heard groaning (in pain) out loudly.
Review of a family provided two minute and two second video dated 01/04/25 at 6:07 P.M. revealed
Resident #18 was in her room in wheelchair. Nurse Aide #329 and Nurse Aide #353 were observed to use
sit to stand lift and take Resident #18 to bathroom.
Review of an email provided by Resident #18's sister dated 01/05/25 timed 8:35 P.M. revealed Resident
#18's sister contacted the former Administrator, former DON, Social Services Designee (SSD) #355, and
Ombudsman with her concerns. In the email, Resident #18's sister noted the resident fell on [DATE] and
hurt her left hip and leg. The sister indicated an x-ray was taken about 6:00 P.M. on 01/03/25; however, she
did not receive notification of results until 01/04/25 at 9:45 A.M. The sister indicated it was apparent
Resident #18 was in pain; however, she was not made aware of a treatment plan in place. The sister stated
Resident #18 was unable to request pain medications. The sister included a series of videos in the email
from a camera in Resident #18's room. The sister indicated on video Nurse Aide #329 was not gentle and
did not appear to be knowledgeable of Resident #18's potentially broken left hip. Sister requested Nurse
Aide #329 be removed from taking care of Resident #18 due to mistreatment. Resident #18's sister also
stated concerns with follow through on agreed plan of care for medications and care.
Review of a facility Self-Reported Incident (SRI) dated 01/06/25 at 9:30 A.M. revealed Resident #18's sister
made an allegation Nurse Aide #329 was rough during incontinence care. The resident's recent fall with
pain was not included on the SRI investigation. There was no evidence of interview with Resident #18's
sister nor inclusion of videos provided by sister. The facility unsubstantiated abuse.
Interview on 03/18/25 at 11:33 A.M. with Admissions/Social Services Designee (SSD) #355 confirmed she
had received a series of videos from Resident #18's sister. SSD #355 indicated she forwarded the email
onto the interim Administrator and former Director of Nursing (DON). SSD #355 indicated she did not watch
the videos she received from sister of Resident #18.
Interview on 03/18/25 at 2:04 P.M. with Administrator and Chief Operating Officer (COO) #300 confirmed
the videos from Resident #18's sister had been received and were not included in SRI investigation. COO
#300 indicated there was nothing in the videos that appeared abusive. COO #300 confirmed information on
Resident #18's fall was not included in the SRI investigation as well.
Interview on 03/19/25 at 2:45 P.M. with Administrator revealed Administrator agreed to view videos
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 21 of116
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
03/31/2025
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 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
submitted by sister of Resident #18. The six videos provided were reviewed. Administrator indicated it
would be important to include these videos in the investigation. Administrator indicated she did not note any
abuse behavior but indicated Nurse Aide #329 displayed a customer service issue.
Review of facility policy Abuse Prevention dated 08/20/21 revealed once notifications of an abuse allegation
were made and investigation would be conducted. The investigation should include interview with parties
involved including resident, alleged perpetrator, and witnesses, expanded interviews to other residents and
staff, review of resident medical records, obtain all medical reports and statements as applicable, and
review employee record if they are identified as alleged perpetrator. All evidence of investigation should be
documented.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 22 of116
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
03/31/2025
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 0636
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure nursing assessments were completed on admission
for residents. This affected one (Resident #48) of 28 residents reviewed for nursing assessments.
Findings include:
Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses
including multiple fractures of ribs, encephalopathy (condition that affects function of the brain),
hallucinations and alcohol use with withdrawal.
Review of Resident #48's electronic medical record and paper chart revealed there were no nursing
admission assessments done when he arrived at the facility.
Interview on 03/19/25 at 11:45 A.M. with the Chief Operating Officer (COO) #300 verified Resident #48 did
not have a nursing assessment performed on admission to the facility on [DATE].
The facility was unable to provide a policy related to nursing assessments and timing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 23 of116
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
03/31/2025
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 0641
Ensure each resident receives an accurate assessment.
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 interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments for
residents were complete and accurate. This affected four (Residents #22, #24, #37 and #43) of 28 residents
reviewed for the accuracy and completion of assessments. The facility census was 54.
Residents Affected - Some
Findings include:
1. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses
including chronic obstructive pulmonary disease, hypertension and heart failure.
Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #22 revealed section C for
cognitive patterns was not completed. Question C100 was answered yes to interview for mental status.
However, questions C200, C300, C400, C500, C600, C700, C800, C900, C1000 and C1310 were all
answered with either not assessed or dashes. Section J revealed question J200 was answered yes to
attempt to interview the resident for pain. However, J300, J410, J520, J530 and J600 were answered not
assessed or had dashes.
Interview on 03/18/25 at 1:12 P.M. with the MDS Coordinator #365 revealed he completed MDS
assessments offsite. He stated Social Services Director (SSD) #355 was responsible of sections C and D
on the MDS assessment. He stated he was unsure why sections C was coded for an interview to be
conducted and then all the questions stated not assessed. For section J, he stated he would call into the
facility and speak to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to review if the
residents had pain. He stated he was not able to speak with anyone for Resident #22's pain assessment.
He verified section J should have been completed.
Interview on 03/18/25 at 1:59 P.M. with SSD #355 verified she answered sections C and D on MDS
assessments for residents, though not always during the time frame of the MDS assessment. She verified
section C was not completed for Resident #22 on his MDS dated [DATE].
2. Review of the medical record for Resident #24 revealed an admission date of 06/04/24 with diagnoses
including dementia, Parkinson's Disease, anxiety and hypertension.
Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #24 revealed section C for
cognitive patterns was not completed. Question C100 was answered yes to interview for mental status.
However, questions C200, C300, C400, C500, C600, C700, C800, C900, C1000 and C1310 were all
answered with either not assessed or dashes. Section D revealed question D100 was answered yes to
conduct a mood interview with Resident #24. However, questions D150 and D160 were answered not
assessed or had dashes. Section J revealed question J200 was answered yes to attempt to interview the
resident for pain. However, J300, J410, J520, J530 and J600 were answered not assessed or had dashes.
Interview on 03/18/25 at 1:12 P.M. with the MDS Coordinator #365 revealed he completed MDS
assessments offsite. He stated SSD #355 was responsible of sections C and D on the MDS assessment.
He stated he was unsure why sections C and D were coded for an interview to be conducted and then all
the questions stated not assessed. For section J, he stated he would call into the facility and speak to the
DON or ADON to review if the residents had pain. He stated he was not able to speak with anyone for
Resident #22's pain assessment. He verified section J should have been completed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 24 of116
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
03/31/2025
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview on 03/18/25 at 1:59 P.M. with SSD #355 verified she answered sections C and D on MDS
assessments for residents, though not always during the time frame of the MDS assessment. She verified
sections C and D were not completed for Resident #22 on his MDS dated [DATE].
3. Review of the medical record for Resident #37 revealed an admission date of 08/21/24 with diagnoses
including chronic obstructive pulmonary disease, diabetes mellitus, depression and chronic pain syndrome.
Review of the admission MDS 3.0 assessment dated [DATE] for Resident #37 revealed section J for pain
was not completed. Section J revealed question J200 was answered yes to attempt to interview the
resident for pain. However, J300, J410, J520, J530 and J600 were answered not assessed or had dashes.
Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #37 revealed section J for pain
was not completed. Section J revealed question J200 was answered yes to attempt to interview the
resident for pain. However, J300, J410, J520, J530 and J600 were answered not assessed or had dashes.
Interview on 03/18/25 at 1:12 P.M. with the MDS Coordinator #365 revealed he completed MDS
assessments offsite. He stated for section J he would call into the facility and speak to the DON or ADON to
review if the resident had pain. He stated he was not able to speak with anyone for Resident #37's pain
assessment. He verified section J should have been completed.
4. Review of the medical record for Resident #43 revealed an admission date of 12/16/24 and diagnoses
including sepsis, paranoid schizophrenia, moderate protein-calorie malnutrition, osteomyelitis, and
traumatic arthropathy of right knee.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed an interview for mental status should
be conducted with Resident #43. The brief interview for mental status (BIMS) interview was marked as not
assessed on MDS section C. An interview for mood should be conducted with Resident #43. Mood
interview was marked as not assessed/no information on MDS section D.
Review of Medicare MDS Quarterly assessment dated [DATE] revealed Resident #43 received as needed
pain medications. An interview for pain assessment should be completed for Resident #43. Pain
assessment interview was marked as not assessed on MDS section J.
Interview on 03/18/25 at 1:12 P.M. with MDS Coordinator #365 revealed he had worked at the facility for a
year and had been completing MDS assessments offsite. MDS Coordinator #365 indicated interviews for
mental status and mood were completed by Social Service Designee (SSD) #355 and the interviews for
pain were completed by Assistant Director of Nursing (ADON). MDS Coordinator #365 confirmed Resident
#43's MDS sections C and D for 12/31/24 assessment and section J for 01/07/25 were incomplete.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 25 of116
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
03/31/2025
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to develop and implement a baseline care plan for Resident
#48. This affected one (Resident #48) out of 19 residents reviewed for baseline care plans. The facility
census was 54.
Findings include:
Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses
including multiple fractures of ribs, encephalopathy (condition that affects function of your brain),
hallucinations and alcohol use with withdrawal.
Review of Resident #48's electronic medical record and paper chart revealed there was no baseline care
plan completed after admission.
Interview on 03/19/25 at 11:45 A.M. with Chief Operating Officer (COO) #300 verified Resident #48 did not
have a baseline care plan completed since admission on [DATE].
Review of the facility policy titled, Baseline Plan of Care, dated 05/01/22, revealed the interdisciplinary
team, resident, resident's representative and physician would develop and implement a baseline care plan
upon admission which would include the instructions needed to provide effective and person-directed care
of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 26 of116
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
03/31/2025
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of
Resident #25's medical record revealed an admission date of 09/16/24 and diagnoses including traumatic
brain injury, insomnia, protein-calorie malnutrition, vascular dementia with other behavioral disturbance,
anxiety and depression.
Review of Resident #25's electronic medical record (EMR) revealed he had an advance directive of Do Not
Resuscitate Comfort Care Arrest (DNRCCA). No care plan was available addressing Resident #25's
advance directives.
Interview on 03/12/25 at 9:11 A.M. with Social Service Designee (SSD) #355 revealed the MDS nurse put
in the care plans, but any staff could update resident care plans. SSD #355 confirmed Resident #25 did not
have a care plan developed addressing his advance directive and should have.
5. Review of Resident #34's medical record revealed an admission date of 08/21/23 and diagnoses
including vascular dementia with psychotic disturbance, paranoid personality disorder, violent behavior,
osteoarthritis and depression.
Review of Resident #34's EMR revealed he had an advance directive of DNRCCA. No care plan was
available addressing Resident #34's advance directives.
Interview on 03/12/25 at 9:14 A.M. with SSD #355 revealed the MDS nurse put in the care plans, but any
staff could update resident care plans. SSD #355 confirmed Resident #34 did not have a care plan
developed addressing his advance directive and should have.Based on record review and interview, the
facility failed to develop comprehensive care plans for residents. This affected seven (Residents #9, #22,
#24, #25, #34, #48 and #49) out of 28 residents reviewed for comprehensive care plans. The facility census
was 54.
Findings include:
1. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses
including chronic obstructive pulmonary disease, hypertension and heart failure.
Review of the care plan dated 11/12/24 for Resident #22 revealed he needed assistance with his activities
of daily living (ADLs). The goal was for him to maintain his current level of functioning through the next
review. Interventions were listed for ADL's including bathing, bed mobility, dressing, toilet use and personal
hygiene. However, the care plan did not specify what amount of assistance Resident #22 required from
staff. The care plan stated as follows:
-Bathing/Showering: I require (specify what assistance) by staff with (specify bathing/showering) at least
weekly and whenever I prefer.
-Bed mobility: I require (specify what assistance) by staff to turn and reposition me frequently while in bed.
-Dressing: I need (specify what assistance) by staff to dress me.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 27 of116
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
03/31/2025
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 0656
-Personal hygiene: I need (specify) assistance from you with personal hygiene and oral care.
Level of Harm - Minimal harm
or potential for actual harm
-Toilet use: I need (specify assistance) by you for toileting.
Residents Affected - Some
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #22's care plan for
ADL's was not resident centered and would not provide staff with the information to care for his needs.
2. Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses
including multiple fractures of ribs, encephalopathy (condition that affects function of the brain),
hallucinations and alcohol use with withdrawal.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48
had impaired cognition and had depression. He used a walker and needed substantial to max assistance
for toileting and showers.
Review of the comprehensive care plan for Resident #48 revealed he had a care plan for his advance
directives dated 03/12/25, one for his emotional, intellectual, physical and social needs dated 02/21/25 and
his nutritional risks dated 02/07/25.
Interview on 03/19/25 at 11:45 A.M. with the Chief Operating Officer (COO) #300 verified Resident #48's
care plan was not a comprehensive look at the resident and would not provide staff with the information to
care for his needs.
3. Review of the medical record for Resident #49 revealed an admission date of 01/31/25 with diagnoses
including heart failure, chronic respiratory failure, kidney failure, obesity and cirrhosis of the liver.
Review of the care plan dated 01/31/25 for Resident #49 revealed he needed assistance with his activities
of daily living (ADLs). The goal was for him to maintain his current level of functioning through the next
review. Interventions were listed for ADL's including bathing, bed mobility, dressing, toilet use and personal
hygiene. However, the care plan did not specify what amount of assistance Resident #22 required from
staff. The care plan stated as follows:
-Bathing/Showering: I require (specify what assistance) by staff with (specify bathing/showering) at least
weekly and whenever I prefer.
-Bed mobility: I require (specify what assistance) by staff to turn and reposition me frequently while in bed.
-Dressing: I need (specify what assistance) by staff to dress me.
-Personal hygiene: I need (specify) assistance ROM you with personal hygiene and oral care.
-Toilet use: I need (specify assistance) by you for toileting.
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #49's care plan for
ADL's was not resident centered and would not provide staff with the information to care for his needs.6.
Review of the medical record for Resident #9 revealed an admission date of 04/12/24
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 28 of116
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
03/31/2025
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
and diagnoses including bell's palsy, systemic lupus erythematosus, congestive heart failure, hypertension,
dementia, metabolic encephalopathy, malignant neoplasm of bronchus and lung, and chronic kidney
disease.
Review of a nurses note dated 01/11/25 revealed Resident #9 was agitated and adamant she was going
home. Resident #9's son came to the facility to try to calm her down. Son reported Resident #9 was
exhibiting symptoms of a urinary tract infection (UTI) as she had in the past. Hospice and Physician were
notified. The physician gave an order for Ciprofloxacin (antibiotic) for seven days and to collect urine
sample.
Review of physician's order dated 01/12/25 revealed order for 500 milligrams (mg) Ciprofloxacin two times
per day for seven days.
Review of physician's order dated 01/21/25 revealed order for 100 mg Macrobid (antibiotic) two times per
day for an unspecified number of days. Order was discontinued on 02/04/25.
Review of the plan of care for January to March 2025 revealed no care plan related to infections was
developed.
Interview on 03/19/25 at 3:37 P.M. with Director of Nursing (DON) confirmed Resident #9 did not have a
care plan related to infections developed.
7. Review of the medical record for Resident #24 revealed admission date of 06/04/24 and diagnoses
including dementia with psychotic disturbance, hypertension, hyperlipidemia, lymphedema, Parkinson's
disease, anxiety disorder, atherosclerotic heart disease.
Review of hospital Discharge summary dated [DATE] revealed Resident #24 was admitted to hospital from
[DATE] to 11/24/24 for cellulitis of left lower extremity. Resident #24 admitted for recurrent left lower
extremity cellulitis and had previously been admitted from 11/05/24 to 11/11/24. Resident #24 was noted to
have Methicillin-resistant Staphylococcus aureus (MRSA) growth on sputum culture, so Doxycycline
(antibiotic) was added. Sputum culture appeared consistent with colonization.
Review of Nurse Practitioner (NP) progress note dated 11/25/24 revealed Resident #24 returned from
hospital on [DATE] with diagnosis of cellulitis. NP noted Resident #24 was discharged on antibiotic for
cellulitis and MRSA in sputum culture.
Review of NP progress note dated 12/16/24 revealed Resident #24 completed oral antibiotic treatment of
Cephalexin for cellulitis and Doxycycline for MRSA of sputum on 12/02/24.
Review of Ohio Department of Health (ODH) Ohio Disease Reporting System (ODRS) report undated
revealed Resident #24 had sputum culture collected on 11/10/24 while at hospital. Results of sputum
culture returned on 11/27/24 and were positive for Citrobacter koseri and Klebsiella aerogenes. Klebsiella
pneumoniae carbapenemase (KPC) was detected.
Review of the plan of care for March 2025 revealed no care plan related to infections or MDRO status.
Interview on 03/19/25 at 3:37 P.M. with Director of Nursing (DON) confirmed Resident #24 did not have a
care plan related to infections or MDRO status developed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 29 of116
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
03/31/2025
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on record review, interview and review of the facility policy, the facility failed to timely update care
plans to address changes in residents' advance directives. This affected three residents (#7, #15 and #20)
out of 26 residents reviewed for care planning. Facility census was 54.
Findings include:
1. Review of Resident #7's medical record revealed an admission date of 05/07/15 and diagnoses including
schizoaffective disorder, hypertension, insomnia, muscle weakness and diabetes.
Review of Resident #7's electronic medical record (EMR) revealed he had an advance directive of Do Not
Resuscitate Comfort Care Arrest (DNRCCA). A plan of care revised 07/05/22 revealed Resident #7 had an
advance directive of full code.
Review of Resident #7's paper medical record revealed he had an advance directive of full code.
Interview on 03/12/25 at 9:13 A.M. with Social Service Designee (SSD) #355 revealed the Minimum Data
Set (MDS) nurse put in the care plans, but any staff could update resident care plans. SSD #355 confirmed
Resident #7's care plan was not revised to reflect his current advance directive of DNRCCA and should
have been.
2. Review of Resident #15's medical record revealed an admission date of 08/01/16 and diagnoses
including dementia with agitation, alcohol dependence with alcohol-induced persisting dementia,
generalized anxiety disorder, paranoid personality disorder and delusional disorders.
Review of Individual #15's EMR revealed he had an advance directive of DNRCCA. A plan of care revised
01/02/22 revealed Resident #15 had an advance directive of full code.
Review of Individual #15's paper medical record revealed he had an advance directive of full code. No
signed do not resuscitate (DNR) was available in his record.
Interview on 03/12/25 at 9:10 A.M. with SSD #355 revealed the MDS nurse put in the care plans, but any
staff could update resident care plans. SSD #355 confirmed Resident #15's care plan was not revised to
reflect his current advance directive of DNRCCA and should have been.
3. Review of Resident #20's medical record revealed an admission date of 11/07/17 and diagnoses
including type two diabetes, chronic kidney disease, traumatic brain injury, dementia with agitation and
generalized anxiety disorder.
Review of Individual #20's EMR revealed he had an advance directive of DNRCCA. A plan of care revised
07/23/19 revealed Resident #20 had an advance directive of full code.
Review of Individual #20's paper medical record revealed he had an advance directive of full code. No
signed DNR was available in his record.
Interview on 03/12/25 at 9:10 A.M. with SSD #355 revealed the MDS nurse put in the care plans, but any
staff could update resident care plans. SSD #355 confirmed Resident #20's care plan was not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 30 of116
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
03/31/2025
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 0657
revised to reflect his current advance directive of DNRCCA and should have been.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy, Baseline Plan of Care, dated 05/01/22 revealed the comprehensive plan of care
will be developed within seven days after completion of the comprehensive assessment . The plan of care
will be reviewed and revised by the interdisciplinary team after each MDS assessment, including both
comprehensive and quarterly review assessments.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 31 of116
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
03/31/2025
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 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of
Resident #15's medical record revealed an admission date of 08/01/16 and diagnoses including dementia
with agitation, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder,
paranoid personality disorder and delusional disorders.
Residents Affected - Few
Review of a quarterly MDS 3.0 assessment dated [DATE] revealed no mental status was completed on the
assessment for Resident #15. Resident #15 was independent with bathing and mobility and rejected care
one to three days in the seven-day look-back period.
Review of the facility shower schedule revealed Resident #15's room number was not listed on the
schedule for staff to offer him showers.
Review of Resident #15's nurses' notes for February 2025 and March 2025 did not record any refusals of
showers.
Review of Resident #15's resident tasks records revealed no shower data for the last 30 days.
Interview on 03/10/25 at 12:41 P.M. with Resident #15 revealed he had not had a shower or bed bath for
the last three weeks and reported the shower door room was kept locked.
Interview on 03/13/25 at 8:46 A.M. with the DON verified she did not have any shower sheets to provide for
Resident #15.
Follow-up interview on 03/13/25 at 12:44 P.M. with the DON and Registered Nurse (RN)/Assistant Director
of Nursing (ADON) #299 verified Resident #15 was not on the facility's shower schedule and should have
been.
Interview on 03/18/25 at 7:40 A.M. with Licensed Practical Nurse (LPN) #325 revealed some residents
refused showers, but if this occurred Certified Nursing Assistants (CNAs) were to write 'refused' on the
paper shower sheet and she would make a nurses' note about the refused shower as well.
Interview on 03/18/25 at 8:47 A.M. with CNA #357 revealed many residents refused their showers in the
facility. CNA #357 stated if this occurred, she let the nurse know and she would write refuse on a paper
shower sheet for that resident, and the nurse would take the shower sheets after that.
Review of the facility policy, Resident ADL Care, dated 07/01/23 the facility believed in supporting and
encouraging the autonomy and independence of all residents in activities of daily living to the fullest extent
possible. Residents will be expected to maintain reasonable standards of hygiene and grooming during
their stay at the facility. When autonomy and independence are no longer possible or feasible, the facility
resident care staff will provide the necessary support in all ADL functioning. All residents will be expected to
bathe, assisted as necessary, twice per week unless otherwise specified by the physician or the resident
requests more frequent bathing.
This deficiency represents noncompliance investigated under Complaint Number OH00162361.
Based on record review, observation and interview, the facility failed to ensure showers were
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 32 of116
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
03/31/2025
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 0676
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
completed for independent residents. This affected three (Residents #15, #22 and #203) of three residents
reviewed who were independent with activities of daily living (ADL). The facility census was 54.
Findings include:
1. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses
including chronic obstructive pulmonary disease, hypertension and heart failure.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had
clear speech, understood staff and staff understood him. There was no cognitive assessment performed on
this MDS. Resident #22 was noted to be independent for showers and dressing.
Review of the care plan dated 11/12/24 for Resident #22 revealed he needed assistance with his activities
of daily living (ADLs). However, his care plan was incomplete and did not state the level of care he required
for assistance with showers.
Review of the medical record for Resident #22 from 01/01/25 through 03/10/25, revealed there was no
evidence he had received showers during that period of time.
Review of the shower schedule for the facility, undated, revealed Resident #22 would receive his showers
on Wednesday and Saturday between 7:00 P.M. and 7:00 A.M.
Interview on 03/10/25 at 10:41 A.M. with Resident #22 revealed he hadn't received his showers as
scheduled and per his preference due to the shower being broken.
Observation on 03/10/25 at 10:59 A.M. revealed the shower room on the west side of the building had a
sign that stated the shower was broken.
Interview on 03/13/25 at 8:46 A.M. with the Director of Nursing (DON) verified she was unable to find any
shower sheets for Resident #22. She stated the staff document all showers on shower sheets.
2. Review of the medical record for Resident #203 revealed an admission date of 03/04/25 with diagnoses
including paranoid schizophrenia, depression and anxiety.
Review of the nursing assessment and baseline care plan dated 03/04/25 revealed Resident #203
preferred to receive a shower and needed set-up help only with bathing.
Review of the shower schedule for the facility, undated, revealed Resident #203 would receive his showers
7:00 P.M. to 7:00 A.M. on Wednesday and Saturday. With this schedule, Resident #203 would have received
showers on 03/05/25, 03/08/25 and 03/12/25 .
Review of the medical record for Resident #203 from 03/04/25 through 03/13/25, revealed he refused a
shower on 03/05/25. There were no other shower sheets in his record.
Interview on 03/10/25 at 10:30 A.M. with Resident #203 revealed he hadn't received his showers as
scheduled and per his preference since being admitted to the facility.
Interview on 03/13/25 at 8:46 A.M. with the DON verified she was unable to find any other shower
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 33 of116
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
03/31/2025
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 0676
sheets for Resident #203. She stated the staff document all showers on shower sheets.
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 34 of116
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
03/31/2025
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** 4. Review of
Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses including lumbago,
low back pain, general anxiety disorder and post-traumatic stress disorder.
Residents Affected - Some
Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a
brief interview for mental status (BIMS) score of 14 out of 15, indicating she was cognitively intact, was
independent with most activities of daily living (ADLs) and required staff set up for showers/bathing.
Review of the facility shower schedule revealed Resident #23 was to receive showers on night shift (7:00
P.M. to 7:00 A.M.) on Mondays and Thursdays.
Review of Resident #23's nurses' notes for February 2025 and March 2025 did not record any refusals of
showers.
Review of resident tasks records revealed no shower data for the last 30 days.
There were no paper shower sheets available to review for Resident #23.
Interview on 03/10/25 at 10:29 A.M. with Resident #23 reported she had not had a shower for the last two
weeks, as both showers had not been working on the unit.
Interview on 03/13/25 at 8:46 A.M. with the Director of Nursing (DON) verified she did not have any shower
sheets to provide for Resident #23.
Interview on 03/18/25 at 7:40 A.M. with Licensed Practical Nurse (LPN) #325 revealed some residents
refused showers, but if this occurred Certified Nursing Assistants (CNAs) were to write 'refused' on the
paper shower sheet and she would make a nurses' note about the refused shower as well.
Interview on 03/18/25 at 8:47 A.M. with CNA #357 revealed many residents refused their showers in the
facility. CNA #357 stated if this occurred, she let the nurse know and she would write refuse on a paper
shower sheet for that resident, and the nurse would take the shower sheets after that.
Review of the facility policy, Resident ADL Care, dated 07/01/23 the facility believed in supporting and
encouraging the autonomy and independence of all residents in activities of daily living to the fullest extent
possible. Residents will be expected to maintain reasonable standards of hygiene and grooming during
their stay at the facility. When autonomy and independence are no longer possible or feasible, the facility
resident care staff will provide the necessary support in all ADL functioning. All residents will be expected to
bathe, assisted as necessary, twice per week unless otherwise specified by the physician or the resident
requests more frequent bathing.
This deficiency represents noncompliance investigated under Complaint Number OH00162361.
Based on record review and interviews, the facility failed to ensure showers were provided as scheduled
and per the resident preference for dependent residents. This affected four (Residents #23, #37, #43 and
#48) of four dependent residents reviewed for activities of daily living. The facility census was 54.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 35 of116
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
03/31/2025
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
Findings include:
Level of Harm - Minimal harm
or potential for actual harm
1. Review of the medical record for Resident #37 revealed an admission date of 08/21/24 with diagnoses
including chronic obstructive pulmonary disease, diabetes mellitus, depression and chronic pain syndrome.
Residents Affected - Some
Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] for Resident #37 revealed
he had intact cognition and did not refuse care. He was dependent on staff for toileting, showers, dressing
and transfers.
Review of the shower schedule for the facility, undated, revealed Resident #37 was scheduled for showers
on Wednesdays and Saturdays from 7:00 A.M. to 7:00 P.M. for the date range of 01/01/25 through
02/25/25. On 02/26/25 his shower schedule was changed and were scheduled on Mondays and
Wednesdays from 7:00 P.M. through 7:00 A.M.
Review of Resident #37's electronic medical record and paper chart revealed there were no shower sheets
from 01/01/25 through 02/25/25. This resulted in Resident #37 not receiving 16 showers during that time
frame. Review of shower sheets from 02/26/25 through 03/11/25 revealed he was not offered a shower on
02/26/25 and 03/10/25.
Interview on 03/10/25 at 10:58 A.M. with Resident #37 revealed he had not received a shower in nine
months.
Interview on 03/13/25 at 8:46 A.M. with the Director of Nursing (DON) verified she was unable to find any
other shower sheets for Resident #37 than what she had provided as above. She stated the staff
documented all showers on shower sheets.
2. Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses
including multiple fractures of ribs, encephalopathy (condition that affects function of the brain),
hallucinations and alcohol use with withdrawal.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48
had impaired cognition. He used a walker and needed substantial to maximum assistance for toileting and
showers.
Review of the shower schedule for the facility, undated, revealed Resident #48 was scheduled for showers
on Wednesdays and Saturdays from 7:00 P.M. to 7:00 A.M.
Review of Resident #48's electronic medical record and paper chart revealed there was one shower sheet
for 03/12/25 during the time frame of 01/31/25 through 03/13/25.
Interview on 03/10/25 at 10:01 A.M. with Resident #48 revealed he had not been able to take a shower
since he was admitted . He stated the shower had been broken as well.
Observation on 03/10/25 at 10:59 A.M. revealed the shower room on the west side of the building had a
sign that stated the shower was broken.
Interview on 03/13/25 at 8:46 A.M. with the DON verified she was unable to find any other shower sheets
for Resident #48 than what she had provided as above. She stated the staff documented all
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 36 of116
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
03/31/2025
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
showers on shower sheets.
Level of Harm - Minimal harm
or potential for actual harm
3. Review of the medical record for Resident #43 revealed an admission date of 12/16/24 and diagnoses
including sepsis, paranoid schizophrenia, moderate protein-calorie malnutrition, osteomyelitis, and
traumatic arthropathy of right knee.
Residents Affected - Some
Review of Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #43
required partial/moderate assistance from staff for showering and bathing.
Review of shower schedule revealed Resident #43's showers were scheduled for Mondays and Thursdays
on 7:00 P.M. shift.
Review of Bath/Shower Report Sheets from February 2025 to March 2025 revealed sheets for refusal on
02/20/25 for refusal on 02/23/25, for refusal on 03/03/25, for refusal on 03/06/25, for no bath given related
to pain on 03/10/25, and a shower on 03/12/25.
Further review of the medical record for Resident #43 revealed no evidence of additional instances of
bathing offered.
Interview on 03/10/25 at 2:13 P.M. with Resident #43 revealed he was unable to get assistance from staff
for showering.
Interview on 03/13/25 at 8:46 A.M. with Director of Nursing (DON) confirmed she was unable to locate any
additional bathing documentation for Resident #43.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 37 of116
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
03/31/2025
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
observation, medical record review, facility policy review, Centers for Disease Control (CDC) guidance on
COVID-19 and interview the facility failed to provide timely and necessary intervention following changes in
resident condition.
Residents Affected - Few
Actual Harm occurred on [DATE] when Resident #18 had unwitnessed fall resulting in increased pain,
decreased functional ability and inability to participate in therapy services due to pain. On [DATE] (15 days
following the fall) Resident #18 was transferred to the hospital and assessed to have an acute fracture of
left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left
acetabulum.
Actual Harm occurred on [DATE] when Resident #55 was admitted to the hospital for treatment of
pneumonia and was experiencing dark, tarry stools. Resident #55 had tested positive for COVID-19 in the
facility on [DATE] with symptoms including dry cough, nasal congestion, nausea, vomiting, and loose stools.
The lack of timely and adequate medical treatment/intervention after testing positive for COVID-19 on
[DATE] contributed to Resident #55's hospitalization and subsequent death on [DATE].
Actual Harm occurred on [DATE] when Resident #31 was transferred to the hospital and admitted for
treatment of acute respiratory failure secondary to COVID-19. However, Resident #31 had been
experiencing symptoms including nasal congestion, cough, nausea, vomiting, and loose stools since
[DATE] that were not timely or adequately treated contributing to the hospitalization. During the
hospitalization, Resident #31 was also noted to have pneumonia. Resident #31 was hospitalized from
[DATE] to [DATE].
This affected one resident (#18) of three residents reviewed for falls/accidents and two residents (#31 and
#55) of 28 residents reviewed for quality of care and treatment. The facility census was 54
Findings include:
1. Review of the medical record for Resident #18 revealed an admission date of [DATE] with diagnoses
including Parkinson's disease, age-related osteoporosis, dementia, generalized muscle weakness, and
dependence on wheelchair. Resident #18 was hospitalized from [DATE] to [DATE].
Review of a physician's order dated [DATE] revealed order for Acetaminophen 650 milligrams (mg) every
four hours as needed.
Review of a physician's order dated [DATE] revealed order for Tramadol 50 mg every six hours as needed.
Review of a physician's order dated [DATE] revealed order for Acetaminophen 500 mg once daily for mild to
moderate pain.
Review of a nurse's note dated [DATE] at 7:35 A.M. revealed Resident #18 was found on floor by nurse aide
lying flat on her back. Nurse and aide picked Resident #18 up off the floor and into her wheelchair. Resident
#18 was taken to the dining room for breakfast. Resident #18 stated she got up from her recliner chair to
pick something up off the floor and fell backwards. It was noted Resident #18
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 38 of116
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
03/31/2025
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
claimed she didn't hit her head and had no complaints of pain at this time.
Level of Harm - Actual harm
Review of an Orders Administration Note dated [DATE] at 5:40 P.M. revealed Resident #18 was
administered as needed Acetaminophen for pain.
Residents Affected - Few
Review of a nurse's note dated [DATE] at 6:03 P.M. revealed Resident #18 received an unspecified x-ray.
Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] at 6:43 P.M. revealed
Resident #18 was noted to have had fall in morning due to ambulating on own. Unable to ensure carry over
of education to wait for staff for transfers due to poor cognition. During therapy session Resident #18 was
unable to use sit to stand lift or ambulate due to pain to left hip while flexing hip. Resident #18 reported
moderate to severe pain. Nursing was notified.
Review of Medicare Skilled Charting assessment dated [DATE] timed 6:55 P.M. revealed Resident #18 was
alert and oriented to person and situation. Resident #18 had unsteady gait, impaired balance, weakness,
and decreased sensation. Resident #18 required assistance for bed mobility and transfers. Resident #18
had pain to left hip/groin area status post fall and was noted to be grimacing. An x-ray was pending at time
of assessment.
Review of an Orders Administration Note dated [DATE] timed 9:06 P.M. revealed Resident #18 was noted to
be in pain.
Review of nurse's note dated [DATE] at 9:46 P.M. revealed Resident #18 complained of pain to groin and
left hip to nurse. It was noted nursing staff and power of attorney (POA) argued through camera in room
about Resident #18's bathing schedule. Resident #18 was noted to be upset during argument and yelled at
POA. Resident #18 received a bed bath.
Review of a Patient Report dated [DATE] revealed Resident #18 had one view x-ray of left hip and pelvis.
X-ray showed no acute fracture or dislocation. It was noted Resident #18 had enlargement of stool within
the rectal vault. Results signed by interpreting physician on [DATE] at 3:19 A.M.
Review of an Orders Administration Note dated [DATE] at 9:45 A.M. revealed Resident #18 was noted to be
in pain.
Review of an Orders Administration Note dated [DATE] at 10:56 A.M. revealed Resident #18 was
administered as needed Tramadol for hip pain.
Review of an Orders Administration Note dated [DATE] at 8:26 P.M. revealed Resident #18 was
administered as needed Tramadol for signs and symptoms of left hip and groin pain. Resident #18 was
noted to guard areas of pain.
Review of an Orders Administration Note dated [DATE] at 9:26 P.M. revealed Resident #18 was noted to be
in pain.
Review of an Orders Administration Note dated [DATE] at 8:08 A.M. revealed Resident #18 was
administered as needed Tramadol.
Review of an Orders Administration Note dated [DATE] at 8:24 P.M. revealed Resident #18 was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 39 of116
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
03/31/2025
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
administered as needed Tramadol for complaints of generalized hip and groin pain.
Level of Harm - Actual harm
Review of a nurse practitioner (NP) progress note dated [DATE] revealed on [DATE] Resident #18
complained of pain to left hip with range of motion during physical therapy. Resident #18 was status post fall
on [DATE]. An x-ray was ordered and completed on [DATE] with no acute abnormalities. No new orders
were obtained.
Residents Affected - Few
Review of a nurse's note dated [DATE] at 11:28 A.M. revealed nurse aide reported Resident #18 was
complaining of pain to pelvic area. The NP was contacted and stated Resident #18's x-ray was negative.
Review of a nurse's note dated [DATE] at 1:00 P.M. revealed nurse aide reported Resident #18 complained
of pain to pelvic area. Nurse notified Director of Nursing (DON), Assistant DON (ADON), NP and POA.
Review of a Pain Tool assessment dated [DATE] at 3:28 P.M. revealed Resident #18 had pain to the pelvic
area. Pain was improved by Tylenol and resting and worsened by standing. Pain affected social activities,
physical activities and mobility, and emotions.
Review of a nurse's note dated [DATE] at 12:56 A.M. revealed Resident #18 continued to complain of left
sided pelvic pain and as needed Tramadol was administered.
Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] at 5:15 P.M. revealed
Resident #18 declined to participate in transfer training due to complaints of left groin pain. Nursing aware.
Review of a physician's order dated [DATE] revealed order for Norco 5-325 mg twice daily for pain
management for 10 days.
Review of a NP progress note dated [DATE] revealed no evaluation of continued pain. The NP noted pain
regimen to be Acetaminophen 500 mg daily, Acetaminophen 650 mg every four hours as needed, Tramadol
50 mg every six hours as needed, and Norco 5-325 mg twice daily.
Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] at 5:55 P.M. revealed
Resident #18 complained of pain through groin during therapy and limited participation. Nursing notified of
pain present during session.
Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] timed 12:48 P.M.
revealed Resident #18 continued to have intermittent pain persisting to left thigh and groin.
Review of a nurse's note dated [DATE] at 5:04 P.M. revealed Resident #18 received morning scheduled
pain medication. During nap time Resident #18 complained of pain to nurse aide when being adjusted in
bed and Resident #18 was administered as needed Tylenol.
Review of an Orders Administration Note dated [DATE] at 8:10 A.M. revealed Resident #18 complained of
pain to leg and was administered Norco.
Review of a NP progress note dated [DATE] revealed no evaluation of the resident's continued pain.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 40 of116
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
03/31/2025
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
Review of a nurse's note dated [DATE] at 1:48 P.M. revealed nurse aide reported bilateral swelling to
Resident #18's lower extremities. The NP was notified, and the diuretic Lasix was ordered as needed.
Level of Harm - Actual harm
Residents Affected - Few
Review of a NP progress note dated [DATE] revealed Resident #18 had increased edema to bilateral lower
extremities. The NP ordered Furosemide (Lasix) 20 milligrams (mg) for three days and as needed. The NP
noted Resident #18's bilateral lower extremities were shiny and firm.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident
#18 had severely impaired cognition and was dependent on staff for activities of daily living (ADLs).
Review of an Orders Administration Note dated [DATE] at 7:12 P.M. revealed Resident #18 was
administered an as needed suppository for constipation.
Review of a Patient Report dated [DATE] revealed Resident #18 had an x-ray of the abdomen. The x-ray
showed a few mildly dilated gas-filled loops of bowel, multiple non-dilated gas filled loops of bowel, and
stool visualized in colon to level of hepatic flexure. Follow-up for resolution was recommended to rule out
ileus or obstruction. Results signed by interpreting physician on [DATE] at 12:09 P.M.
Review of a nurse's note dated [DATE] at 9:55 A.M. revealed Resident #18's abdominal x-ray results were
returned. An order was received to transfer the resident to the hospital for an evaluation. Ambulance
services arrived at 9:16 A.M.
Review of a Hospital Medicine History and Physical dated [DATE] revealed Resident #18 presented to
hospital for concern of bowel obstruction. Resident #18 had abdominal distension and stiffness. An
abdominal x-ray completed prior to admission showed concern for high stool burden/obstruction. Resident
#18 passed stool successfully while in hospital. While in the emergency department (ED) a cat (CT) scan
was completed, and Resident #18 was noted to have a fracture of the pelvis. CT results showed acute
fractures of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial
left acetabulum. Orthopedics were following; however, the fracture was nonsurgical. Resident #18's sister
was present at hospital and reported on [DATE] Resident #18 had a fall and had been complaining of pain
to left hip since. Physical examination showed edema to right lower extremity and trace edema to left hip.
Resident #18 had pain to the left hip inguinal fold area and when laying on side.
Review of the Hospital Discharge summary dated [DATE] revealed diagnoses including closed
nondisplaced fracture of pelvis, chronic constipation, and cellulitis of extremity.
Review of a nurse's note dated [DATE] at 3:29 P.M. revealed the hospital reported Resident #18 had pelvic
fracture with no surgical interventions. Resident #18 would return to facility weight bearing as tolerated.
Review of a nurse's note dated [DATE] at 6:30 P.M. revealed Resident #18 returned to the facility from the
hospital.
Review of a NP progress note dated [DATE] revealed Resident #18 re-admitted to facility from hospital with
diagnoses of left pelvic fracture. The NP noted prior to admission Resident #18 was totally
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 41 of116
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
03/31/2025
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
dependent on staff for ADL care needs.
Level of Harm - Actual harm
Review of the Medication Administration Record (MAR) for [DATE] revealed Resident #18 received as
needed Acetaminophen 650 mg on [DATE] at 11:12 A.M. Resident #18 received as needed Tramadol 50
mg on [DATE] at 10:56 A.M. and 8:26 P.M., [DATE] at 8:08 A.M. and 8:24 P.M., and [DATE] at 12:56 P.M.
Resident #18 received Norco 5-325 mg twice daily from [DATE] at 9:00 P.M. to [DATE] to 9:00 A.M.
Resident #18 received routine Acetaminophen 500 mg once a day.
Residents Affected - Few
Review of plan of care revised [DATE] revealed there was no care plan developed related to Resident #18's
pain status.
Interview on [DATE] at 8:00 A.M. with Resident #18's sister revealed she had made an allegation of neglect
in [DATE] and had provided videos as supporting evidence to facility staff. During the interview, the
resident's sister also shared Resident #18 had a fall at the beginning of [DATE]. An x-ray was completed
that did not show a fracture; however, Resident #18 was in pain following the incident and was unable to
advocate for herself. The resident's sister revealed around the middle of [DATE] Resident #18's stomach
was hard and full for a few days and she was having edema. The sister indicated while at the hospital
Resident #18 was found to have a hip fracture.
Review of a family provided two minute and one second video dated [DATE] at 9:08 A.M. revealed Resident
#18 was receiving incontinence care while in bed from Nurse Aide #329 and Nurse Aide #353. Resident
#18 could be heard groaning when turned by the staff. During turning at the one minute and 39 second
mark Resident #18 could be heard saying ouch and says ow again at the one minute and 57 second mark
while staff were attempting to re-dress the resident.
Review of a family provided one minute and 28 second video dated [DATE] at 11:20 A.M. revealed Resident
#18 was being prepared for transfer using sit to stand lift by Nurse Aide #329 and Nurse Aide #353. At the
34 second mark Nurse Aide #329 pulls Resident #18's legs to edge of bed and the resident could be heard
groaning (in pain) out loudly.
Review of an email provided by Resident #18's sister dated [DATE] timed 8:35 P.M. revealed Resident #18's
sister contacted the former Administrator, former DON, Social Services Designee (SSD) #355, and
Ombudsman with her concerns. In the email, Resident #18's sister noted the resident fell on [DATE] and
hurt her left hip and leg. The sister indicated an x-ray was taken about 6:00 P.M. on [DATE]; however, she
did not receive notification of results until [DATE] at 9:45 A.M. The sister indicated it was apparent Resident
#18 was in pain; however, she was not made aware of a treatment plan in place. The sister stated Resident
#18 was unable to request pain medications. The sister included a series of videos in the email from a
camera in Resident #18's room. The sister indicated on video Nurse Aide #329 was not gentle and did not
appear to be knowledgeable of Resident #18's potentially broken left hip. The sister shared additional
unrelated concerns related to the care of Resident #18 in the email.
Review of a facility Self-Reported Incident (SRI) dated [DATE] at 9:30 A.M. revealed Resident #18's sister
made an allegation Nurse Aide #329 was rough during incontinence care. The resident's recent fall with
pain was not included on the SRI investigation.
Interview on [DATE] at 11:54 A.M. with Physical Therapy Assistant (PTA) #372 confirmed Resident #18 had
been complaining of pain, during walking, after her fall on [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 42 of116
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
03/31/2025
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
During an interview on [DATE] at 2:04 P.M. with the Administrator and Chief Operating Officer (COO) #300,
Resident #18's fall was reviewed. COO #300 indicated she was unable to remember any details of Resident
#18's fall. COO #300 and the Administrator confirmed they were unable to provide any additional details
related to Resident #18's fall and subsequent fracture including interventions, investigation, interdisciplinary
review, or root cause analysis.
Interview and review of the incident with the DON on [DATE] at 3:18 P.M. verified there was no follow-up to
Resident #18's continued pain. The DON said she was not employed by the facility at the time of the
incident but questioned why there wasn't another X-ray completed, since the resident was still experiencing
pain. She also verified the facility was unable to locate or provide any additional information regarding the
resident's fall and delay in her treatment despite concerns shared from the resident's sister and no
improvement in the resident's condition.
Review of facility policy Change in Condition Monitoring dated [DATE] revealed the nurse would record in
the medical record information related to change in condition and notify attending physician and guardian.
Review of facility policy Falls and Incident Investigation dated [DATE] revealed resident falls would be
documented and investigated to determine root cause and have plan developed to prevent reoccurrence.
The nurse would assess the resident and provide as needed first aide, record vital signs, initiate head injury
precautions, notify supervisor, initiate incident reporting and document on incident in progress note, and
notify physician and family. The DON would reassess the resident for any additional monitoring or changes
to plan of care, ensure investigation occurs promptly, obtain statements from staff, and document and
ensure implementation of corrective interventions. The resident would be followed on the 24-hour report
and progress notes for 72 hours post-accident. The interdisciplinary team would review falls.
2. Review of the closed medical record for Resident #55 revealed an admission date of [DATE] and
discharge date of [DATE]. Resident #55 had diagnoses including chronic obstructive pulmonary disease,
peripheral vascular disease, chronic kidney disease, dementia, and nontraumatic intracerebral hemorrhage.
Review of the immunizations record revealed Resident #55 was not up to date with the COVID-19
vaccination with the last dose administered [DATE] and Resident #55 was not up to date with
pneumococcal vaccinations as pneumococcal Polysaccharide Vaccine (PPSV) 23 was administered before
the age of 65.
Review of the physician's order dated [DATE] revealed an order for a consult to oncology for a follow up to
lung mass and a repeat chest x-ray on [DATE].
Review of the nurse's note dated [DATE] revealed Resident #55 tested positive for COVID-19.
Review of the physician's orders dated [DATE] revealed orders for contact and droplet precautions for five
to 10 days if symptomatic, Dexamethasone six milligrams (mg) once daily, two to four liters of oxygen via
nasal cannula to keep oxygen saturation above 92 percent, and vitals monitoring every shift.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be
administered Dexamethasone. Reason noted Medication not received by pharmacy.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 43 of116
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
03/31/2025
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 the Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #55 had nasal
congestion. The NP ordered oxygen via nasal cannula to keep oxygen saturation above 92 percent,
Dexamethasone six mg daily for seven days, and monitor temperature, pulse oximetry (ox), and
respirations every shift for 10 days. The NP noted to continue Eliquis five mg twice per day, Acetaminophen
650 mg every six hours as needed, and Albuterol nebulizer every four hours as needed.
Review of a physician's order dated [DATE] revealed an order for Resident #55 for a complete blood count
with differential (CBC with diff) to be obtained on [DATE]. Further review of the medical record revealed no
evidence the laboratory services (labs) were obtained as ordered.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be
administered Dexamethasone. Reason noted on order.
Review of the physician's order dated [DATE] revealed Resident #55's chest x-ray was rescheduled to
[DATE] due to current COVID-19 positive status.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be
administered Omeprazole. Reason noted was none in med cart.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be
administered Omeprazole. Reason noted was not available.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 required two liters of
oxygen.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 had multiple episodes of
diarrhea and as needed Polyethylene Glycol medication was held.
Review of the NP progress note dated [DATE] revealed Resident #55 was having loose stools and nausea.
The NP ordered Zofran four mg every six hours as needed. Resident #55's second finger on the right hand
was noted to be discolored and cool to touch. The NP noted all fingers on the right hand were noted to be
discolored and the NP contributed this to peripheral vascular disease. The NP ordered an ultrasound of the
residents right upper extremity.
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was administered
Acetaminophen for discomfort, headache and low-grade temperature of 99.1 degrees Fahrenheit (F).
Review of the Orders Administration Note dated [DATE] revealed Resident #55 was administered
Acetaminophen for stomach pain and Zofran for nausea and vomiting.
Review of the NP progress note dated [DATE] revealed Resident #55 had complaints of nausea and loose
stools. Stools were noted to be loose and dark tarry colored. Resident #55 reported not feeling well and not
eating due to nausea and abdominal pain. Resident #55 told the nurse he was having difficulty breathing
and he felt like he was dying. Resident #55 had a harsh, moist cough. The NP ordered to send Resident
#55 to the emergency room for evaluation. The NP noted the ultrasound of the right upper extremity had not
yet been completed.
Review of the nurse's note dated [DATE] revealed Resident #55 was transported to hospital for complaints
of stomach pain for a few days and black stool. Resident #55 was noted to be on a blood
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 44 of116
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
03/31/2025
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
thinner.
Level of Harm - Actual harm
Review of the nurse's note dated [DATE] revealed Resident #55 was admitted to hospital for pneumonia.
Review of the Ohio Department of Medicaid Facility Communication dated [DATE] revealed Resident #55
had passed away at the hospital on [DATE]. As of [DATE] the resident's death certificate was not available.
Residents Affected - Few
Interview on [DATE] at 8:03 A.M. with the legal guardian of Resident #55 confirmed Resident #55 had
passed away at the hospital. The guardian indicated she had not received the resident's death certificate
yet. Additional attempts to contact the legal guardian during the survey were unsuccessful.
Interview on [DATE] at 11:27 A.M. with the Administrator, COO #300, and Registered Nurse/Infection
Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the facility but had been assisting
the facility with infection control in interim between IPs. Surveyor identified COVID-19 cases and Resident
#55's hospitalization were reviewed with Administrator, COO #300, and RN/IP #374. The Administrator,
COO #300, and RN/IP #374 were unaware of the number of COVID-19 cases that had occurred in [DATE]
and were unaware Resident #55 had been hospitalized for pneumonia and subsequently passed away at
hospital despite having symptoms of a change in condition since testing positive for COVID-19 on [DATE].
Interview on [DATE] at 2:13 P.M. with COO #300 revealed the facility was unable to locate evidence
Resident #55 received the chest x-ray or labs as ordered.
Staff present during this time period when Resident #55 experienced this change in condition were not
available for interview as they either no longer worked at the facility or were agency staff. Current staff
interviewed as part of the investigation including Registered Nurses (RNs) #341 and #348, Licensed
Practical Nurses (LPNs) #304, #327, #369, and Certified Nurse Aides #303, #305, #326, #337, #339, #352,
#353, and #357 revealed they had no knowledge of Resident #55 or the resident's change in condition that
occurred from [DATE] to [DATE].
Review of facility policy Change in Condition Monitoring dated [DATE] revealed the nurse would record in
the medical record information related to change in condition and notify attending physician and guardian.
Review of facility policy COVID-19 Precautions and Prevention dated [DATE] revealed the facility would
follow current guidelines and recommendations to ensure the facility was prepared to respond to
COVID-19. A reportable outbreak was noted to be when one case had suspected or confirmed COVID-19,
residents with severe respiratory infection resulting in hospitalization or death, or three or more cases of
new-onset respiratory symptoms within 72 hours.
Review of Centers for Disease Control (CDC) guidance on COVID-19 dated [DATE] revealed COVID-19
vaccination was recommended for prevention of severe health outcomes. Several antiviral medications
were recommended including Paxlovid, Remdesivir, and Lagevriol as treatment for COVID-19 to help
prevent severe illness and death.
3. Review of the medical record for Resident #31 revealed an admission date of [DATE] with diagnoses
including diabetes mellitus, bipolar disorder, hypothyroidism, muscle weakness, and unspecified intellectual
disabilities. Resident #31 was hospitalized from [DATE] to [DATE].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 45 of116
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
03/31/2025
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
Review of immunizations record revealed no evidence of Resident #31's COVID-19 or pneumococcal
vaccinations status.
Level of Harm - Actual harm
Residents Affected - Few
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident
#31 had severely impaired cognition and was independent for activities of daily living. The assessment
revealed Resident #31 was not up to date on COVID-19 vaccinations and had not received pneumococcal
vaccination.
Review of Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #31 complained of nasal
congestion and not feeling well. The NP ordered to obtain pulse oximetry (ox), respirations, and
temperature every shift for four days. There was no evidence of COVID-19 testing completed and/or any
other intervention to treat the resident's symptoms at that time.
Review of the NP progress note dated [DATE] revealed Resident #31 continued to have nasal congestion
and a cough. Resident #31 reported cough but was unable to clear anything. The NP ordered Mucinex 600
milligrams (mg) two times per day for seven days. There was no evidence of COVID-19 testing completed at
this time.
Review of an NP progress note dated [DATE] revealed Resident #31 complained of not feeling well and told
staff He feels like he is dying. Resident #31 observed with a dry cough and nasal congestion. Resident #31
reported an episode of vomiting. The NP ordered Vitamin C 250 milligrams daily and to continue Mucinex
as needed for cough. There was no evidence of COVID-19 testing completed at this time.
Review of a nurse's note dated [DATE] revealed Resident #31 was experiencing a harsh, productive cough.
Lung sounds were noted to be diminished. Resident #31 had four to five episodes of watery diarrhea and
reported not being able to make it to the bathroom. A COVID-19 test was completed and negative.
However, there was no evidence of any additional interventions being implemented at this time to treat the
resident's symptoms.
Review of a NP progress note dated [DATE] revealed Resident #31 had an episode of vomiting and was
ordered Zofran. Resident #31 continued to have dry cough. The NP ordered a chest x-ray and laboratory
services (labs).
Review of a Patient Report dated [DATE] revealed Resident #31 had chest x-ray with no acute findings.
Review of a NP progress note dated [DATE] revealed Resident #31 continued to have cough and
congestion. On [DATE] Resident #31 had a chest x-ray with no findings. On [DATE] Resident #31 had four
to five watery stools and was ordered Loperamide two mg every six hours as needed for diarrhea. Resident
#31 also complained of nausea and emesis. Labs were ordered on [DATE] and were not obtained. Resident
#31's pulse ox was 92 percent on room air and the resident's heart rate was 109 (tachycardic). There was
no evidence of COVID-19 testing completed. While the NP was visiting, she was alerted Resident #31 had
fallen in his room. Resident #31 was trying to walk to bathroom and became dizzy causing a fall. The NP
ordered Resident #31 to be sent to the emergency room for evaluation.
Review of nurse's note dated [DATE] revealed Resident #31 had been admitted to the hospital with acute
hypoxic respiratory failure, pneumonia, dehydration, acute kidney injury, and was positive for COVID-19.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 46 of116
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
03/31/2025
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 a hospital note revealed Resident #31 was admitted to the step-down unit on [DATE] for acute
hypoxic respiratory failure and acute kidney injury. Resident #31 was found to have COVID-19 and
pneumonia. Resident #31 had episodes of oxygen desaturation and required oxygen. Resident #31 was
treated with Remdesivir, steroids and antibiotics. Remdesivir had to be stopped due to Transaminitis.
Resident #31 continued to have intermittent coughing while hospitalized .
Review of a NP progress note dated [DATE] revealed Resident #31 had re-admitted to the facility from the
hospital on [DATE]. Resident #31 was diagnosed with COVID-19, pneumonia, bilateral pulmonary
embolism, left leg deep vein thrombosis, and acute kidney injury.
Interview on [DATE] at 4:50 P.M. with Chief Operating Officer (COO) #300 revealed the facility was unable
to locate any type of facility COVID-19 tracking log or additional information related to a COVID-19 outbreak
that occurred in the facility in [DATE].
Interview on [DATE] at 11:27 A.M. with Administrator, COO #300, and Registered Nurse/Infection
Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the facility but had been assisting
the facility with infection control in interim between IPs. Surveyor identified COVID-19 cases and Resident
#31's hospitalization were reviewed with Administrator, COO #300, and RN/IP #374. The Administrator,
COO #300, and RN/IP #374 were unaware of the number of COVID-19 cases that had occurred in [DATE]
and were unaware Resident #31 had been hospitalized for treatment of COVID-19 and pneumonia after the
resident had been symptomatic since [DATE].
Interview on [DATE] at 12:05 P.M. with Medical Director #366 revealed when a resident was having upper
respiratory infection symptoms his first step would be to test for COVID-19. Medical Director #366 indicated
if a resident was having cough and nasal congestion he would test for COVID-19.
Interview on [DATE] at 2:13 P.M. with COO #300 revealed the facility was unable to locate evidence
Resident #31 received labs as ordered. COO #300 confirmed Resident #31 had not been COVID-19 tested
prior to [DATE] despite persisting symptoms from [DATE].
Interview on [DATE] at 9:52 A.M. with Resident #31 revealed he was educated regarding the influenza and
pneumococcal vaccines by the facility and he did consent to and received the vaccines, but he could not
remember when he had them or when the education was. Resident #31 stated he knew he had to go to the
hospital because he was sick, but he could not remember when it was, and he also could not remember
any treatments or medications he was given prior to the hospitalization. He stated he had poor memory.
Staff present during this time period when Resident #31 experienced this change in condition were not
available for interview as they either no longer worked at the facility or were agency staff. Current staff
interviewed as part of the investigation including Registered Nurses (RNs) #341 and #348, Licensed
Practical Nurses (LPNs) #304, #327, #369, and Nurse Aides #303, #305, #326, #337, #339, #352, #353,
and #357 revealed they had no knowledge of Resident #31 or[TRUNCATED]
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 47 of116
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
03/31/2025
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 - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #11's medical record revealed an admission date of 01/25/17 with diagnoses including vitamin D
deficiency, depression, repeated falls, dysphagia, dementia with mood disturbance and urinary and fecal
incontinence.
Residents Affected - Few
Review of Resident #11's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #11 was
cognitively impaired and dependent on staff for eating, toileting, lower body dressing and required
substantial/maximal staff assistance to roll left and right. Resident #11 was noted to have a Stage III
pressure ulcer, not present on admission.
Review of Resident #11's physician's orders revealed an order dated 08/01/24 to admit to hospice for
end-stage cerebral infarction; an order dated 11/23/24 for ProSource oral liquid (nutritional supplement) 30
milliliters (ml) by mouth twice daily; an order dated 11/24/24 for pressure reduction boots as tolerated, when
in bed; an order dated 11/24/24 for air mattress; an order dated 11/26/24 for hospice to change wound
dressings on Tuesday and Thursday only every night shift for wound; an order dated 11/26/24 for monitor
erythema to right foot, notify physician and hospice for signs/symptoms of infection, edema or drainage and
discontinue when resolved. No as-needed (PRN) wound care orders were available on Resident #11's
physician's orders list.
Review of an interdisciplinary team post-wound investigation summary for Resident #11 dated 11/23/24 at
10:33 (morning or evening not specified) and authored by Registered Nurse (RN) #313, who was the
facility's previous DON, revealed aide (not named) informed nurse (not named) of suspected new area to
the right foot. When assessed, new open areas were identified to the right shin, right lateral foot, and right
pinky toe. The right foot peri-wound skin was reddened and edematous. No drainage or foul odors were
noted upon assessment. Contributing factors included hospice client, limited physical activity, risk for
impaired skin integrity and non-compliance with hygiene and refusals of care. Wound management
completed by wound nurse practitioner, orders obtained and in place for daily treatment of wounds.
Review of a weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident
#11 had a facility-acquired venous ulcer to his right lateral foot measuring 3.0 centimeters (cm) length by
2.5 cm width by 0.0 cm depth with a scab noted. The assessment indicated it was the first observation of
the wound, and no odor or drainage was present. Prophylactic antibiotics (Augmentin) initiated for
suspected cellulitis. Cleanse the area with normal saline, pat dry. Apply calcium alginate to the wound bed.
Cover with an abdominal (ABD) pad and Kerlix gauze daily and as needed.
Review of the next available weekly wound healing record-wound care nurse assessment dated [DATE]
revealed Resident #11 had a facility-acquired pressure ulcer to right lateral foot as of 12/18/24 that was
originally a Stage III pressure ulcer and remained at that stage. The wound was unchanged, had a dry scab
area and had no drainage or odor. The area measured 0 cm by 0 cm by 0 cm. Comments at the bottom
indicated the wound nurse did not measure the area, leave area open to air. Treatment changed this date to
Skin Prep (forms a film to protect the skin by reducing friction) to the scabbed area once daily.
Review of the weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident
#11 had an improving Stage III pressure area to right lateral foot. No wound measurements were included
on this assessment.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 48 of116
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
03/31/2025
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 - Actual harm
Review of the weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident
#11 had an improving Stage III pressure area to the right lateral foot. No drainage or odor was noted. The
wound measured 3.2 cm by 1.0 cm by 0.0 cm. The current treatment plan was listed as Skin Prep with ABD
and Kerlix gauze change daily and PRN.
Residents Affected - Few
Review of Resident #11's nurses' notes from November 2024 through March 2025 revealed no wound
measurements.
Review of Resident #11's plan of care for skin/pressure areas dated 02/03/17 listed an intervention dated
11/03/19 for monitor/document/report to physician PRN changes in skin status: appearance, color, wound
healing, signs/symptoms of infection, wound size (length by width by depth) and stage.
Interview on 03/11/25 at 11:48 A.M. with the DON revealed the wound nurse practitioner saw Resident #11
weekly and shared Certified Nurse practitioner (CNP) #364 told her she does not measure wounds in the
facility. The DON verified she had no further wound tracking for Resident #11 as the wound started in
November 2024, which was before she started her employment with the facility three weeks ago. The DON
confirmed she began tracking all in-house wounds two weeks ago and indicated Resident #11's Stage III
pressure ulcer on his foot was a scab and was improving. The DON verified Resident #11 did not have a
PRN order for wound care in case the dressing needed to be changed in between the scheduled times and
verified he should have had such an order. The DON also verified hospice completed Resident #11's wound
dressing Tuesdays and Thursdays on night shift as ordered by the physician.
Interview on 03/12/25 at 2:33 P.M. with CNP #364 revealed she came to the facility weekly and sometimes
every other week. CNP #364 verified she did not put wound measurements in her assessments as it was
the responsibility of the facility to measure the wounds. CNP #364 indicated Resident #11's Stage III
pressure wound to the foot had been improving and was now a scab.
Review of the facility policy, Wound Care, dated 05/01/22, revealed all residents' skin conditions would be
properly tracked and cared for. The nursing staff and attending physician will assess and document and
individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss
and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following:
a) full assessment of pressure sore including location, stage, length, width and depth, presence of exudates
or necrotic tissue; pain assessment; resident's mobility status; current treatments including support surfaces
and all active diagnoses. The staff will examine the skin of a new admission for ulcerations or alterations in
skin. The physician will authorize pertinent orders related to wound treatments, including would cleansing
and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agent if
indicated for type of skin alteration .during resident visits, the physician will evaluate and document the
progress of wound healing-especially for those with complicated, extensive or non-healing wounds. The
physician will help the staff review and modify the care plan as appropriate.
Based on observation, record review, facility policy review, and interview, the facility failed to implement an
adequate and effective pressure ulcer prevention program to promote healing and to ensure Resident #49,
who was cognitively impaired, dependent on staff for activity of daily living care and incontinent of bowel
and bladder, received timely and necessary pressure ulcer prevent and treatment. Additionally, the facility
failed to ensure accurate and comprehensive weekly skin assessments for Resident #11's in-house
acquired pressure ulcer. This affected two residents (#49 and #11) of two residents reviewed for pressure
ulcers. The facility census was 54.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 49 of116
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
03/31/2025
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 - Actual harm
Residents Affected - Few
Actual Harm occurred beginning on 01/31/25 when nursing staff failed to comprehensively assess,
implement effective interventions and provide timely and necessary treatment to prevent an open area to
Resident #49's coccyx/buttocks area from deteriorating to a Stage III (full-thickness loss of skin, in which
subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are
often present) pressure ulcer.
Findings include:
Review of the medical record for Resident #49 revealed an admission date of 01/31/25 with diagnoses
including heart failure, chronic respiratory failure, kidney failure, obesity and cirrhosis of the liver.
Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was
cognitively impaired, had no behaviors, was always incontinent of bowel and bladder and was dependent
on staff for toileting hygiene, rolling and transfers. There were no pressure ulcers/sores documented,
however, the assessment noted the resident was at risk for developing one.
Review of the Nursing admission Assessment with Care Plan dated 01/31/25 revealed Resident #49 was
alert, was always incontinent of bowel and bladder, had skin tears to the right and left knees and was a
smoker. There was no initial care plan for skin integrity or skin impairment for the resident.
Review of a nursing progress note for Resident #49 revealed on 01/31/25 at 3:00 P.M. the resident arrived
at the facility with skin tears to his knees, maceration to his abdominal folds and an open area to the
coccyx. The progress note did not include any additional information related to the area on the coccyx,
including staging or a description of the ulcer. In addition, there was no evidence pressure ulcer prevention
measures/interventions were implemented at this time.
Review of the head-to-toe assessments for Resident #49 revealed on 01/31/25 there were skin tears noted
to his right and left knees.
On 02/01/25, Nurse Practitioner (NP) #363 assessed Resident #49 and documented the resident had skin
issues on admission with treatments in place. There was no documentation of the actual pressure ulcers by
NP #363 in the resident's nursing progress notes.
Review of the admission MDS 3.0 assessment dated [DATE] revealed the resident had no skin conditions,
no pressure ulcers, no turning and repositioning program and no pressure reducing devices for the chair or
bed.
The head-to-toe assessment dated [DATE] included there was a pressure ulcer to the coccyx. However,
there was no description or stage of the ulcer.
Review of the physician's orders for Resident #49 revealed pressure relieving interventions and wound
treatments were not initiated until 02/10/25. In addition, an order dated 02/10/25 revealed head-to-toe skin
check to be completed every night shift on Monday, Wednesday and Thursday was ordered.
The head-to-toe assessment on 02/13/25 included there was left elbow bruising and a pressure ulcer to the
coccyx. Again, there was no description or staging of the coccyx ulcer.
On 02/18/25 a note at the bottom of the head-to-toe assessment revealed previously documented
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 50 of116
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
03/31/2025
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
pressure sore to left buttock with treatment recommendations in place, no new areas noted.
Level of Harm - Actual harm
On 02/21/25 a note at the bottom of the head-to-toe assessment revealed impaired skin on left buttocks,
previously mentioned. There was a note that included resident was non-compliant with turning and
repositioning. However, no additional care plan or documentation to support the non-compliance as it
pertained to the impaired skin integrity.
Residents Affected - Few
On 02/26/25 at 7:05 P.M., nursing staff documented they did not have time to do a skin assessment during
the shift.
Review of a Weekly Wound Healing Record for Resident #49 dated 02/26/25 revealed the resident had a
Stage III pressure ulcer to the right medial buttock that was acquired on 01/31/25 when the resident was
admitted to the facility. The pressure ulcer measured 2.0 centimeters in length by 2.0 centimeters width with
0.2 centimeters depth with granulation tissue and a small amount of bloody drainage. There was odor
present to the wound. Treatment was initiated with Triad Paste and the wound progress was noted to be
unchanged.
On 02/26/25 a treatment order was obtained for Triad Hydrophilic Wound Dress External Paste, apply to
buttock topically two times a day for wound.
Review of a Weekly Wound Healing Record for Resident #49 dated 03/05/25 revealed the Stage III
pressure ulcer to the right medial buttock was improving. The ulcer measured 2.0 centimeters by 2.0
centimeters by 0.1 centimeters. There was no change in treatment.
On 03/07/25 pressure relieving interventions were ordered to float the heels, have a pressure reducing
mattress, utilize a pressure relieving cushion to wheelchair and turning and repositioning every two hours
every shift. The medication administration record and treatment administration record corresponded to
these orders for Resident #49.
Review of the care plan for Resident #49 dated 03/07/25 revealed the resident had potential/actual
impairment to skin integrity of the right medial buttock related to fragile skin. Interventions included to
encourage good nutrition and hydration, observe and document the location of skin impairment, and weekly
treatment documentation to include measuring of each area of the skin breakdown's width, length, depth,
type of tissue exudate and any other notable changes or observations.
Interview on 03/12/25 at 2:33 P.M. with NP #364 (the wound nurse) revealed she was at the facility weekly
or biweekly. She stated she did not measure Resident #49's wounds and stated it was the responsibility of
the facility staff to keep the measurements and document on pressure ulcers. NP #364 revealed Resident
#49 had a Stage III pressure ulcer to his right medial buttock.
Interview on 03/12/25 at 3:40 P.M. with the Director of Nursing (DON) verified Resident #49 had no
pressure ulcers documented on his 01/31/25 head-to-toe assessment. She verified the only documentation
that revealed an open area to his coccyx was on a nursing progress note on 01/31/25. The DON revealed
on Resident #49's head-to-toe assessment on 02/10/25 the Stage III pressure ulcer to his coccyx was
documented the first time without measurements. She stated she started at the facility on 02/17/25 and
initially saw Resident #49's pressure ulcer on 02/26/25. She stated the coccyx Stage III pressure ulcer was
more to the right medial buttock with measurements of 2.0 centimeters by 2.0 centimeters by 0.2
centimeters. The DON stated she was the first person to document Resident #49's Stage III pressure as the
facility had not been measuring/assessing it prior.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 51 of116
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
03/31/2025
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
Interview on 03/17/25 at 2:29 P.M. with NP #363 revealed she was not aware the facility was not measuring
any resident wounds.
Level of Harm - Actual harm
Residents Affected - Few
Interview on 03/18/25 at 10:09 A.M. with the DON verified Resident #49 did not have a wound care plan
until 03/07/25 for potential interventions to his coccyx/right buttock pressure ulcer. She also verified
Resident #49 did not have any wound documentation by NP #364 from 01/31/25 through 02/26/25.
Observation on 03/12/25 at 2:33 P.M. of wound care to Resident #49 with NP #364 and the DON revealed
the resident had a Stage III pressure ulcer measuring 1.6 centimeters by 1.0 centimeters by 0.1
centimeters. NP #364 stated the pressure ulcer was more to the right buttock than the coccyx.
Review of the facility policy titled, Wound Care, dated 05/01/22 revealed it was the policy of the facility to
ensure that all residents skin conditions were properly tracked and cared for. The nursing staff would
assess and document the resident's significant risk factors for developing pressure ulcers as well as the
nurse would document a full assessment including location, stage, length, width, depth and presence of
exudates or necrotic tissue. During resident visits, the physician would evaluate and document the progress
of wound healing. The physician would help the staff review and modify the care plan as appropriate,
especially when wounds were not healing as anticipated or new wounds developed despite existing
interventions. During monitoring, the physician would also evaluate and document the progress of the
wound.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 52 of116
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
03/31/2025
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, facility policy review and interview, the facility failed to develop and
implement a comprehensive and individualized fall prevention program for Resident #18 and Resident #204
to prevent falls. The facility also failed to ensure cigarette butts were properly disposed of after smoking.
This affected two residents (#18 and #204) of three residents reviewed for falls/accidents and 19 residents
(Residents #1, #2, #3, #9, #11, #12, #14, #16, #23, #25, #27, #29, #38, #39, #42, #43, #44, #48 and #203)
identified by the facility as residents who smoke. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 with diagnoses
including Parkinson's disease, age-related osteoporosis, dementia, generalized muscle weakness, and
dependence on wheelchair.
Review of the st risk for falls related to deconditioning, balance problems, incontinence, intermittent
aggressive behaviors, impaired safety awareness and impulse control initiated on 06/11/18 and revised on
05/13/24 revealed interventions including anticipate and meet resident's needs as able, call light reminder
sign in room, custom wheelchair to allow the resident to sit upright/safely related to balance deficits; give
the resident a reacher to pick up items off the floor when she drops them; locked bedside table that will
remain in the side of the resident's recliner; provide a safe environment with even floors free from spills
and/or clutter, adequate, glare free light, a working and reachable call light and personal items within reach.
Review of the medical record revealed Resident #18 was last assessed for fall risk on 03/15/23 and was
identified as at risk.
Review of a physician's orders dated 02/29/24 revealed an order for a hand reacher tool at bedside for a fall
intervention.
Review of a physician's order dated 12/20/24 revealed an order for Dycem (non-slip self-adhesive strips) to
the recliner chair. Resident #18 also had an order, dated 12/20/24 for non-skid fall strips to the floor in front
of the recliner chair for safety intervention.
Review of an Orders Administration Note dated 01/03/25 timed 2:09 A.M. revealed Resident #18 was
having anxiety/agitation and was administered as needed Lorazepam.
Review of an Orders Administration Note dated 01/03/25 timed 6:10 A.M. revealed Resident #18 was
having anxiety and was administered as needed Lorazepam. However, record review revealed no evidence
the resident's safety needs and/or fall risk were evaluated related to the two doses of anti-anxiety
medication administered approximately four hours apart on 01/03/25.
Review of a nurse's note dated 01/03/25 at 7:35 A.M. revealed Resident #18 was found on the floor by a
nurse aide, lying flat on her back. Nurse and aide picked Resident #18 up off the floor and into her
wheelchair. Resident #18 was taken to the dining room for breakfast. Resident #18 stated she got up from
her recliner chair to pick something up off the floor and fell backwards. It was noted Resident #18 claimed
she didn't hit her head and had no complaints of pain at this time.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 53 of116
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
03/31/2025
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Review of an incident report dated 01/03/25 at 7:35 A.M. revealed Resident #18 was reaching for
something on the floor and fell backwards (unwitnessed). Resident #18 was educated on the importance of
call before you fall. Resident #18 was noted to be wheelchair bound. Factors contributing to the fall were
ambulating without assistance and gait imbalance. Resident #18's physician and power of Attorney (POA)
were notified. There was no mention of the use or availability of the ordered reacher.
Residents Affected - Some
Review of a nurse practitioner (NP) progress note dated 01/03/25 revealed Resident #18 had a fall and was
found laying on her back in room. Resident #18 was noted to be a poor historian due to cognitive and
psychiatric impairments. Resident #18 told staff she stood from the recliner chair to pick something up and
fell backwards. Resident #18 denied hitting her head and denied pain. Resident #18 was noted to be
dependent on a wheelchair and staff to help push the wheelchair. Interventions for falls included hand
reacher tool at bedside, specialized wheelchair, Dycem to recliner chair, and non-skid strips to the floor in
front of the recliner.
Review of a Medicare Skilled Charting assessment dated [DATE] at 6:55 P.M. revealed Resident #18 was
alert and oriented to person and situation. Resident #18 had unsteady gait, impaired balance, weakness,
and decreased sensation. Resident #18 required assistance for bed mobility and transfers.
Review of a fall follow-up assessment dated [DATE] at 2:09 A.M. revealed Resident #18 had a fall on
01/03/25. An intervention was noted to keep Resident #18 in the dining room during the day.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident
#18 had severely impaired cognition and was dependent on staff for activities of daily living (ADLs).
Review of the plan of care revised 02/14/25 revealed Resident #18 was at risk for falls. Interventions
included keep adaptive reacher at bed side, anticipate and meet needs as able, call light reminder sign in
room, custom wheelchair, Dycem to recliner and in front of recliner, encourage non-skid footwear,
encourage resident to ask for assistance with toileting and ambulation, keep call light accessible, monitor
for adverse effects of medications, and provide safe environment. Resident #18 had activities of daily living
(ADL) self-care performance deficit related to severe cognitive impairment. Interventions included extensive
assistance of two staff for transfers with mechanical stand up lift as Resident #18 does not stand without
lift. Resident #18 does not walk, and uses tilt and space wheelchair.
Further review of Resident #18's medical record revealed no evidence of routine and appropriate fall follow
up or monitoring, no evidence of implemented interventions, and no evidence of review by an
interdisciplinary team.
During an interview on 03/18/25 at 2:04 P.M. Resident #18's fall was reviewed with the Administrator and
Chief Operating Officer (COO) #300. COO #300 indicated she was unable to remember any details of
Resident #18's fall. COO #300 and the Administrator confirmed they were unable to provide any additional
details related to Resident #18's fall including interventions, investigation, interdisciplinary review, or root
cause analysis.
Review of facility policy Falls and Incident Investigation dated 07/22/22 revealed resident falls would be
documented and investigated to determine root cause and have plan developed to prevent reoccurrence.
The nurse would assess the resident and provide as needed first aide, record vital signs, initiate head injury
precautions, notify supervisor, initiate incident reporting and document on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 54 of116
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
03/31/2025
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 0689
Level of Harm - Minimal harm
or potential for actual harm
incident in progress note, and notify physician and family. The DON would reassess the resident for any
additional monitoring or changes to plan of care, ensure investigation occurs promptly, obtain statements
from staff, and document and ensure implementation of corrective interventions. The resident would be
followed on the 24-hour report and progress notes for 72 hours post-accident. The interdisciplinary team
would review falls.
Residents Affected - Some
2. Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses
including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's Disease and dementia.
Review of the fall risk assessment dated [DATE] revealed Resident #204 was at high risk for falls.
Review of the nursing admission assessment dated [DATE] for Resident #204 revealed he had a history of
falls. His fall care plan stated he was at risk for falls and had a history of falls. Interventions included to
ensure the call light was in reach and bed was in lowest position.
Review of the nursing progress notes for Resident #204 dated from 03/03/25 through 03/11/25 revealed
nursing staff had not documented him having any falls while at the facility.
Observation on 03/10/25 at 2:26 P.M. of Resident #204 revealed he was on the mat on the floor beside his
bed. He was repeatedly yelling for someone to help him. He was noted earlier in the shift on the mat on the
floor as well. At 2:39 P.M., Licensed Practical Nurse (LPN) #362 verified Resident #204 was on the floor.
With the assistance of two nurse aides, LPN #362 assisted Resident #204 back in bed. She did not perform
an assessment on the resident prior to placing him back in bed.
Observation on 03/11/25 at 7:12 A.M. revealed Resident #204 in bed, however, the mat was not beside the
bed on the floor. At 7:52 A.M., Resident #204 was yelling out for staff and leaning towards the side of the
bed towards the floor. There was no mat on the floor next to the bed. At 7:59 A.M., LPN #304 verified
Resident #204 did not have a mat next to his bed as care planned for his behaviors. She stated when
Resident #204 would place himself on the mat on the floor, the nursing staff would not count it as a fall. She
stated they were not performing assessments on him or implementing new interventions to assist in
preventing future falls as they believed it was a behavior.
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified there were no fall
investigations for Resident #204's falls out of bed. She also verified there were no interventions put into
place to assist in preventing future falls of Resident #204.
Review of the facility policy titled, Falls and Incident Investigation, dated 07/22/22, revealed all resident
occurrences, whether falls or incidents, would be documented and investigated to ascertain root cause and
have a plan developed to prevent reoccurrence. A fall was defined as any unexpected event that happens to
a resident which results in any unintentional change in elevation. Following a fall, the nurse was to check
the resident and provide first aid if needed, record vital signs, update the nursing supervisor, initiate an
accident incident report, document the findings in a progress note and notify the physician and family.
3. Review of the facility document titled, Smoking List, undated, revealed 19 Residents #1, #2, #3, #9, #11,
#12, #14, #16, #23, #25, #27, #29, #38, #39, #42, #43, #44, #48 and #203 who resided in the facility and
smoked.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 55 of116
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
03/31/2025
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Observation on 03/10/25 at 11:05 A.M. of smoking in the courtyard revealed nine (Resident #2, #3, #11,
#16, #23, #27, #43, #48 and #203) residents who smoked were in the designated smoking area. Activities
Director #330 was present and provided the smoking materials to the residents. The observation revealed
cigarette butts were in the mulch and rocks next to the building, in plastic flower pots, wooden flower beds,
on the sidewalks and in the grass areas. Resident #27 was observed to take her cigarette and put it out in
the wooden flower bed that she was sitting next to.
Interview on 03/10/25 at 11:05 A.M. with Activities Director #330 verified the cigarette butts on the ground,
in the mulch, in the flower pots and in the wooden flower planters. She stated residents would throw their
cigarettes on the ground and in the pots. She stated she attempted to clean the area everyday but residents
would still continue to dispose of their cigarette butts improperly.
Review of the facility policy titled, Smoking, dated 05/01/22, revealed the facility would establish and
maintain safe smoking practices, allowing resident's who wished to smoke while also doing it in a safe
manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 56 of116
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
03/31/2025
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on record review, observation and interview, the facility failed to ensure an anchoring device for
Resident #204's indwelling urinary catheter was implemented to prevent catheter-related complications.
This affected one resident (Resident #204) of one resident reviewed for indwelling urinary catheters. The
facility census was 54.
Findings include:
Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses
including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's Disease and dementia.
Review of Resident #204's physician's orders for March 2025 revealed there were no orders for an
anchoring device for his urinary catheter.
Review of Resident #204's baseline care plan dated 03/03/25 revealed he had a catheter care plan.
Interventions included providing a leg strap for the catheter (for anchoring of the catheter).
Observation on 03/10/25 at 2:26 P.M. revealed Resident #204 was on a mat on the floor beside his bed. His
urinary catheter tubing was stretched tight and the drainage bag was under the mat. At 2:39 P.M. Resident
#204 was still on the mat on the floor and his catheter drainage bag showed reddish-yellow urine in the
drainage bag. Licensed Practical Nurse (LPN) #362 came to Resident #204's room and verified there was
no anchoring device to assist in securing the urinary catheter tubing to prevent pain, potential injury or
other catheter-related complications from the amount of tension on the catheter tubing due to a lack of an
anchoring leg strap.
Interview on 03/12/25 at 10:15 A.M. with the Director of Nursing (DON) revealed and verified the facility did
not have a urinary catheter policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 57 of116
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
03/31/2025
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, review of the facility contract, review of the facility policy and interview, the facility failed to
complete pre and post dialysis assessments as required and to collaborate care with the outside dialysis
center. Also, the facility failed to ensure there was a valid contract between the facility and the outside
dialysis center to ensure coordination of all care and services pertaining to dialysis treatment for Resident
#25. This affected one resident (#25) of one resident reviewed for dialysis. The facility identified no other
residents as receiving dialysis. The facility census was 54.
Residents Affected - Few
Findings include:
1. Review of Resident #25's medical record revealed an admission date of 09/16/24 and diagnoses
including traumatic brain injury, insomnia, protein-calorie malnutrition, vascular dementia with other
behavioral disturbance, anxiety, depression and dependence on renal dialysis.
Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 was
cognitively impaired, independent with eating and required substantial/maximal assistance with toileting.
The assessment indicated Resident #25 currently received hemodialysis.
Review of Resident #25's plan of care dated 09/21/24 revealed Resident #25 needed hemodialysis due to
renal failure and chronic kidney disease. Resident #25 went to dialysis Mondays, Wednesdays and Fridays
and had listed interventions including auscultate/palpate my shunt for a thrill and bruit each shift, monitor
my vital signs as ordered and notify my doctor of any significant abnormalities and observe and report if I
have any signs/ symptoms of renal insufficiency, such as changes in my level of consciousness, changes in
my skin turgor, mouth or changes in my heart and lung sounds.
Review of Resident #25's physician's orders revealed no order specifically relating to Resident #25
receiving dialysis. In his electronic medical record (EMR) a special instruction across the top of the page
read: Dialysis every Monday, Wednesday and Friday at 10:00 A.M. at Davita. A phone number was listed for
Provide-A-Ride with pick up time listed as 8:45 A.M. There was an order dated 09/17/24 for checking
dialysis catheter location: right chest port; an order dated 09/17/24 for post-dialysis dry weight every day
shift every Monday, Wednesday and Friday for dialysis; an order dated 11/17/24 for vital signs before
dialysis; and an order dated 11/17/24 for vital signs and blood glucose after dialysis.
Further review of the medical record for Resident #25 revealed no evidence the facility had pre and post
dialysis assessment tools being completed to contain pertinent assessment information for the resident on
the tool for communication of assessment findings with the dialysis center.
Interview on 03/12/25 at 2:26 P.M. with Licensed Practical Nurse (LPN) #362 revealed Resident #25 was
supposed to return to the facility with a paper from the dialysis center but never did. LPN #362 indicated the
facility did not have a dialysis binder with the dialysis communication sheets documenting pre and post
dialysis assessments.
Interview on 03/12/25 at 4:30 P.M. with LPN #304 revealed Resident #25 did not come back to the facility
from dialysis with any forms or assessments. While the facility did vitals and weights before and after
dialysis, the facility did not have a dialysis form or binder with communication sheets.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 58 of116
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
03/31/2025
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 0698
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 03/13/25 at 8:20 A.M. with LPN #325 revealed there was a dialysis form that was supposed to
go with Resident #25 but the facility did not get the forms back. LPN #325 confirmed she never called the
dialysis center to try to obtain the completed forms.
Interview on 03/13/25 at 8:32 A.M. with the Director of Nursing (DON) verified the facility did not have any
dialysis communication forms for Resident #25 and confirmed there was not an assessment piece in use at
this time for dialysis residents. The DON stated there should be some kind of assessment the nurse did
prior to the resident leaving to include skin, weights and vitals, the assessment would go with the resident
and then the information would come back from the dialysis center to the facility with the resident.
Review of the facility policy, Dialysis, reviewed 05/01/22 revealed risk factors related to potential for
bleeding, alteration in fluid volume, potential for infection, alteration in fluid volume, potential for infection,
psychosocial needs and risk for adverse medication effects should be identified, assessed and
interventions to manage addressed in the individualized care plan. An individual care plan should be
developed and followed in coordination with comprehensive assessment. A nutrition and hydration
assessment should be completed and incorporated into the care plan. Arrangements should be made prior
to admission for acquisition and storage of supplies, location and type of dialysis and accommodation. The
policy did not identify how the facility would communicate pre and post dialysis assessment information with
the dialysis center.
2. Review of the facility's dialysis transfer agreement between the facility and [NAME] Dialysis, Limited
Liability Corporation (LLC) (affiliate of DaVita Incorporated) revealed it was signed by the Administrator and
by the Regional Operations Director of [NAME] Dialysis, but no dates were noted on the contract or by
either signature.
In an interview on 03/12/25 at 3:57 P.M. the Administrator was asked regarding the date of the facility's
dialysis contract. The Administrator verified the contract was effective on this date, 03/12/25, and she did
not put a date as the dialysis center representative did not put a date. The Administrator confirmed a
previous contract with the dialysis center from prior to 03/12/25 was unavailable for review.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 59 of116
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
03/31/2025
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 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the personnel files, review of the facility assessment and interview, the facility failed to ensure
Certified Nursing Assistants (CNAs) #305 and #329 received annual performance reviews. This affected
two of two CNA's personnel files reviewed and had the potential to affect all 54 residents residing in the
facility.
Residents Affected - Many
Findings include:
1. Review of the personnel file for CNA #305 revealed there were no annual performance evaluations in her
file or 12 hours of in-services as required.
Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNA #305 did not
have an annual performance evaluation in her personnel file. She stated the facility was unable to provide
evidence of CNA #305 receiving 12 hours of in-services as required annually.
Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as
determined in nurse aide performance reviews during training and in-services. The facility assessment also
stated training topics for staff would include communication, resident rights, abuse, infection control, culture
change and dementia management.
2. Review of the personnel file for CNA #329 revealed there were no annual performance evaluations in her
file or 12 hours of in-services as required.
Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNA #305 did not
have an annual performance evaluation in her personnel file. She stated the facility was unable to provide
evidence of CNA #329 receiving 12 hours of in-services as required annually.
Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as
determined in nurse aide performance reviews during training and in-services. The facility assessment also
stated training topics for staff would include communication, resident rights, abuse, infection control, culture
change and dementia management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 60 of116
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
03/31/2025
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 0740
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident must receive and the facility must provide necessary behavioral health care and
services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observations and interviews, the facility failed to ensure staff were providing necessary
behavioral health care for residents to attain and maintain their highest physical, mental and psychosocial
well-being. This affected one (Resident #204) of six residents reviewed for behaviors. The facility census
was 54.
Findings include:
Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses
including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's Disease and dementia.
Review of the nursing admission assessment dated [DATE] for Resident #204 revealed he was alert to
person only and had agitation.
Review of the care plan dated 03/03/25 for Resident #204 revealed he was dependent on staff for meeting
his emotional, intellectual, physical and social needs. Interventions included for staff to invite him to
scheduled activities, encourage him to participate and introduce him to others with similar background and
interests. He also had a care plan dated 03/03/25 due to behavioral problems related to at times rolling
himself off of the bed and onto a mattress on the floor and yelling out. Interventions included for staff to
anticipate and meet his needs, assist him with more appropriate methods of coping and interacting,
observe his behaviors, attempt to determine the underlying causes and provide a program of activities that
met his interest.
Observation on 03/10/25 at 2:26 P.M. of Resident #204 revealed he was on the mat on the floor beside his
bed. He was repeatedly yelling for someone to help him. He was noted earlier in the shift on the mat on the
floor as well. At 2:27 P.M. Licensed Practical Nurse (LPN) #362 spoke to the resident who stated he wanted
vegetable soup. LPN #362 told him they did not have vegetable soup. He then stated he would take any
soup. LPN #362 stated to Resident #204 he would have to wait until dinner. At 2:39 P.M. LPN #362 verified
Resident #204 was still on the floor and with the assistance of two nurse aides, the assisted Resident #204
back into bed. They did not offer Resident #204 any diversional activities or address his behaviors.
Observation on 03/11/25 at 7:52 A.M. of Resident #204 revealed he was yelling out for staff and leaning
towards the side of the bed towards the floor. There was no mat on the floor next to the bed. At 7:59 A.M.,
LPN #304 verified Resident #204 did not have a mat next to his bed as care planned for his behaviors. She
stated when Resident #204 would place himself on the mat on the floor, the nursing staff would not count it
as a fall. She stated they were not performing assessments on him or implementing new interventions to
assist in preventing future falls as they believed it was a behavior.
Observation on 03/11/25 at 12:15 P.M. revealed Resident #204 was still in bed and yelling out. Staff were
not providing him with activities or diversions.
Interview on 03/12/25 at 10:40 A.M. with Certified Nursing Assistant (CNA) #305 verified staff were not
getting Resident #204 out of bed. She stated due to safety concerns with kicking his legs out of the
wheelchair, the staff were leaving him in bed. She was unable to state what activities or
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 61 of116
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
03/31/2025
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 0740
interventions they were providing to him for behaviors.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified staff should have been
providing diversional activities for Resident #204 instead of leaving him in bed.
Residents Affected - Few
Interview on 03/19/25 at 2:21 P.M. with the Administrator revealed staff were in-serviced on 02/20/25
related to behaviors from the facility's in-house drug/alcohol program. She was able to provide the topics of
the in-service which were care of residents with drug and alcohol withdrawal as well as behaviors of verbal
aggression, demanding behaviors, drug seeking, seeking a replacement for the drug and isolation. She was
unable to provide other education in the previous 12 months for behaviors.
The facility was unable to provide a behavioral healthcare policy and procedure.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 62 of116
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
03/31/2025
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 interview, the facility failed to ensure medications were obtained timely from
the pharmacy and administered as ordered. This affected one (Resident #23) of 28 residents reviewed for
medication administration. The facility census was 54.
Findings include:
Review of the medical record for Resident #23 revealed an admission date of 06/27/24 with diagnoses
including asthma, anxiety and chronic pain.
Review of the physician's orders for Resident #23 revealed she had an order for Fluticasone Propionate
Nasal 50 micrograms (mcg) one time a day for allergy symptoms dated 09/18/24, Hydroxyzine HCl 10
milligrams (mg) three times a day for anxiety dated 12/31/24, Cran-B-OTC Oral Liquid 30 milliliters (mL)
one time a day for supplement dated 01/21/25 and Tizanidine 2 milligrams (mg) three times a day for pain
dated 02/20/25.
Review of the Medication Administration Record (MAR) for Resident #23 for January 2025 revealed
Cran-B-OTC was not administered on 01/22/25 and 01/28/25 at 9:00 A.M. Hydroxyzine HCl 10 mg was not
administered on 01/02/25 at 10:00 P.M. and at 6:00 A.M. on 01/03/25, 01/04/25, 01/08/25, 01/12/25,
01/17/25 and 01/22/25.
Review of the MAR for Resident #23 for February 2025 revealed Cran-B-OTC was not administered on
02/02/25 at 9:00 A.M. Fluticasone was not administered on 02/24/25 and 02/25/25 at 9:00 A.M. as it was
unavailable and on order from the pharmacy.
Review of the MAR for Resident #23 for March 2025 revealed Hydroxyzine and Tizanidine were not
administered on 03/06/25 at 6:00 A.M.
Interview on 03/19/25 at 11:45 A.M. with the Director of Nursing (DON) verified Resident #23's medications
were not given as ordered as noted above.
Review of the facility policy titled, Medication Administration, dated 05/01/22, revealed medications were to
be administered as prescribed.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 63 of116
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
03/31/2025
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview and review of the facility policy, the facility failed to act upon pharmacy reviews in a
timely manner. This affected five (Residents #5, #7, #18, #24 and #37) of five residents reviewed for
unnecessary medications. Facility census was 54.
Findings include:
1. Review of Resident #5's medical record revealed an admission date of 07/26/17 and diagnoses including
heart failure, schizophrenia, anxiety, constipation, type two diabetes, depression and unspecified psychosis.
Review of Resident #5's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she
received insulin, antipsychotic's, antianxiety medications, antidepressants, anticoagulants, diuretics and
opioids.
Review of Resident #5's discontinued orders revealed an order dated 07/21/24 for hydroxyzine pamoate
oral capsule 25 milligrams (mg) give by mouth every six hours as needed (PRN) for itching. The order was
discontinued on 02/04/25.
Continued review of Resident #5's discontinued orders revealed an order dated 10/11/24 for Ativan oral
tablet 0.5 mg give by mouth every four hours as needed (PRN) for anxiety. The order was discontinued on
02/04/25.
Review of Resident #5's assessments revealed the last Abnormal Involuntary Movement Test (AIMS)
completed was on 05/24/24.
Review of a pharmacy recommendation dated 09/24/24 revealed the pharmacist recommended adding a
stop date to Resident #5's PRN Ativan. The recommendation was left blank and was not signed and not
dated.
Review of a pharmacy recommendation dated 10/23/24 revealed the pharmacist recommended adding a
stop date to Resident #5's PRN Ativan and PRN hydroxyzine. The recommendation was left blank and was
not signed and not dated.
Review of a pharmacy recommendation dated 11/21/24 revealed the pharmacist recommended for an
AIMS to be added now and every six months thereafter. The recommendation was left blank and was not
signed and not dated.
Nurses' notes from September 2024 through November 2024 did not indicate the pharmacy
recommendations were addressed.
Interview on 03/17/25 at 2:46 P.M. with the Director of Nursing (DON) revealed the pharmacy
recommendations had not been available in the residents' medical records so she had called the pharmacy
to obtain them. The DON verified Resident #5's PRN Ativan and PRN hydroxyzine medication reviews were
not timely addressed as they continued without stop dates until 02/04/25. The DON also confirmed there
were no additional AIMS assessments for Resident #5 to review since the one completed on 05/24/24.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 64 of116
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
03/31/2025
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
2. Review of Resident #7's medical record revealed an admission date of 05/07/15 and diagnoses including
schizoaffective disorder-bipolar type, depression, generalized anxiety disorder, dementia with agitation and
legal blindness.
Review of Resident #7's quarterly MDS 3.0 assessment date 12/05/24 revealed Resident #7 was
moderately cognitively impaired and received insulin, antianxiety medications, antidepressant medications,
anticoagulants and opioids.
Review of Resident #7's physician's orders revealed an order dated 09/05/24 for Xarelto 20 mg and an
order dated 09/05/24 for cetirizine hydrochloride oral tablet 10 mg.
Review of a pharmacy recommendation dated 05/29/24 revealed the pharmacist recommended to reduce
the dose of Xarelto 20 mg to 10 mg daily. The recommendation was left blank and was not signed and not
dated.
Review of a pharmacy recommendation dated 05/29/24 revealed the pharmacist recommended to reduce
the dose of Zyrtec 10 mg to 5 mg daily. The recommendation was left blank and was not signed and not
dated.
Nurses' notes from May 2024 and June 2024 did not indicate the pharmacy recommendations were
addressed.
Interview on 03/17/25 at 2:46 P.M. with the DON revealed the pharmacy recommendations had not been
available in the residents' medical records so she had called the pharmacy to obtain them. The DON
verified Resident #7's pharmacy recommendations for reducing Xarelto and Zyrtec were blank as of the
time of the interview and should have been addressed timely as required.
3. Review of the medical record for Resident #24 revealed an admission date of 06/04/24 with diagnoses
including dementia with psychotic disturbance, hypertension, insomnia and anxiety.
Review of the Note To Attending Physician/Prescriber, dated 09/24/24 from the pharmacist revealed
Resident #24 was on Seroquel and Zyprexa (antipsychotic medications used to treat symptoms of
psychosis such as delusion, hallucination, paranoia and confused thoughts) and requested the facility
either document the use for two antipsychotics or adjust therapy as appropriate. The form was not
addressed by the facility or the physician.
Review of the Note To Attending Physician/Prescriber, dated 11/21/24 from the pharmacist revealed
Resident #24 was on Seroquel, Risperdal and Zyprexa (antipsychotic medications used to treat symptoms
of psychosis such as delusion, hallucination, paranoia and confused thoughts) and requested the facility
evaluate the use of the three medications from the same drug class and adjust therapy or give clinical
rationale for continued use. The form was not addressed by the facility or the physician.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24's
cognition and depression were not assessed. He was noted to be on anti-psychotics and anti-depressants.
There was no gradual dose reduction attempted for the anti-psychotic medications.
Review of the physician's orders for March 2025 for Resident #24 revealed he was medications including
blood pressure medications, medications for insomnia, three anti-psychotic medications and an
anti-depressant.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 65 of116
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
03/31/2025
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the care plan dated 03/10/25 for Resident #24 revealed he was on psychotropic medications
(drugs that affect behavior, mood, thoughts or perceptions) related to behavior management and psychotic
disturbance. Interventions included to consult with the pharmacy and his doctor to consider dosage
reduction if clinically appropriate when indicated.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) verified the pharmacy
recommendations for Resident #24 were not addressed by the staff or the physician for the past year.
Interview on 03/17/25 at 2:46 P.M. with the DON verified the pharmacy recommendations she provided
were printed off the pharmacy's website during the survey.
4. Review of the medical record for Resident #37 revealed an admission date of 08/21/24 with diagnoses
including chronic obstructive pulmonary disease, diabetes mellitus, depression, heart failure and bipolar
disorder (mental illness that causes mood shifts between mania and depression).
Review of the care plan dated 08/21/24 for Resident #37 revealed he was on psychotropic medications
(drugs that affect behavior, mood, thoughts or perceptions) related to depression and bipolar disorder.
Interventions included to consult with the pharmacy and his doctor to consider dosage reduction if clinically
appropriate when indicated.
Review of the Note To Attending Physician/Prescriber, dated 01/13/25 from the pharmacist revealed
Resident #37 was on Trazadone (medication for depression) and the facility should attempt to taper the
medication. If the reduction in dose was contraindicated, the physician was to document why the reduction
was not indicated. The form was not addressed by the facility or the physician.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had
intact cognition and was depressed. He was noted to be on anti-psychotics, anti-depressants, insulin and
hypnotic medications. There was no gradual dose reduction listed for the anti-psychotic medication.
Review of the physician's orders for March 2025 for Resident #37 revealed he was on medications
including insulin, blood pressure medications, medications for insomnia, anti-psychotics and
anti-depressants.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) verified the pharmacy
recommendations for Resident #37 were not addressed by the staff or the physician for the past year.
Interview on 03/17/25 at 2:46 P.M. with the DON verified the pharmacy recommendations she provided
were printed off the pharmacy's website during the survey.
5. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses
including Parkinson's disease, schizophrenia, depression, dementia with severe behavioral disturbance,
anxiety disorder, and depressive type schizoaffective disorder.
Review of pharmacy recommendations Note to Attending Physician/Prescriber dated 09/24/24 revealed
pharmacist recommended to add duration and provide supporting clinical documentation for continued use
of as needed Ativan. There was no evidence of physician/prescriber response or action. The pharmacist
recommended as Resident #18 was receiving Sinemet four times per day to increase Comtan from two
times per day to four times per day to allow for more active Levodopa. There was no evidence of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 66 of116
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
03/31/2025
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 0756
physician/prescriber response or action.
Level of Harm - Minimal harm
or potential for actual harm
Review of pharmacy recommendations Note to Attending Physician/Prescriber dated 10/24/24 revealed
pharmacist recommended to attempt a dose reduction of Zoloft 50 milligrams (mg) once daily. There was
no evidence of physician/prescriber response or action.
Residents Affected - Some
Review of pharmacy recommendations Note to Attending Physician/Prescriber dated 11/22/24 revealed
pharmacist recommended to add duration and provide supporting clinical documentation for continued use
of as needed Ativan. There was no evidence of physician/prescriber response or action. The pharmacist
recommended to evaluate 12-hour frequency on as needed Melatonin and consider change to once daily
as needed. There was no evidence of physician/prescriber response or action.
Review of pharmacy recommendations Note to Attending Physician/Prescriber dated 01/13/25 revealed
pharmacist recommended to attempt a dose reduction of Ativan 0.5 milligrams (mg) twice daily. There was
no evidence of physician/prescriber response or action.
Further review of Resident #18's medical record revealed pharmacy recommendations were not addressed
in a timely manner.
Interview on 03/19/25 at 3:18 P.M. with Director of Nursing (DON) confirmed there had not been any
evidence of physician/prescriber follow up to pharmacy recommendations.
Review of facility policy Pharmacy Services Policy and Procedure dated 2025 revealed each resident shall
have a drug regimen review at least monthly by a licensed pharmacist. The attending physician shall
document in the resident's medical record that any medication irregularities had been reviewed and what
actions were taken to address. If there were no changes to the medication the attending physician shall
document rationale in the resident's medical record. Further review revealed, the facility would ensure
residents who used psychotropic drugs received gradual dose reductions unless clinically contraindicated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 67 of116
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
03/31/2025
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #5's medical record revealed an admission date of 07/26/17 and diagnoses including heart failure,
schizophrenia, anxiety, constipation, type two diabetes, depression and unspecified psychosis.
Review of Resident #5's physician's orders revealed an order for Lorazepam 0.5 milligrams (mg) every four
hours as needed for anxiety for 14 days (03/13/25); an order for buspirone hydrochloride oral tablet 10 mg
twice a day for anxiety (02/04/25); an order for bupropion hydrochloride extended release oral tablet 150 mg
give two tablets once a day for depression (02/04/25); an order for abilify oral tablet 10 mg daily for anxiety
(07/22/24); and an order for Zoloft tablet 100 mg daily for depression (07/22/24). Further review of the
physician's orders revealed no psychotropic medication monitoring was currently in place. Review of
discontinued orders revealed antipsychotic, antidepressant and antianxiety medication monitoring was last
in place on 07/09/24.
Review of Resident #5's quarterly MDS 3.0 assessment dated [DATE] revealed she received insulin,
antipsychotics, antianxiety medications, antidepressants, anticoagulants, diuretics and opioids.
Review of Resident #5's plans of care revealed an anxiety care plan dated 10/04/17 and revised 02/24/22
with an intervention including administer medications as ordered, see medication record. Monitor for
effectiveness and side effects (10/04/17). An additional plan of care dated 07/27/17 and revised 02/14/23
revealed Resident #5 utilized psychotropic medications (antipsychotic, antianxiety, antidepressant) related
to anxiety, depression, schizophrenia, behavioral disturbance and insomnia. Listed interventions included
lists of side effects for antidepressants, antipsychotics and antianxiety medications; monitor for side effects
and effectiveness; monitor AIMS test for extrapyramidal symptoms and report abnormal findings (07/27/17).
Review of Resident #5's assessments revealed the last AIMS completed was on 05/24/24.
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #5's AIMS testing
had not been done again since 05/24/24 and verified although Resident #5 was on hospice services, her
psychotropic medications were still to be monitored for side effects. The DON could not state why Resident
#5's previous orders for psychotropic medication monitoring were discontinued as she had only been
working at the facility since 02/17/25.
3. Review of the medical record for Resident #37 revealed an admission date of 08/21/24 with diagnoses
including chronic obstructive pulmonary disease, diabetes mellitus, depression and chronic pain syndrome.
Review of Resident #37's electronic medical record and paper chart revealed facility staff had not assessed
the side effects of medications with the Abnormal Involuntary Movement Scale (AIMS) since he was
admitted .
Review of the physician's orders for March 2025 for Resident #24 revealed he had psychotropic
medications (drugs that affect behavior, mood, thoughts or perception) including Trazodone HCl 150
milligrams (anti-depressant) once daily for insomnia dated 09/03/24 and Quetiapine Fumarate 400
milligrams (mg) (antipsychotic medication) for bipolar disorder daily dated 03/03/25. There were no orders
for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 68 of116
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
03/31/2025
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 0758
monitoring of these medications or his behaviors.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 03/18/25 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #37 did not have
an AIMS assessment in his medical record or monitored the psychotropic medications or behaviors of
Resident #37. The DON also verified the facility did not have a policy on psychotropic monitoring.
Residents Affected - Few
Based on interview and record review, the facility failed to ensure residents were monitored for the use of
psychotropic medications. This affected three residents (#5, #18, and #37) of five residents reviewed for
unnecessary medications. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses
including Parkinson's disease, schizophrenia, depression, dementia with severe behavioral disturbance,
anxiety disorder, and depressive type schizoaffective disorder.
Review of physician's order dated 04/22/23 revealed order for six milligrams (mg) Vraylar (an antipsychotic
medication).
Review of physician's order dated 12/19/23 revealed order for 0.5 mg Lorazepam (a medication used for
anxiety).
Review of physician's order dated 07/17/24 revealed order for 150 mg Clozaril (an antipsychotic
medication).
Review of Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] revealed Resident #18
was not observed to have any abnormal movements.
Review of physician's order dated 10/26/24 revealed order for 75 mg Zoloft (an antidepressant medication).
Review of plan of care dated 02/14/25 revealed Resident #18 received psychoactive medications to treat
mental illness. Interventions included to monitor AIMS test for extrapyramidal symptoms (EPS) and report
any abnormal findings.
Review of physician's order dated 03/13/25 revealed order for 0.5 mg Lorazepam every four hours as
needed for 14 days.
Further review of the medical record revealed there were no additional assessments to monitor AIMS test
for EPS.
Interview on 03/19/25 at 3:18 P.M. with Director of Nursing (DON) confirmed there had not been any
evidence of additional monitoring for EPS with AIMS testing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 69 of116
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
03/31/2025
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, record review, and policy review, the facility failed to ensure residents received
medications as ordered. This affected one resident (#18) of 28 residents reviewed for medications. The
facility census was 54.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses
including Parkinson's disease, oropharyngeal phase dysphagia, schizophrenia, depression, dementia with
severe behavioral disturbance, anxiety disorder, and depressive type schizoaffective disorder.
Review of physician's order dated 04/22/23 revealed order for six milligrams (mg) Vraylar one time per day.
The medication was scheduled for 9:00 A.M.
Review of physician's order dated 12/19/23 revealed order for 0.5 mg Lorazepam two times per day. The
medication was scheduled for 9:00 A.M. and 9:00 P.M.
Review of physician's order dated 03/20/24 revealed order to ensure Carbidopa-Levodopa was
administered one hour prior to a meal to assist with swallowing and to hold meal tray until at least 60
minutes have passed since medication administration.
Review of physician's order dated 07/17/24 revealed order for 150 mg Clozaril two times per day. The
medication was scheduled for 9:00 A.M. and 9:00 P.M.
Review of physician's order dated 07/23/24 revealed an order for one tablet of Carbidopa-Levodopa 25-100
mg in the evening. It was noted to give medication 60 minutes prior to eating.
Review of physician's order dated 08/17/24 revealed an order for two tablets of Carbidopa-Levodopa
25-100 mg before meals (three times per day). It was noted to give medication one hour prior to meals.
Review of physician's order dated 10/26/24 revealed order for 75 mg Zoloft one time per day. The
medication was scheduled for 9:00 A.M.
Review of Medication Administration Record (MAR) for January 2025 revealed no evidence
Carbidopa-Levodopa was administered at 6:00 P.M. dose on 01/04/25 and 6:00 P.M. dose on 01/14/25.
Review of Medication Administration Record (MAR) for February 2025 revealed no evidence
Carbidopa-Levodopa was administered at 6:30 A.M. dose on 02/04/25, 6:00 P.M. dose on 02/12/25, 6:30
A.M. dose on 02/13/25, and 6:00 P.M. dose on 02/27/25.
Review of Medication Administration Record (MAR) for March 2025 revealed no evidence
Carbidopa-Levodopa was administered at 6:30 A.M. dose on 03/13/25 and 6:00 P.M. dose on 03/14/25.
Review of Administration History Report from February 2025 to March 2025 revealed the report indicated
medication administration of Carbidopa-Levodopa had delays in treatment as follows:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 70 of116
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
03/31/2025
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 0760
4:00 P.M. dose on 2/15/25 was not administered until 5:30 P.M.
Level of Harm - Minimal harm
or potential for actual harm
6:30 A.M. dose on 02/18/25 was not administered until 7:25 A.M.
Residents Affected - Few
11:00 A.M. dose on 02/22/25 was not administered until 12:27 P.M.
11:00 A.M. dose on 02/25/25 was not administered until 12:23 P.M.
4:00 P.M. dose on 02/25/25 was not administered until 5:53 P.M.
11:00 A.M. dose on 03/10/25 was not administered until 12:34 P.M.
4:00 P.M. dose on 03/10/25 was not administered until 5:22 P.M.
11:00 A.M. dose on 03/12/25 was not administered until 12:08 P.M.
11:00 A.M. dose on 03/15/25 was not administered until 12:59 P.M.
The report indicated medication administration of Clozaril, Lorazepam, Vraylar, and Zoloft had delays in
treatment as follows:
9:00 A.M. dose on 02/19/25 was not administered until 11:03 A.M.
9:00 A.M. dose on 03/02/25 was not administered until 11:04 A.M.
9:00 A.M. dose on 03/05/25 was not administered until 11:15 A.M.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 71 of116
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
03/31/2025
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 0760
-
Level of Harm - Minimal harm
or potential for actual harm
9:00 A.M. dose on 03/07/25 was not administered until 10:58 A.M.
-
Residents Affected - Few
9:00 A.M. dose on 03/10/25 was not administered until 12:02 P.M.
Interview on 03/10/25 at 4:19 P.M. with Resident #18's sister revealed concerns regarding timely
medication pass particularly for Carbidopa Levodopa and her morning psych medications. Resident #18's
sister indicated when the medications were not passed timely Resident #18 had difficulty with meals.
Observation on 03/18/25 at 8:00 A.M. of Resident #18 for breakfast meal revealed Resident #18's sister
had visited for breakfast and was assisting with feeding. Resident #18 was noted to have the correct diet
order of puree texture with thickened liquids however Resident #18 was still noted to cough at times.
Resident #18's sister indicated this was what she meant by how Resident #18 was affected by timeliness of
medications. Resident #18 made few attempts to self-feed but was able to hold glass when put in hands.
Interview on 03/19/25 at 3:18 P.M. with Director of Nursing (DON) confirmed Resident #18 did not receive
medications as ordered or in a timely manner for Carbidopa-Levodopa, Clozaril, Lorazepam, Vraylar, or
Zoloft.
Review of facility policy Medication Administration dated 05/01/22 revealed medications shall be
administered in a safe and timely manner and as prescribed. Medications must be administered within one
hour prior and after their prescribed time.
This deficiency represents non-compliance investigated under Complaint Number OH00162361.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 72 of116
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
03/31/2025
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review and review of the facility policy, the facility failed to follow the menu
spreadsheets as written to ensure proper portion sizes were served to the residents. This affected 53
residents receiving food from the kitchen as Resident #10 was ordered nothing by mouth (NPO). Facility
census was 54.
Findings include:
Review of the facility menu corresponding to Tuesday, 03/11/25 revealed a lunch meal consisting of
smothered and covered pork chop (one each), seasoned rice (four ounces), Price [NAME] vegetable blend
(four ounces), yellow cake with frosting (one slice) and beverage of choice (four ounces).
Review of the facility production sheet for lunch on 03/11/25 revealed those receiving a mechanical-soft diet
received a #10-scoop (three ounces) of ground pork and those on a low-concentrated sweets (LCS) diet
were to have a half-portion of yellow cake with frosting.
Review of the facility's diet list as of 03/10/25 revealed Resident #10 was NPO, eight residents were
ordered mechanical soft diets (Residents #7, #8, #16, #28, #32, #33, #35 and #204) and eight residents
were ordered LCS diets (Residents #5, #20, #21, #29, #31, #36, #37 and #44).
Observation on 03/11/25 starting at 11:23 A.M. revealed [NAME] #315 was taking temperatures of the
foods to be served using the facility's self-calibrating electronic thermometer and putting serving utensils in
each pan on the steam table. The rice was noted to have a green #12-scoop (serving 2.66 ounces) and the
ground pork had a blue #16-scoop (serving two ounces). Trayline began at 11:34 A.M. Clear plastic and
colored plastic bowls with cake in them were noted on the individual trays and all of the portions of cake
appeared to be the same size.
Interview on 03/10/25 at 10:36 A.M. with Resident #22 revealed the food at the facility was inadequate and
he bought his own food because it is so bad.
Interview on 03/11/25 at 11:43 P.M. with Dietary Manager (DM) #361 verified all the portions of cake for this
meal were the same size.
Interview on 03/11/25 at 12:09 P.M. with [NAME] #315 verified the mechanical soft pork had a #16-scoop
which did not follow the spreadsheet as written.
Interview on 03/11/25 at 12:15 P.M. with DM #361 verified the rice had a #12-scoop which did not follow the
spreadsheet as written.
During a follow-up interview on 03/11/25 at 12:40 P.M. DM #361 was made aware the facility did not follow
the portion sizes for the LCS diets as a full piece of cake was provided, did not follow the portion sizes for
the mechanical soft diets as too small of a scoop was used and did not follow the portion size for the rice as
too small of a scoop was used and DM #361 did not disagree.
Review of the facility policy, Portion Control, no date, revealed a specific portion size shall be established
for all menu items. A serving utensil that will yield the designated portion will be
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 73 of116
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
03/31/2025
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 0803
specified for each menu item.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy, Portion Sizes, no date, revealed menu items shall be served according to
pre-determined portion size. The standard portion is a level measure using the appropriate serving utensil,
which is used to accurately serve the designated portion size.
Residents Affected - Many
This deficiency represents noncompliance investigated under Complaint Number OH00162361.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 74 of116
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
03/31/2025
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and review of the menu, the facility failed to serve palatable meals at appetizing
temperatures. This had potential to affect all 53 residents receiving meals from the kitchen as Resident #10
was ordered nothing-by-mouth. The facility census was 54.
Residents Affected - Many
Findings include:
Review of the facility menu corresponding to Tuesday, 03/11/25 revealed a lunch meal consisting of
smothered and covered pork chop, seasoned rice, Prince [NAME] vegetable blend, yellow cake with
frosting and beverage of choice.
Interview on 03/10/25 at 10:20 A.M. with Resident #48 revealed the hot food was served cold and terrible.
Interview on 03/10/25 at 10:36 A.M. with Resident #22 revealed the food at the facility was inadequate and
he bought his own food because it is so bad and the hot food was really cold.
Interview on 03/10/25 at 1:23 P.M. with Resident #42 revealed the food at the facility was terrible as it was
cold, tasted awful and was a low quality of food.
Observation on 03/11/25 starting at 11:23 A.M. revealed [NAME] #315 was taking temperatures of the
foods to be served using the facility's self-calibrating electronic thermometer and putting serving utensils in
each pan on the steam table. Temperatures of the foods to be served were as follows: pork chop, 173
degrees Fahrenheit (F); vegetable blend, 177 degrees F; rice, 172 degrees F and cake, room temperature
(not taken). Trayline began at 11:34 A.M. The east cart began at 12:09 P.M. and a test tray was requested.
The test tray was made at 12:21 P.M., on the cart at 12:22 P.M., and was on the unit at 12:23 P.M. Nursing
staff began passing trays from the cart immediately after its arrival. The test tray was sampled at 12:40 P.M.
with Dietary Manager (DM) #361 and temperatures obtained at that time with the facility's self-calibrating
electronic thermometer were as follows: pork, 116 degrees F; rice, 112 degrees F; milk, 45 degrees F;
vegetable, 115 degrees F. The foods sampled were lukewarm and not palatable at the current
temperatures.
Interview on 03/11/25 at 12:40 P.M. with DM #361 confirmed the test tray was lukewarm and the hot foods
were not at appropriate temperatures during the sampling of the test tray thus were not palatable. DM #361
stated hot foods were to be at 145 degrees F minimum at point of service.
This deficiency represents noncompliance investigated under Complaint Number OH00162361.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 75 of116
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
03/31/2025
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 observation, interview, review of the facility policy and record review the facility failed to ensure
foods were labeled, dated and not retained when expired. This had the potential to affect 53 residents
receiving meals from the kitchen as Resident #10 was ordered nothing-by-mouth (NPO). The facility census
was 54.
Findings include:
Observation of the kitchen on 03/10/25 from 9:20 A.M. to 9:54 A.M. with Dietary Manager (DM) #361
revealed the following areas of concern:
•
In the walk-in cooler, there were two expired cartons of cream dated 02/27/25 and 03/02/25, a package of
bologna that did not have a date nor a label, two expired bags of salad lettuce dated 01/14/25 and expired
coleslaw dated 01/28/25.
•
In the dry stock room, there were nine expired cartons of thickened dairy beverage dated 02/13/25 that
were in between rows of thickened beverages that still had appropriate dates.
Interviews with DM #361 verified the above findings at the time of observation. DM #361 stated the first shift
cook was responsible for checking for expired food and this was documented on the cleaning sheets. DM
#361 confirmed foods were to be labeled and dated.
Review of the supplied cleaning schedules revealed the morning cook was responsible for removing
out-of-date items from the refrigerator at the beginning of their shift. This was not documented as
completed on 03/09/25 and 03/10/25, with 03/08/25 being the last day this task was marked as completed.
Review of the facility policy, Labeling and Dating Foods, dated 07/30/23 revealed to decrease the risk of
foodborne illness and to provide the highest quality, foods are labeled with the date received. If the product
does not have an expiration date, the product is labeled with a discard or use by date.
Review of the facility policy, First In, First Out (FIFO), no date, revealed food products are used by the
expiration date, if not, food items are discarded. Do not use any item that for which the manufacturers'
suggested use by date has passed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 76 of116
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
03/31/2025
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 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, review of facility job descriptions and interview the facility failed to ensure effective
administration to manage the facility and identify care concerns, implement appropriate and sustainable
corrective actions to prevent reoccurrence and attain or maintain the highest practicable physical, mental
and psychosocial well being of all 54 residents residing in the facility.
Residents Affected - Many
Findings include:
1. Review of the Administrator's job description, dated May 2022 and signed by the Administrator on
01/20/25, revealed the Administrator would provide overall direction for all activities related to
administration, personnel, physical structure, information systems, office management and marketing of the
entire facility. The Administrator works closely with all members of the management team and others to
ensure their responsibilities are effectively and consistently discharged . The Administrator will ensure all
facility operations are in compliance with federal, state and local regulations. The essential functions
included developing and implementing facility policies and procedures that comply with federal, state and
local regulations; act as liaison with the governing body, outside medical professionals, nursing staff and
other professional and supervisory staff through regular meetings and periodic reporting; reports all
hazardous conditions, damaged equipment and supply issues to appropriate persons; assists appropriate
department heads with development and implementation of infection control procedures; and maintains the
comfort, privacy and dignity of residents.
Review of the Director of Nursing (DON) job description, dated May 2022 and signed by the DON on
02/14/25, revealed the DON played a critical role in providing superior customer service and nursing
services to all residents in the facility. The DON works with the Administrator and the Medical Director in the
planning, development and overall operation of the nursing department which ensures residents receive
quality care 24 hours a day. The essential functions included assuring that established infection control and
standard precaution practices are maintained at all times; and maintains the comfort, privacy and dignity of
residents.
Interview on 03/19/25 at 4:32 P.M. with the Administrator, DON and Chief Operating Officer (COO) #300
revealed the Administrator had assumed her position on 01/27/25 and the DON had assumed her position
on 02/17/25.
During the onsite investigation, the following concerns were identified related to a lack of comprehensive
and effective administrative oversight:
2. Review of the QAPI meeting minutes and sign-in sheets from January 2024 through February 2025
revealed no evidence the facility's previous Medical Director, Physician #367, attended the QAPI meetings
on 03/19/24, 04/16/24, 05/21/24, 06/18/24 and 07/16/24. There was no evidence a member of the facility's
governing body attended the QAPI meetings until the January 2025 meeting. Additionally, there was no
identification of the facility's Infection Preventionist (IP) on the sign-in sheets provided to ensure the IP was
involved as required.
On 03/17/25 starting at 3:02 P.M. interview with Chief Operating Officer (COO) #300 revealed if the medical
director attended by phone or in person, their attendance should have been reflected on the QAPI
signature sheets. COO #300 was made aware during the interview there was no evidence Physician #367
had attended any of the QAPI meetings before Physician #366 took over the Medical Director
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 77 of116
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
03/31/2025
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 0835
Level of Harm - Minimal harm
or potential for actual harm
role in July 2024. COO #300 verified there were no QAPI meeting minutes or sign-in sheets for November
2024 and December 2024 available for review.
3. Observations of the facility on 03/10/25 revealed loose hand-rails, broken blinds, discolored ceiling tiles,
dented and chipped walls and a broken shower room.
Residents Affected - Many
Interview on 03/10/25 at 1:00 P.M. with the Administrator verified the observed findings and shared the
facility did not have a maintenance director as of the time of the interview.
4. Continued observations of the facility on 03/12/25 revealed hot water temperatures across the facility
ranged from 77 degrees Fahrenheit (F) to 102.6 degrees F which did not provide the residents with a
comfortable, homelike environment.
Interview on 03/12/25 at 11:42 A.M. with Housekeeping Director (HD) #306 verified the observed findings,
indicated this was the first time he had checked water temperatures and had no record of water
temperatures being checked previously.
5. Review of the facility's infection control program documentation revealed a lack of a legionella water
management program and an incomplete infection tracking and trending log including antibiotic use and
COVID-19. There was no documentation to show there had been a routine and consistent infection
preventionist at the facility in the time leading up to the survey. Documentation indicated concerns were
identified with offering and providing influenza, COVID-19 and pneumonia vaccines as required.
Additionally, the facility did not collaborate timely with the local health department regarding residents with
suspected Carbapenem-Resistant Enterobacterales (CRE) infections and did not identify or place residents
in Enhanced Barrier Precautions (EBP) as indicated per the Centers for Disease Prevention and Control
(CDC).
Interviews with administrative staff, including the Administrator, DON and COO #300 during the survey
period verified the infection control concerns identified during the survey.
6. Review of QAPI meeting minutes revealed for the month of April 2024 (date not specified) there was an
action plan to a (unidentified date) state agency survey with citations for dignity, not providing private
communication, quality of care, notification of condition change, homelike environment, reporting
allegations of abuse, investigating allegations of abuse, assistance with activities of daily living, activities to
meet the needs of the residents, accidents/hazards, nutrition, significant medication errors, medication
storage, notification of laboratory results and infection control. The plan referenced to see the plan of
correction and indicated the department responsible for the corrective action. The columns under
completion date and follow-up were blank. There was no additional information provided to verify the
correction plan was completed.
During the current annual survey, repeat deficiencies were identified related to privacy, homelike
environment, reporting abuse to the state agency, investigating allegations of abuse, activities of daily living
assistance, quality of care, falls, significant medication errors and infection control in addition to additional
citations due to a lack of oversight and monitoring.
7. Review of the July 2024 QAPI meeting minutes included an action plan related to a survey (not identified)
with citations for food storage and appropriate garbage disposal. Under tasks, the minutes directed to see
plan of correction (POC). Departments were assigned, completion dates were indicated as ongoing and no
follow-up was identified. There was no evidence corrective actions or a PIP were
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 78 of116
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
03/31/2025
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 0835
completed.
Level of Harm - Minimal harm
or potential for actual harm
During the annual survey, concerns were identified related to expired and undated foods.
Residents Affected - Many
8. Review of the second set of July 2024 QAPI meeting minutes included an action plan to address missing
copies of Do Not Resuscitate (DNR) forms, also known as advance directives. Tasks were listed and staff
were assigned. The columns under completion date and follow up were blank and there was no evidence
corrective actions or a PIP were completed.
During the annual survey, concerns were identified related to advance directives.
9. Review of the August 2024 QAPI meeting minutes included an action plan related to a survey (not
identified) with citations related to dignity, reporting allegations of abuse to the state survey agency,
thoroughly investigating allegations of abuse, bowel and bladder concerns, nutrition, significant medication
errors and safe, homelike environment. Under tasks, the minutes directed to see plan of correction (POC).
Staff were assigned, completion dates were indicated as ongoing and no follow-up was identified. There
was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified in some of the identified areas including reporting
alleged abuse to the state survey agency, thoroughly investigating allegations of abuse, bowel and bladder,
significant medication errors and a safe, homelike environment.
10. Review of the November 2024 QAPI meeting minutes included an action plan to address an in-house
acquired pressure ulcer, affecting Resident #11. Tasks were listed and staff were assigned. The columns
under completion date and follow up were blank and there was no evidence corrective actions or a PIP
were completed.
During the annual survey, concerns were identified related to pressure ulcers. Resident #11, the resident
with the identified in-house acquired pressure ulcer found on 11/23/24, had a task including weekly
measurements of all areas input into the Electronic Medical Record (EMR) no longer than seven days
apart. Record review and interview indicated Resident #11's wound was not measured again until 02/26/25.
A deficiency was issued regarding pressure ulcers during the annual survey.
11. The February 2025 QAPI meeting minutes revealed an environmental PIP was started on 02/02/25 with
weekly updates on the program documented in the minutes.
During the annual survey, concerns were identified related to the environment and deficiencies were
issued.
Interview on 03/19/25 at 4:32 P.M. with Chief Operating Officer (COO) #300 revealed she relied on the
facility's DON and the Administrator to follow up with any QAPI-related concerns. The COO verified she was
unaware the PIPs were not completed prior to the interview.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 79 of116
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
03/31/2025
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 0838
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Conduct and document a facility-wide assessment to determine what resources are necessary to care for
residents competently during both day-to-day operations (including nights and weekends) and
emergencies.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure the facility assessment was accurately completed.
The facility also did not implement their facility assessment in regard to staff training and education. This
had the potential to affect all 54 residents residing at the facility.
Findings include:
1. Review of the letter dated 05/25/23 from the state survey agency to the facility revealed the facility had
their request approved to decrease the capacity and licensed beds to 72 residents.
Review of the facility assessment dated [DATE] revealed the resident profile portion was incorrect. The
number of residents the facility was licensed to care for stated 118. Their average daily census ranged from
35 to 85 residents (the capacity for the facility was 72 as of 05/25/23).
On 03/17/25 at 12:05 P.M. interview with the Administrator verified the facility assessment was inaccurate
and did not reflect the correct capacity.
2. Review of in-services provided by the facility from 05/13/24 through 02/20/25 revealed staff had received
eight trainings total and the topics included abuse, human resource issues, answering call lights, infection
prevention, documentation, supplies, communication, resident smoking, harassment free working
conditions, mechanical lift policy, transfers, therapy, dementia care, stepping stones program (drug and
alcohol program), customer service, hydration and calling off to the facility. In-service sheets revealed not all
employees were present at the eight trainings and had not received all the trainings listed above.
Review of the facility assessment dated [DATE] revealed the facility would address areas of weakness as
determined in nurse aide performance reviews during training and in-services. The facility assessment
stated training topics for staff would include communication, resident rights, abuse, infection control, culture
change and dementia management.
Review of the personnel file for Certified Nursing Assistant (CNA) #305 revealed a hire date of 06/03/21
and no evidence the CNA had received 12 hours of in-services annually (March 2024 24 through March
2025) nor had they received their annual performance evaluations to address areas of weakness during
training and in-services. No evaluation was located for 2024.
Review of the personnel file for CNA #329 revealed a hire date of 03/04/05 and no evidence the CNA had
received 12 hours of in-services annually (March 2024 24 through March 2025) nor had they received their
annual performance evaluations to address areas of weakness during training and in-services. No
evaluation was located for 2024.
Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNA #305 and
CNA #329 did not receive 12 hours of in-services as required annually or their annual performance
evaluations as indicated in the facility assessment.
Interview on 03/19/25 at 2:21 P.M. with the Administrator verified she was unable to locate any
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 80 of116
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
03/31/2025
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 0838
other in-services or education for staff from March 2024 through March 2025.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 81 of116
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
03/31/2025
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 0841
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Designate a physician to serve as medical director responsible for implementation of resident care policies
and coordination of medical care in the facility.
Based on record review, contract review, review of the facility policy and staff interview, the facility failed to
ensure the medical director fulfilled his responsibilities related to the coordination of medical care, the
implementation of facility policies and procedures and evidence of participation in Quality Assurance and
Performance Improvement to ensure quality care is provided to residents. This affected all 54 residents who
reside in the facility.
Findings include:
Review of available Medical Director reports from January 2024 through February 2025 revealed one report
from February 2025. The report indicated the environment was clean and hazard free and residents
appeared to be clean and comfortable with safety measures in place. There were no documented concerns
relating to pressure areas, falls or changes in condition.
During an interview on 03/17/25 at 12:05 P.M., Medical Director #366 stated he had been the facility's
Medical Director since 07/01/24. Medical Director #366 did not voice concerns relating to effective
administration of the facility or indicate any areas that needed to be addressed by the facility to ensure they
provided appropriate care and services to the residents.
Interview on 03/19/25 at 1:12 P.M. with Chief Operating Officer (COO) #300 verified the only Medical
Director report available from the last 12 months was from February 2025. COO #300 stated the previous
Director of Nursing did not keep this kind of documentation and should have.
Review of a medical director agreement with Physician #366 dated 06/10/24 revealed the Medical Director
was to assist the facility in meeting the applicable standards established under state and federal law. The
Medical Director shall be responsible for the implementation of policies related to the care of residents at
the facility and for the coordination of medical care at the facility and was responsible for assisting the
facility to provide appropriate care, both medical and clinical, to residents. The Medical Director shall
monitor and ensure the implementation of resident care policies and provide oversight and supervision of
the nursing, medical care and physician services rendered to residents of facility with respect to the
implementation of policies related to care of residents at facility, physician shall be responsible for assisting
in implementing policies related to admission, transfers/discharges, infection control, the use of restraints,
physician privileges/practices, non-physician health care workers, accidents and incidents, ancillary
services, use of medication, use/release of clinical information, patient rights, utilization review and any
other policies related to the quality of care at facility as deemed necessary by facility and/or required by
applicable law or regulation.
Review of the facility policy, Medical Director Policy and Procedure, dated 2025 revealed the medical
director shall be responsible for the implementation of the coordination of the medical care in the facility.
The medical director shall be responsible for the following areas of care/services: implementation of
resident care policies, such as ensuring physicians and other practitioners adhere to facility policies on
diagnosing and prescribing medications; participation in the quality assessment and assurance (QAA)
committee; addressing issues related to the coordination of medical care and implementation of resident
care policies identified through the facility's QAA committee and other activities and active involvement in
the process of conducting the facility assessment. Additional medical responsibilities include but are not
limited to administrative decisions, quality of care,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 82 of116
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
03/31/2025
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 0841
professional development, infection control, establishing policies, resident self-determination, identifying
expectations and facilitating feedback an medical care intervention and oversight.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 83 of116
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
03/31/2025
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 - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on record review, observations and interviews, the facility failed to ensure medical records were
complete and accurate. This affected four (Residents #11, #18, #22 and #43) of 28 records reviewed. The
facility census was 54.
Findings include:
1. Review of the medical record for Resident #11 revealed an admission date of 01/25/17 with diagnoses
including dementia with behavioral disturbance and Coronavirus Disease 2019 (COVID-19).
Review of the physician's orders for Resident #11 revealed an order dated 12/27/24 to maintain contact and
droplet precautions every shift.
Review of the Treatment Administration Record (TAR) for March 2025 for Resident #11 revealed nursing
staff were still signing that Resident #11 was on contact and droplet precautions for COVID-19.
Observation and interview on 03/10/25 at 11:46 A.M. with Certified Nursing Assistant (CNA) #305 verified
Resident #11 was on enhanced barrier precautions related to having a wound. She stated staff wore gowns
and gloves when providing care.
Interview on 03/18/24 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #11 should not
have the physician's order for contact/droplet precautions as he no longer had COVID-19. She stated the
order should have been discontinued in January 2025.
2. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses
including chronic obstructive pulmonary disease, hypertension and heart failure.
Review of the physician's orders for Resident #22 revealed an order dated 12/28/24 to maintain contact and
droplet precautions every shift for 5 to 10 days if symptomatic.
Review of the Treatment Administration Record (TAR) for March 2025 for Resident #22 revealed nursing
staff were still signing that Resident #22 was on contact and droplet precautions for COVID-19.
Interview on 03/13/25 at 12:25 P.M. with Resident #22 verified he had COVID-19 in December of 2024. He
verified he was not on isolation for COVID-19.
Interview on 03/18/24 at 10:09 A.M. with the Director of Nursing (DON) verified Resident #22 should not
have the physician's order for contact/droplet precautions as he no longer had COVID-19. She stated the
order should have been discontinued in January 2025.
3. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses
including Parkinson's disease, oropharyngeal phase dysphagia, schizophrenia, depression, dementia with
severe behavioral disturbance, anxiety disorder, and depressive type schizoaffective disorder.
Review of nurses note dated 12/27/24 revealed Resident #18 had tested positive for COVID-19.
Review of physician's order dated 12/30/24 revealed an order to maintain contact and droplet
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 84 of116
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
03/31/2025
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
precautions. There was no noted duration on the order.
Level of Harm - Minimal harm
or potential for actual harm
Review of the Treatment Administration Records (TAR) from January 2025 to March 2025 revealed nursing
staff continued to signed off on confirmation of contact and droplet precautions through 03/17/25.
Residents Affected - Some
Observations from 03/10/25 to 03/20/25 revealed no evidence Resident #18 was on any kind of
transmission based precautions.
Interview on 03/18/25 10:09 A.M. with Director of Nursing (DON) confirmed Resident #18 still had an order
for contact/droplet precautions that needed discontinued due to resolved symptoms. The DON indicated
she noticed the orders in place that were no longer applicable when she was doing medication pass.
4. Review of the medical record for Resident #43 revealed an admission date of 12/16/24 and diagnoses
including COVID-19 (12/28/24), sepsis, anemia, diabetes mellitus, paranoid schizophrenia, and chronic
obstructive pulmonary disease.
Review of nurses note dated 12/27/24 revealed Resident #43 had tested positive for COVID-19.
Review of physician's order dated 12/30/24 revealed an order to maintain contact and droplet precautions.
There was no noted duration on the order.
Review of Treatment Administration Records (TAR) from January 2025 to March 2025 revealed nursing
staff continued to sign off on confirmation of contact and droplet precautions through 03/17/25.
Observations from 03/10/25 to 03/20/25 revealed Resident #43 was on enhanced barrier precautions for a
wound.
Interview on 03/18/25 10:09 A.M. with the Director of Nursing (DON) confirmed Resident #43 still had an
order for contact/droplet precautions that needed discontinued due to resolved symptoms. The DON
indicated she noticed the orders in place that were no longer applicable when she was doing medication
pass.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 85 of116
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
03/31/2025
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 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
Based on record review, facility policy and procedure review and interview the facility failed to ensure an
effective Quality Assurance and Performance Improvement (QAPI) committee that identified concerns
timely and effectively. This had the potential to affect all 54 residents in the facility.
Findings include:
Review of the facility QAPI minutes and Performance Improvement Plan (PIP) documentation revealed the
following plans without continued corrective action, evidence the plan was revised when necessary or
changed once identified to be ineffective:
1. Review of QAPI meeting minutes revealed for the month of April 2024 (date not specified) there was an
action plan to a (unidentified date) state agency survey with citations for dignity, not providing private
communication, quality of care, notification of condition change, homelike environment, reporting
allegations of abuse, investigating allegations of abuse, assistance with activities of daily living, activities to
meet the needs of the residents, accidents/hazards, nutrition, significant medication errors, medication
storage, notification of laboratory results and infection control. The plan referenced to see the plan of
correction and indicated the department responsible for the corrective action. The columns under
completion date and follow-up were blank. There was no additional information provided to verify the
correction plan was completed.
During the current annual survey, repeat deficiencies were identified related to privacy, homelike
environment, reporting abuse to the state agency, investigating allegations of abuse, activities of daily living
assistance, quality of care, falls, significant medication errors and infection control in addition to additional
citations due to a lack of oversight and monitoring.
2. Review of the July 2024 QAPI meeting minutes included an action plan related to a survey (not identified)
with citations for food storage and appropriate garbage disposal. Under tasks, the minutes directed to see
plan of correction (POC). Departments were assigned, completion dates were indicated as ongoing and no
follow-up was identified. There was no evidence corrective actions or a PIP were completed.
During the annual survey, concerns were identified related to expired and undated foods.
3. Review of the second set of July 2024 QAPI meeting minutes included an action plan to address missing
copies of Do Not Resuscitate (DNR) forms, also known as advance directives. Tasks were listed and staff
were assigned. The columns under completion date and follow up were blank and there was no evidence
corrective actions or a PIP were completed.
During the annual survey, concerns were identified related to advance directives.
4. Review of the August 2024 QAPI meeting minutes included an action plan related to a survey (not
identified) with citations related to dignity, reporting allegations of abuse to the state survey agency,
thoroughly investigating allegations of abuse, bowel and bladder concerns, nutrition, significant medication
errors and safe, homelike environment. Under tasks, the minutes directed to see plan of correction (POC).
Staff were assigned, completion dates were indicated as ongoing and no follow-up was identified. There
was no evidence corrective actions or a PIP were completed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 86 of116
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
03/31/2025
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 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
During the annual survey, concerns were identified in some of the identified areas including reporting
alleged abuse to the state survey agency, thoroughly investigating allegations of abuse, bowel and bladder,
significant medication errors and a safe, homelike environment.
5. Review of the November 2024 QAPI meeting minutes included an action plan to address an in-house
acquired pressure ulcer, affecting Resident #11. Tasks were listed and staff were assigned. The columns
under completion date and follow up were blank and there was no evidence corrective actions or a PIP
were completed.
During the annual survey, concerns were identified related to pressure ulcers. Resident #11, the resident
with the identified in-house acquired pressure ulcer found on 11/23/24, had a task including weekly
measurements of all areas input into the Electronic Medical Record (EMR) no longer than seven days
apart. Record review and interview indicated Resident #11's wound was not measured again until 02/26/25.
A deficiency was issued regarding pressure ulcers during the annual survey.
6. The February 2025 QAPI meeting minutes revealed an environmental PIP was started on 02/02/25 with
weekly updates on the program documented in the minutes.
During the annual survey, concerns were identified related to the environment and deficiencies were
issued.
Interview on 03/19/25 at 4:32 P.M. with the Administrator, Director of Nursing (DON) and Chief Operating
Officer (COO) #300 revealed QAPI was a mechanism in place to use the support of the interdisciplinary
team to identify and resolve issues. The facility preferred to meet monthly for QAPI instead of just quarterly,
as well as any time there was a problem. The Administrator indicated if there was a self-reported incident
(SRI) or if there was an outbreak of an illness, such as COVID-19 the facility could hold an ad hoc (not
planned) QAPI meeting. Staff verified there was not an ad hoc QAPI meeting during December 2024 when
the facility had an outbreak of COVID-19 but stated there should have been. During the interview, COO
#300 was made aware none of the QAPI meeting minutes provided prior to February 2025 did not have a
full PIP developed, evidence of auditing, education or other corrective measures completed to address the
facility identified concerns or for ongoing monitoring to prevent reoccurrence. COO #300 was not aware of
this prior to the interview and stated she relied on the facility's DON and the Administrator to follow up with
any QAPI-related concerns. Staff verified the facility had one PIP in place for the environment but verified
the hot water temperatures were not identified as part of the environmental issues leading to the
development of their PIP. The Administrator verified as of the time of the interview, there was not yet a
mechanism in place for residents and staff to report issues to the facility's QAPI program.
Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Policy and
Procedure, dated 2025 revealed the facility implemented a comprehensive QAPI program which addresses
all the care and unique services that the facility provides. To ensure continuous evaluation of the facility's
systems the facility would ensure care delivery systems function consistently, accurately and incorporate
current and evidence-based practice standards where available; preventing deviation from care processes,
to the extent possible; identifying issues and concerns with the facility's systems as well as identifying
opportunities for improvement; and developing and implementing plans to correct and/or improve identified
areas. The facility would develop, implement and maintain an effective, comprehensive, data driven QAPI
program that focuses on indicators of the outcomes of care and quality of life. The facility would develop
and implement systems that ensure the care and services it delivers meet acceptable standards of quality
in accordance with recognized standard of practice.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 87 of116
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
03/31/2025
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 0867
The facility shall maintain proper documentation of its QAPI program and provide evidence of its ongoing
QAPI program.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 88 of116
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
03/31/2025
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 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, interview and review of the facility policy, the facility failed to ensure all required
members of the quality assurance performance improvement (QAPI) committee met quarterly as required.
This affected all 54 residents residing in the facility.
Residents Affected - Many
Findings include:
Review of the QAPI meeting minutes and sign-in sheets from January 2024 through February 2025
revealed QAPI met on 03/19/24, 04/16/24, 05/21/24, 06/18/24, 07/16/24, 08/16/24, 09/17/24, 10/15/24,
January 2025 and February 2025. There was no evidence the facility's previous Medical Director, Physician
#367, attended the QAPI meetings on 03/19/24, 04/16/24, 05/21/24, 06/18/24 and 07/16/24. There was no
evidence a member of the facility's governing body attended the QAPI meetings until the January 2025
meeting. Additionally, there was no identification of the facility's Infection Preventionist (IP) on the sign-in
sheets provided to ensure the IP was involved as required.
On 03/17/25 at 12:05 P.M. telephone interview with Physician #366 revealed he had been the Medical
Director at the facility since 07/01/24. Physician #366 stated the facility had QAPI meetings monthly which
he strove to attend and denied any concerns with the facility at this time.
On 03/17/25 starting at 3:02 P.M. interview with Chief Operating Officer (COO) #300 revealed if the medical
director attended by phone or in person, their attendance should have been reflected on the QAPI
signature sheets. COO #300 was made aware during the interview there was no evidence Physician #367
had attended any of the QAPI meetings before Physician #366 took over the Medical Director role in July
2024. COO #300 verified there were no QAPI meeting minutes or sign-in sheets for November 2024 and
December 2024 available for review.
Follow-up interview on 03/19/25 at 2:28 P.M. with COO #300 confirmed she was unable to provide IP
certificates for the former Assistant Director of Nursing (ADON) or the night nurse (not identified) that
helped to cover the IP 'role for a time.' COO #300 confirmed she only covered the facility's infection control
program for January 2025 and February 2025 and attended the facility's QAPI meetings those months and
verified there was no evidence the IP routinely attended QAPI meetings as required.
Review of the facility policy, QAPI Committee Meetings, dated 05/01/22 revealed the facility's Quality
Assurance (QA)/Quality Improvement (QI) committee members include but are not limited to: Director of
Nursing, Medical Director/Physician, Administrator, Director of Housekeeping/Laundry, Director of
Therapeutic Recreation, Director of Social Work, Director of Food Services, Director of Rehabilitation, QA
Nurse, Director of Maintenance and Other designated facility staff. The policy did not identify the IP role as
a required component of its QA/QI meetings. The QA/QI committee will meet at least quarterly to identify
QA/QI issues and to develop appropriate plans of action needed to correct the issues. The Committee
monitors the effect of the implemented changes and makes any revisions necessary to the plan of action.
Review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Policy and
Procedure, dated 2025 revealed the facility implemented a comprehensive QAPI program which addresses
all the care and unique services that the facility provides .the IP shall report to the facility's governing body
on the facility's infection prevention and control program and on incidents such as
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 89 of116
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
03/31/2025
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 0868
Level of Harm - Minimal harm
or potential for actual harm
healthcare associated infections on a regular basis; the IP shall attend each QAPI meeting in order to be
considered an active participant and if the IP cannot attend a QAPI meeting, then another staff member of
the facility may attend in lieu of the IP but that does not change or absolve the IP's responsibility to fulfill the
role of a QAA committee member or reporting on the facility's infection control and prevention program.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 90 of116
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
03/31/2025
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of
the medical record for Resident #49 revealed an admission date of 01/31/25 with diagnoses including heart
failure, chronic respiratory failure, kidney failure, obesity and cirrhosis of the liver.
Residents Affected - Many
Review of the physician's orders for Resident #49 revealed a treatment order for Triad Hydrophilic Wound
Dress External Paste (debriding paste utilized as a wound dressing), apply to buttock topically two times a
day dated 02/26/25. There were no orders for Resident #49 to be on EBP (gown and gloves) during care.
Observation on 03/12/25 at 2:33 P.M. of wound care to Resident #49 with NP #364 (wound nurse) and the
DON revealed he had a Stage III pressure ulcer to Resident #49's right buttock. NP #364 and DON washed
their hands prior to wound care and donned gloves. There were no gowns available in the room, and there
was no sign on the door revealing Resident #49 was on EBP.
Interview on 03/12/25 at 3:40 P.M. with the DON verified Resident #49 did not have an order for EBP, but he
should have had one due to the Stage III pressure ulcer to his right medial buttock.
Review of the facility policy titled, Transmission Based Precautions dated 05/01/22 revealed EBP should be
implemented for high contact resident care activities that provide opportunities for transfer of MDRO's to
staff hands and or clothing. The use of gown and gloves for high contract resident care activities was
indicated when contact precautions would not apply otherwise for nursing homes residents with wound
and/or indwelling medical devices regardless of MDRO colonization as well as residents with MDRO
infection or colonization. Examples of high contact resident care activities requiring gown and gloves are
providing hygiene, device care such as urinary catheter and wound care.
7. Review of the medical record for Resident #11 revealed an admission date of 01/25/17 with diagnoses
including dementia with behavioral disturbance and non-compliance.
Review of the physician's orders for March 2025 revealed an order initiated on 11/26/24 for hospice was to
change Resident #11's wound dressings on Tuesdays and Thursdays on night shift. On 02/26/25 an order
was initiated for staff to apply Skin Prep (forms a film to protect the skin by reducing friction) daily to the
right side of the foot and then leave the foot in the boot at bedtime for wound care.
Observation on 03/12/25 at 2:33 P.M. of wound care with the DON and NP #364 (wound nurse) to Resident
#11's right lateral foot. During the dressing change and assessment, NP #364 removed Resident #11's
dressing, removed the scab to the wound, measured the wound and then applied Skin Prep via wipe. NP
#364 then placed a dry dressing over the wound. NP #364 was asked if the Skin Prep was a cleansing
agent, and she verified it was not a cleansing agent but was like a liquid band-aid. NP #364 stated the
wound had been cleaned during the last dressing change earlier in the night or day shift.
Interview on 03/12/24 at 3:40 P.M. with the DON verified NP #364 did not cleanse Resident #11's right
lateral foot wound during the dressing change.
Review of the facility policy titled, Wound Care dated 05/01/22 revealed the facility would ensure all
residents skin conditions were properly tracked and cared for.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 91 of116
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
03/31/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
8. Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses
including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's disease and dementia.
Review of Resident #204's nursing admission assessment dated [DATE] revealed he had an indwelling
Foley catheter in place. There was no documentation related to Resident #204 needing to be placed on
EBP.
Observation on 03/12/25 at 10:40 A.M. of care to Resident #204 by CNA #305 and CNA #353 revealed he
had an indwelling Foley catheter. CNA #305 and CNA #353 washed their hands, donned gloves and then
provided Foley catheter care to Resident #204. There were no gowns available in the room and there was
no sign on the door revealing Resident #204 was on EBP. Both CNA #305 and CNA #353 verified Resident
#204 was not on EBP
Interview on 03/12/25 at 11:30 A.M. with the Administrator verified Resident #204 was not on EBP but he
should have been due to having an indwelling Foley catheter.
Review of the facility policy titled, Transmission Based Precautions dated 05/01/22 revealed EBP should be
implemented for high contact resident care activities that provide opportunities for transfer of MDRO's to
staff hands and/or clothing. The use of gown and gloves for high contract resident care activities was
indicated when contact precautions would not apply otherwise for nursing homes residents with wound
and/or indwelling medical devices regardless of MDRO colonization as well as residents with MDRO
infection or colonization. Examples of high contact resident care activities requiring gown and gloves are
providing hygiene, device care such as urinary catheter and wound care.
9. Review of four out of six new employee personnel files revealed the facility was not ensuring staff were
given a purified protein derivative (PPD) test (test for tuberculosis) on hire. The Administrator,
Housekeeping Supervisor #306, Activities Director #330 and Receptionist #335 tuberculosis screenings
were blank or not in their files.
Interview on 03/18/25 at 1:04 P.M. with COO #300 verified the Administrator, Housekeeping Supervisor
#306, Activities Director #330 and Receptionist #335 did not have tuberculosis screening on hire.
The facility was unable to provide a tuberculosis screening policy for staff.
This deficiency represents noncompliance investigated under Master Complaint Number OH00163232 and
Complaint Number OH00162361.
Based on record review, observations, interviews, review of hospital discharge summaries, review of the
Ohio Department of Health (ODH) Ohio Disease Reporting System (ODRS), review of the Summit County
Public Health (SCPH) Public Health Nurse (PHN) communications, and facility policy review, the facility
failed to develop, maintain, and implement an effective infection control program. This had the potential to
affect all 54 residents residing in the facility.
The failed to follow the local health department's directives for Resident #24 with a MDRO. This affected
one resident (#24) of one resident reviewed for a MDRO and had the potential to affect all residents.
The facility failed to ensure infection control tracking was not complete or accurate. This had the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 92 of116
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
03/31/2025
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 0880
potential to affect all residents.
Level of Harm - Minimal harm
or potential for actual harm
The facility failed to have effective COVID-19 outbreak testing, or infection surveillance for staff and
residents. The affected 20 residents (#2, #9, #11, #16, #18, #21, #22, #31, #35, #36, #37, #38, #40, #41,
#42, #43, #44, #46, #47, and #55) and had the potential to affect all residents.
Residents Affected - Many
The facility failed to have an effective legionella water management program. This had the potential to affect
all residents.
The facility failed to ensure EBP, transmission-based precautions (TBP) and/or contact precautions were in
place for Residents #10, #14, #25, #30, #38, #49, and #204. This affected seven residents (#10, #14, #25,
#30, #38, #49, and #204) of 12 residents reviewed for infection control and had the potential to affect all
residents.
The facility failed to ensure maintain proper infection control practices while providing wound care for
Resident #11. This affected one resident (#11) of two residents reviewed for wound care.
The facility failed to ensure tuberculosis screening upon hire for four employees (Administrator,
Housekeeping Supervisor #306, Activities Director #330 and Receptionist #335) of ten employee personnel
files reviewed. This had the potential to affect all residents.
Findings include:
1. Review of the medical record for Resident #24 revealed admission date of 06/04/24 with diagnoses
including dementia with psychotic disturbance, hypertension, hyperlipidemia, lymphedema, Parkinson's
disease, anxiety disorder, and atherosclerotic heart disease.
Review of a nurses note dated 11/05/24 revealed Resident #24 stated he was not feeling well. Resident
#24 had a temperature of 101.4 degrees Fahrenheit (F), blood pressure of 132/87, oxygen saturation of 93
percent, and heart rate of 117. Resident #24 was sent to hospital for evaluation.
Review of the hospital Discharge summary dated [DATE] revealed Resident #24 was admitted to hospital
from [DATE] to 11/11/24 for sepsis (a life-threatening condition that occurs when the body's immune system
overreacts to an infection, leading to widespread inflammation and organ damage). It was noted blood and
respiratory cultures had no growth.
Review of a nurses note dated 11/20/24 timed 7:30 A.M. revealed Resident #24 complained of being cold
and not feeling well.
Review of a nurse's note dated 11/20/24 timed 1:58 P.M. revealed Resident #24 had a temperature of 99.8
degrees F and symptoms had not improved. Resident #24 was sent to hospital for evaluation.
Review of the hospital Discharge summary dated [DATE] revealed Resident #24 was admitted to hospital
from [DATE] to 11/24/24 for cellulitis (an acute bacterial infection of the skin and underlying tissues) of the
left lower extremity. Resident #24 admitted for recurrent left lower extremity cellulitis and had previously
been admitted from 11/05/24 to 11/11/24. Resident #24 was noted to have Methicillin-resistant
Staphylococcus aureus (MRSA) growth on the sputum culture, so doxycycline (antibiotic) was added. The
sputum culture appeared consistent with colonization (the presence and multiplication of microorganisms
on or within a host organism without causing any apparent symptoms or
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 93 of116
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
03/31/2025
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 0880
disease).
Level of Harm - Minimal harm
or potential for actual harm
Review of a Nurse Practitioner (NP) progress note dated 11/25/24 revealed Resident #24 returned from
hospital on [DATE] with a diagnosis of cellulitis. The NP noted Resident #24 was discharged on an antibiotic
for cellulitis and MRSA in the sputum culture.
Residents Affected - Many
Review of a NP progress note dated 12/16/24 revealed Resident #24 completed an oral antibiotic treatment
of cephalexin for cellulitis and doxycycline for MRSA of sputum on 12/02/24.
Review of a nurses note dated 02/24/25 revealed Director of Nursing (DON) spoke with Resident #24's
daughter regarding concerns about testing. The DON assured Resident #24's daughter the test would be
completed, and she would be notified when the sample was sent to the lab. There was no specification
regarding what the test was for.
Review of the current physician's orders for March 2025 revealed no evidence Resident #24 had order for
enhanced barrier precautions (EBP) related to MDRO status.
Review of the plan of care for March 2025 revealed no care plan related to infections or MDRO status.
Further review of the medical record for Resident #24 revealed no additional information on Resident #24's
MDRO status of colonization.
Review of the undated ODH ODRS report revealed Resident #24 had sputum culture collected on 11/10/24
while at hospital. Results of sputum culture returned on 11/27/24 and were positive for Citrobacter koseri
and Klebsiella aerogenes. Klebsiella pneumoniae carbapenemase (KPC) was detected.
Review of the facility infection control logs from November 2024 to February 2025 revealed no evidence
Resident #24's MDRO infection was logged, tracked, or monitored.
Review of documented notes from SCPH PHN #370 revealed:
•
On 12/04/24 PHN #370 contacted the hospital requesting labs and provider notes with information on
Resident #24's location of residence.
•
On 12/10/24 PHN #370 attempted phone contact to facility without success.
•
On 12/18/24 PHN #370 attempted phone contact to facility without success.
•
On 12/27/24 PHN #370 attempted phone contact to facility. PHN #370 was able to obtain DON's email
address and email communication was sent.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 94 of116
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
03/31/2025
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 0880
•
Level of Harm - Minimal harm
or potential for actual harm
On 01/07/25 PHN #370 had not received response to email to DON. A follow-up call was placed to facility
and voicemail was left for Admissions/Social Service Designee (SSD) #355. SSD #355 returned phone call
and confirmed Resident #24 had not been in EBP. PHN #370 provided education on colonization screening
and would send follow up email with more information. DON returned call to PHN #370 and was also
educated on EBP and screening needs.
Residents Affected - Many
•
On 01/15/25 PHN #370 had not received follow up from facility on initiating colonization screening. PHN
#370 left voicemail for SSD #355.
•
On 01/17/25 PHN #370 was contacted by Chief Operating Officer (COO) #300. PHN #370 forwarded email
with screening recommendations, swab request form, and education.
•
On 01/27/25 PHN #370 had not received screening request forms and placed follow up call to COO #300
without successful contact.
•
On 02/04/25 PHN #370 had not received follow up for screening from facility. SCPH Medical Director called
facility and spoke with the Administrator. The Administrator indicated the facility was having turnover and
requested email be forwarded to her.
•
On 02/12/25 PHN #370 received a request for testing kits from DON.
•
On 02/28/25 PHN #370 noted the facility was scheduled to perform screening on 02/17/25; however. No
results had returned. PHN #370 followed up with lab and discovered no specimens were received from
facility.
Review of email communication dated 12/27/24 at 3:01 P.M. from SCPH PHN #370 addressed to
Registered Nurse (RN)/Former DON #313 revealed PHN #370 notified facility of Resident #24 was
reported to SCPH for a carbapenemase producing organism (CPO) and PHN #370 requested more
information. It was noted Resident #24 should be on EBP.
Review of email communication dated 01/07/25 at 2:56 P.M. from SCPH PHN #370 addressed to Former
DON #313 and SSD #355 revealed PHN #370 provided educational materials and instructions for
Carbapenemase Producing Carbapenem Resistant Enterobacteriaceae (CP-CRE) screening. PHN #370
indicated Point-Prevalence Screening (PPS) should be completed on Resident #24's unit. Resident #24
was identified as the index case and should be on EBP. Screenings were by rectal swab and must be
completed on an
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 95 of116
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
03/31/2025
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 0880
agreed collection date.
Level of Harm - Minimal harm
or potential for actual harm
Review of email communication dated 01/17/25 at 11:55 A.M. from SCPH PHN #370 addressed to COO
#300 revealed PHN #370 forwarded email sent to Former DON #313 and SSD #355.
Residents Affected - Many
Review of email communication dated 02/04/25 at 1:41 P.M. from SCPH PHN #370 addressed to the
Administrator revealed PHN #370 re-sent email sent to Former DON #313, SSD #355, and COO #300.
Review of email communication dated 02/10/25 at 11:23 A.M. from COO #300 addressed to SCPH PHN
#370 revealed COO #300 attached order form for rectal swab test kits with no specification of number of
kits needed.
Review of email communication dated 02/12/25 at 10:09 A.M. from Former DON #313 addressed to SCPH
PHN #370 revealed Former DON #313 attached consent forms for five swab culture kits.
Review of Laboratory Report dated 03/05/25 revealed a rectal swab was obtained on 02/28/25 for Resident
#24 and KPC gene deoxyribonucleic acid (DNA) was detected.
Review of Laboratory Report dated 03/05/25 revealed rectal swabs were obtained on 02/28/25 for
Residents #34 and #46. Residents #34 and #46 were identified to share a bathroom with Resident #24.
Residents #34 and #46's swabs were negative for any detectable genes.
Observation on 03/10/25 at 12:55 P.M. revealed Resident #24 was on EBP.
Observation on 03/11/25 at 5:55 A.M . revealed Resident #24 was changed to contact precautions.
Interview on 03/11/25 at 9:55 A.M. with PHN #370 revealed the facility had been difficult to contact and did
not complete screening as scheduled. PHN #370 indicated Resident #24 was the index case and due to
colonization status needed to be on EBP. PHN #370 indicated screening was necessary to determine if
there had been any transmission.
Interview on 03/11/25 at 11:53 A.M. with the DON confirmed she had changed Resident #24 from EBP to
contact precautions as she had noticed report of CRE in sputum. DON indicated she became aware of the
issue in a care conference with Resident #24's daughter. The DON indicated in her investigation she
realized the facility had been contacted by SCPH, and there were required screenings to be done. She
collected the samples and got the swabs sent out for testing.
Interview on 03/11/25 at 1:59 P.M. with SSD #355 revealed she became involved with SCPH via phone.
SSD #355 indicated the DON was on vacation and she took a message. SSD #355 indicated she relayed
all information to COO #300.
Interview on 03/11/25 at 2:13 P.M. with the Administrator and COO #300 confirmed SCPH had reached out
about Resident #24. COO #300 indicated SCPH was working with RN/Former DON #313.
Interview on 03/11/25 at 4:20 P.M. with RN/Former DON #313 revealed she was contacted sometime in
January 2025 by SCPH. DON #313 indicated SCPH PHN #370 had emailed her information on EBP and
screening that needed done. DON #313 indicated the screening specimens were collected mid-February
2025 and she had left the specimens for the new DON to send out. DON #313 indicated she was unaware
of a 02/17/25 testing date with the lab. DON #313 indicated she was on vacation during this time.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 96 of116
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
03/31/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Interview on 03/12/25 8:23 A.M. with the DON revealed there had not been any information left for her on
swabs or documentation on Resident #24's MDRO status left by Former DON #313. When she became
aware, she took action to get test swabs sent to lab to comply with SCPH recommendations. The DON
confirmed there was no documentation in Resident #24's medical record on MDRO status or order for EBP.
Review of undated SCPH provided educational document Enhanced Barrier Precautions revealed EBP was
recommended for life for diagnosed clinical cases and colonized positive residents of CPOs due to
increased risk for transmission. EBP required use of gowns and gloves during high contact patient care
activities including dressing, bathing, transfers, hygiene, changing linens, care of or use of medical devices,
and wound care.
Review of SCPH provided educational document Facility Guidance for Control of CRE dated November
2015 revealed CDC CRE tool kit was intended for all long-term care facilities. The effort to prevent
transmission of resistant organisms could be coordinated by local public health.
Review of the facility policy Screening and Management of Residents with Infections dated 05/01/22
revealed the infection preventionist would maintain a log of residents with current evidence of infection or
colonization due to MDRO. Room placement should be considered to prevent placing a resident with
MDRO with a resident at high risk for infection. A resident admitted with colonization of MDRO should be
reviewed prior to return for details of the status and any possible infection control risks the situation
presents.
Review of the facility policy Infection Surveillance dated 10/27/21 revealed cultures may be sent for
infections or colonization with epidemiologically important organisms. All MDRO reports required immediate
attention to ensure appropriate precautions were in place and notifications were made. The infection control
committee would communicate important surveillance data to state and local health departments.
2. Review of infection control logs from January 2024 to December 2024 revealed that starting in June 2024
logs were not completed appropriately to adequately track and trend infections. Identified infections did not
include dates of onset, culture or testing results, symptoms, if resident was placed on isolation, or if
organisms were sensitive to medications. The Infection Preventionist (IP) had only recorded the residents'
name, room number, general infection type and antibiotic ordered. There was no evidence of ongoing
analysis of infection data.
Review of the Antibiotic Use Audit Tool for January 2025 and February 2025 revealed COO #300 had
audited use of antibiotics for infections. There was no evidence of complete and accurate infection control
tracking or trends.
Interview on 03/10/25 at 12:01 P.M. with COO #300 revealed she was unsure if there was a full 12 months
of infection control logs. COO #300 indicated she had started an infection control book for January 2025
and February 2025.
Interview on 03/12/25 at 8:23 A.M. with the DON confirmed infection control tracking was not complete or
accurate. There was not much available to review for the past 12 months. The facility should be tracking
infections on a log and using mapping to identify patterns.
Review of the facility policy Infection Surveillance dated 10/27/21 revealed the infection
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 97 of116
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
03/31/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
preventionist was responsible for gathering and interpreting surveillance data. Surveillance data should
include identifying information of resident, diagnoses, admission date, date of onset of infection, site of
infection, pathogens, risk factors, pertinent remarks on signs and symptoms, if resident was admitted to
hospital or other outcomes, and treatment measures and precautions. Monthly data should be collected
and entered onto a line listing report then data should be summarized for each nursing unit by site and
pathogen. Predominant pathogens or sites should be identified for trending.
3. Observation on 03/10/25 at revealed there were no current residents on isolation for COVID-19.
Interview on 03/11/25 at 11:25 A.M. with COO #300 revealed she was aware there were a few cases of
COVID-19 in December 2024 but was trying to get a list from the Former DON #313.
Interview on 03/12/25 at 4:50 P.M. with COO #300 confirmed there was no COVID-19 infection tracking.
COO #300 indicated the last outbreak was handled by the Former DON #313 and Former Assistant DON
(ADON) #368.
Interview on 03/13/25 at 8:22 A.M. with SCPH Staff #371 revealed she was responsible for COVID-19
tracking in the community. SCPH #371 indicated there was an online form that facilities could fill out weekly
for reporting purposes. SCPH #371 indicated they asked facilities to fill out the form even if there were no
cases of COVID-19. SCPH #371 indicated the last data submitted for the facility was for 12/04/24. SCPH
#371 indicated there had been no data submitted about a COVID-19 outbreak in December 2024. SCPH
#371 indicated the facility needed to report COVID-19 cases or outbreaks to be considered compliant.
Interview on 03/13/25 at 12:25 P.M. with Resident #22 confirmed he had COVID-19 in December 2024.
Resident #22 stated staff wore appropriate personal protective equipment (PPE) while in his room and they
moved his roommate to another room.
Despite multiple requests on 03/10/25, 3/11/25, 03/12/25, and 03/13/25 the facility was unable to provide
any COVID-19 infection tracking.
On 03/13/25 the surveyor completed a record review of residents residing in the facility. It was discovered
that Residents #2, #11, #16, #18, #21, #22, #31, #37, #42, #43, #44, #47, and #55 tested positive for
COVID-19 on 12/27/24. Resident #31 tested positive for COVID-19 while in the hospital. It was discovered
that Resident #38 tested positive for COVID-19 on 12/30/24. It was discovered that Resident #35 tested
positive for COVID-19 on 01/01/25. It was discovered that Residents #9, #40, #41, #46 tested positive for
COVID-19 on 01/03/25. There was no evidence able to be obtained on staff positives for COVID-19, and no
staff identified themselves as having COVID-19. Residents #9, #16, #35, #40, #41, and #46 had no
identified orders for transmission-based precautions (TBP) related to COVID-19 positive status. Residents
#21, #22, #37, #42, #47, and #55 TBP orders were added on 12/28/24. Residents #2, #11, #18, #34, #38,
#43, and #44 TBP orders were added on 12/30/24. It was discovered that there was no evidence COVID-19
positive Resident #22's roommate COVID-19 negative Resident #36 was moved until 12/30/24.
Attempts on 03/13/25 and 03/17/25 to reach Former DON #313 and Former ADON #368 via phone were
unsuccessful.
Interview on 03/17/25 at 8:00 A.M. with Certified Nurse Aide (CNA) #305 and CNA #353 revealed they had
not been on the schedule when the COVID-19 outbreak started in December 2024. Both nurse aides
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 98 of116
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
03/31/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
recalled there being plenty of PPE and isolation in place for COVID-19 positive residents. Neither CNA
#305 or CNA #353 could recall the testing procedures followed during the outbreak.
Interview on 03/17/25 at 9:06 A.M. with Central Supply/Scheduler #338 confirmed there were cases of
COVID-19 in December 2024 among staff and residents. Central Supply/Scheduler #338 indicated she
knew there was a whole facility round of testing done. Central Supply/Scheduler #338 indicated Former
DON #313 and Former ADON #368 were completing the testing. Central Supply/Scheduler #338 indicated
she was not sure who the staff were that had COVID-19, and there was no method for monitoring staff
illness.
Interview on 03/17/25 at 11:27 A.M. with COO #300, Administrator, and RN/IP #374 revealed RN/IP #374
was not employed by the facility but had been assisting the facility with infection control in interim between
IPs. RN/IP #374 indicated she knew there was a COVID-19 outbreak in December 2024. Surveyor
identified COVID-19 cases were reviewed with COO #300, Administrator, and RN/IP #374, and COO #300
indicated she did not know there were so many cases. COO #300, Administrator, and RN/IP #374 were
unable to provide additional information related to the COVID-19 outbreak, outbreak testing, or infection
surveillance.
Interview on 03/17/25 at 2:26 P.M. with NP #363 revealed Resident #31 was sent to the hospital after a fall
on 12/26/24. NP #363 indicated they were made aware Resident #31 tested positive for COVID-19 at the
hospital and the facility did whole house testing on 12/27/24. NP #363 reported no concerns with COVID-19
management at the facility.
Review of the facility policy COVID-19 Precautions and Prevention dated 10/05/22 revealed the IP should
maintain communication and collaboration with state and local health authorities including notification. IP
should conduct frequent monitoring and surveillance for new respiratory illnesses. An outbreak would be
declared when one case had suspected or confirmed COVID-19, residents with severe respiratory infection
resulting in hospitalization or death, or more than three residents or staff display new-onset respiratory
symptoms within 72 hours of each other. IP should follow the local health department's recommendations
for the next steps on managing a COVID-19 outbreak.
4. Interview on 03/11/25 at 11:25 A.M. with COO #300 revealed she was unable to find the legionella water
management program binder.
Interview on 03/11/25 at 1:08 P.M. with Administrator confirmed she was unable to locate any evidence of
water management program or evidence of water temperature logs.
The facility provided documents Water Management Plan for Potable Water and policies on Legionella
Water Management on 03/12/25.
Interview on 03/17/25 at 11:27 A.M. with Administrator, COO #300, and RN/IP #374 confirmed they were
unable to locate any additional information on legionella water management program. COO #300 confirmed
provided Water Management Plan for Potable Water and policy for Legionella Water Management did not
meet requirements for assessing risk, measures to prevent growth of Legionella in building water systems
based on nationally accepted standards, or method for monitoring measures in place.
Review of the undated facility Water Management Plan for Potable Water revealed a section indicating
water system was fed bottom-up, potable water system had two loops, there were no holding tanks for
potable water, there were two water mains from public water supply with one for potable water and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page 99 of116
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
03/31/2025
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 0880
Level of Harm - Minimal harm
or potential for actual harm
one for sprinkler system, and water mains were equipped with backflow preventers. The plan went on to
indicate an environmental assessment would be updated annually and as needed. There was no evidence
of an environmental assessment being completed. From the environmental assessment water testing would
be completed. There was no evidence of water testing or sampling completed. There was no evidence of
lab testing samples.
Residents Affected - Many
Review of the facility policy Legionella dated 07/01/23 revealed the facility would establish protocols for
prevention and control of transmission of Legionnaire's disease including conducting sampling of potable
water per facility's water management plan, disinfecting water distribution system using a high temperature
flush, and keeping a log reflecting flushes.
Review of the facility policy Legionella Water Management dated 05/01/22 revealed as part of the facility's
infection control program there would be a water management team to oversee water management
program. The team would include an infection preventionist, administrator, medical director, director of
maintenance, and director of environmental services. The water management program would be based on
Centers for Disease Control and Prevention (CDC) and American Society of Heating, Refrigeration, and
Air-Conditioning Engineers (ASHREA) recommendations. The water management program would include a
detailed description and diagram of water system in the facility, identification of areas in water system that
could encourage growth and spread, identification of situations that could lead to growth, specific measures
used to control, control limits or acceptable parameters, diagram of where control measures are applied, a
system to monitor control limits and effectiveness, a plan for when control limits are not met, and
documentation of program.
5. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed Residents #11, #20, #24, #30, #39,
and #43 were identified as on EBP. There was signage for EBP instructions and to see nurse before
entering and PPE was available at the entrance to the room. It was not clear which resident in the shared
room for Resident #11 and #39 was on EBP. Resident #25 was identified as on contact precautions. There
was signage for contact precautions instructions and a door hanger with PPE on the back of the door that
contained gloves and red biohazard bags. There were no gowns readily available for Resident #25.
Interview on 03/10/25 at 12:43 P.M. with Licensed Practical Nurse (LPN) #369 revealed she worked for an
agency and it was only her second time working at this facility. LPN #369 indicated she was unsure why
Resident #25 was on contact precautions.
Follow up tour on 03/10/25 from 4:10 P.M. to 4:18 P.M. the DON revealed that she had been working at the
facility for approximately three weeks and verified that she had not yet provided the survey team with the
requested list of residents on precautions. She observed Residents #11, #20, #24, #30 and #43 and
confirmed the residents were on EBP. The DON observed Resident #25 and confirmed the resident was on
contact precautions for a Clostridium difficile (C. diff) infection, but it was cleared now. She indicated the
signage needed changed to EBP. The DON confirmed there were no gowns readily available for Resident
#25, and she verified Residents #11, #20, #24, #25, #30, and #43 all required EBP or TBP.
Observations on 03/11/25 from 5:45 A.M. to 5:55 A.M. revealed Residents #10, #14, #38, and #204 were
newly placed on EBP, and Resident #24 was changed to contact precautions.
Int[TRUNCATED]
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page100of116
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
03/31/2025
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 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, record review, review of infection control logs, and review of facility policy, the facility
failed to ensure implementation of appropriate antibiotic stewardship measures. This affected one Resident
(#9) of three reviewed for urinary tract infections and 15 residents (#2, #9, #19, #23, #24, #25, #29, #32,
#33, #35, #37, #42, #43, #50, and #55) of 15 residents reviewed in the infection control log. The facility
census was 54.
Residents Affected - Some
Findings include:
1. Review of the medical record for Resident #9 revealed an admission date of 04/12/24 and diagnoses
including bell's palsy, systemic lupus erythematosus, congestive heart failure, hypertension, dementia,
metabolic encephalopathy, malignant neoplasm of bronchus and lung, and chronic kidney disease.
Review of the nurses note dated 01/11/25 revealed Resident #9 was agitated and adamant she was going
home. Resident #9's son came to the facility to try to calm her down and he reported that Resident #9 was
exhibiting symptoms of a urinary tract infection (UTI) as she had in the past. Hospice and the residents
physician were notified. The physician gave an order for Ciprofloxacin (Cipro) for seven days and to collect
a urine sample.
Review of Resident #9's physician's orders for January 2025 revealed no documented evidence of an order
for a urine sample.
Review of Resident #9's laboratory results for January 2025 revealed no documented evidence of a
urinalysis or culture completed to support the antibiotic treatment for UTI symptoms.
Review of the Antibiotic Use Audit Tools for January 2025 revealed on 01/11/25 Resident #9 received Cipro
with an indication for use of a UTI. The tool indicated Resident #9 did not meet McGeer's Criteria, indicating
that the resident did not exhibit the necessary signs, symptoms, and/or laboratory findings to be definitively
diagnosed with a UTI.
Review of Resident #9's physician's order dated 01/12/25 revealed an order for Ciprofloxacin 500
milligrams (mg) two times per day for seven days.
Review of Resident #9's physician's order dated 01/21/25 revealed order for Macrobid (Nitrofurantoin) 100
mg two times per day for an unspecified number of days. The order was discontinued on 02/04/25.
Review of the Antibiotic Use Audit Tools for January 2025 revealed on 01/21/25, Resident #9 received
Nitrofurantoin with an indication for use of a UTI. The tool indicated Resident #9 did not meet McGeer's
Criteria, indicating that the resident did not exhibit the necessary signs, symptoms, and/or laboratory
findings to be definitively diagnosed with a UTI.
Interview on 03/17/25 at 10:32 A.M. with Chief Operating Officer (COO) #300 confirmed she was unable to
find a urinalysis completed for Resident #9 in January 2025 when Resident #9 was treated with an
antibiotic for UTI symptoms.
Interview on 03/17/25 at 2:26 P.M. with Nurse Practitioner (NP) #363 indicated Resident #9's family
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page101of116
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
03/31/2025
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 0881
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
reported she had history of UTI's and she was on hospice. NP #363 indicated she did not find it unusual for
hospice to treat symptoms.
2. Review of the infection control logs from January 2024 to December 2024 revealed starting in June 2024,
logs were not completed appropriately to adequately track and trend infections. Identified infections did not
include the date of onset, culture or testing results, symptoms, if the resident was placed on isolation, or if
organisms were sensitive to medications. The log had only recorded the residents' name, room number,
general infection type and antibiotic ordered. Fifteen residents (#2, #9, #19, #23, #24, #25, #29, #32, #33,
#35, #37, #42, #43, #50, and #55) were identified in the incomplete infection control log from June 2024 to
December 2024.
Review of the Antibiotic Use Audit Tool for January 2025 and February 2025 revealed Chief Operating
Officer (COO) #300 had audited the use of antibiotics for infections. COO #300 had indicated none of the
residents with infections that were treated with antibiotics had met McGeer's Criteria, indicating that the
resident did not exhibit the necessary signs, symptoms, and/or laboratory findings to be definitively
diagnosed with an infection.
Interview on 03/10/25 at 12:01 P.M. with COO #300 revealed she was unsure if there was a full 12 months
of infection control logs. COO #300 indicated she had started an infection control book for January 2025
and February 2025.
Interview on 03/12/25 at 8:23 A.M. with Director of Nursing (DON) confirmed she was unable to locate any
information on the facility's antibiotic stewardship program. DON indicated there was limited information
available left for her regarding infection control in general. The DON indicated she would expect to see the
use of McGeer's criteria and would have the nurse practitioner evaluate if the resident did not meet criteria
for treatment with antibiotic.
Interview on 03/13/25 at 11:29 A.M. with COO #300 revealed she had created logs for January and
February 2025 by reviewing progress notes. COO #300 indicated a lot of the residents on the log came in
from the hospital already on antibiotics. COO #300 indicated residents did not always meet McGeer's
criteria, but the physician did not want to change or discontinue the antibiotic. COO #300 indicated they just
followed what the physician said.
Interview on 03/13/25 at 12:01 P.M. with COO #300 confirmed she did not have McGeer's criteria filled out
on each infection with an antibiotic ordered, however she had cross referenced it when she created her
logs.
Review of facility policy Antibiotic Stewardship Program dated 07/01/23 revealed lab results would be
reported to prescriber to determine if antibiotic therapy should be started, continued, modified, or
discontinued. The infection preventionist would continue infection line listing and review antibiotic utilization
on a monthly basis to ensure appropriate prescribing and use of antibiotics.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page102of116
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
03/31/2025
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 0882
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Designate a qualified infection preventionist to be responsible for the infection prevent and control program
in the nursing home.
Based on review of Quality Assurance and Performance Improvement (QAPI) meetings, staff interview,
review of staff certificates and personnel files, the facility failed to ensure there was a qualified infection
preventionist (IP) working on at least a part time basis. This had the potential to affect all residents residing
in the facility. The facility census was 54.
Findings include:
Review of the Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheets from March
2024 to February 2025 revealed no designation of an IP or evidence of an IP participation in meetings,
except for in January 2025 and February 2025 when Chief Operating Officer (COO) #300 was present.
Interview on 03/10/25 at 12:01 P.M. with COO #300 revealed there was not currently an infection
preventionist (IP) employed at the facility. COO #300 indicated she held an IP certificate and Registered
Nurse (RN) #374 was a Director of Nursing and IP for another facility, who was assisting with the
changeover in staff. COO #300 indicated former Assistant Director of Nursing (ADON) #368 was the IP
from May 2024 through December 2024.
Interview on 03/11/25 at 8:00 A.M. with the Director of Nursing (DON) revealed she had an IP certificate,
but was unable to provide evidence of the certificate.
Interview on 03/19/25 at 2:28 P.M. with COO #300 confirmed she was unable to locate an IP certificate for
the former ADON #368 and confirmed there had not been consistent participation from an IP on QAPI
meetings as required. She stated she was only at the facility from January 2025 to current and was only
present one day per week and RN #374 worked mostly offsite.
Review of the certificate dated 06/05/20 revealed RN #374 completed IP training course with Centers for
Disease Control and Prevention (CDC) via web-based training.
Review of certificate dated 01/09/25 revealed COO #300 completed IP training course with CDC via
web-based training.
Review of the personnel file of former ADON #368 revealed no evidence of an IP certificate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page103of116
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
03/31/2025
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, review of a facility immunization report, facility policy review, review of facility census, review
of Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed to ensure
residents were offered, screened, educated and received influenza and pneumococcal vaccinations as
required. This affected nine residents (#23, #24, #25, #26, #31, #38, #43, #55 and #204)
reviewed/interviewed as part of the survey and the lack of an effective system to manage vaccinations and
prevent incidents of influenza/pneumonia had the potential to affect all 54 residents residing in the facility.
The facility census was 54.
Residents Affected - Many
Findings include:
1.Review of the facility census on 12/04/24 revealed there were 45 residents, Resident #2, #4, #5, #6, #7,
#8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #27, #29, #30, #31,
#32, #33, #34, #35, #36, #37, #38, #40, #41, #42, #44, #45, #46, #50, #51, #55, #56, #57, and #58 who
resided in the facility on this date.
Review of the facility Immunization Report from 01/01/24 to 03/13/25 revealed there was no documented
evidence of any pneumococcal vaccinations completed for any residents during this time period of 01/01/24
to 03/31/25. In addition, record review revealed there was no documented evidence of consent/declination,
screenings, or education regarding pneumococcal vaccinations for any facility residents during this time
period.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) revealed she was unable to find any
evidence of pneumococcal vaccinations being completed as required for any residents between 01/01/24
and 03/13/25.
Review of a facility Immunizations Report from 01/01/24 to 03/13/25 revealed 23 residents (#4, #5, #7, #8,
#11, #12, #15, #18, #20, #21, #24, #25, #27, #29, #32, #33, #36, #40, #41, #44, #45, #46, #51) were
included on the report as having received an influenza vaccination on 12/04/24 and 12 residents (#2, #9,
#10, #16, #19, #22, #23, #30, #35, #37, #38, #42) who refused the influenza vaccination. However, there
was no documented evidence of consent/declination, screenings, or education regarding influenza
vaccinations for any facility residents during this time period.
Interview on 03/13/25 at 12:10 P.M. with the DON confirmed she was unable to locate evidence of
education or any of the 23 consents for influenza vaccinations that were completed on 12/04/24.
A follow-up interview on 03/17/25 at 11:27 A.M. with the Administrator, Chief Operating Officer (COO) #300,
and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the
facility but had been assisting the facility with infection control in interim between IPs. They were unaware of
how the previous DON, DON #313 and Assistant DON (ADON) #368 had been handling vaccinations and
acknowledged there was a lot of missing vaccination forms. COO #300 indicated she was unsure why the
annual influenza vaccinations were not administered until 12/04/24. COO #300 indicated that was the
responsibility of Former DON #313 and she likely did not place her order for vaccinations in a timely
manner.
A follow-up interview on 03/19/25 at 2:28 P.M. with COO #300 confirmed she was unable to locate any
additional information on pneumococcal or influenza vaccinations for any residents.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page104of116
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
03/31/2025
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
A follow-up interview on 03/19/25 at 3:37 P.M. with the DON confirmed she was unable to provide any
additional information on pneumococcal or influenza vaccinations for any residents.
Interview on 03/27/25 at 11:09 A.M. with Resident #26 revealed she was admitted right before Christmas,
on 12/20/24. She stated she was never educated about or asked if she wanted the influenza or
pneumococcal vaccines. She stated she would have taken the influenza vaccine.
Interview on 03/27/25 at 11:13 A.M. with Resident #43 revealed he arrived in December 2024 (12/16/24)
and he was never offered or educated on the influenza or pneumococcal vaccines. He stated he did not
receive any vaccines while he was at the facility and he would have liked to have had them.
Review of the facility policy Pneumococcal (Pneumonia) Vaccine dated 10/27/21 revealed administration of
pneumococcal vaccines or revaccinations would be made in accordance with current Centers for Disease
Control and Prevention (CDC) recommendations at time of vaccination. Residents would be assessed for
eligibility as indicated and offered within 30 days of admission to facility unless medically contraindicated or
already up to date on vaccination status. The resident or legal representative would receive information and
education on benefits and potential side effects. Administration and refusal would be documented in the
resident's medical record.
Review of the facility policy Influenza Vaccine dated 07/01/23 revealed all residents should receive
influenza vaccinations annually unless there was a documented contraindication. Influenza vaccinations
should be offered from October 1st through March 31st of each year. Consent and declination shall be
documented in resident's medical record.
2. Review of the medical record for Resident #23 revealed an admission date of 06/27/24 with diagnoses
including asthma and pulmonary embolism. The medical record revealed Resident #23 was her own
responsible party and the resident was [AGE] years old.
Review of the immunizations record revealed no historical records of the resident receiving a
pneumococcal vaccination. There was no evidence of the facility offering, screening, or educating Resident
#23 for pneumococcal vaccinations. The record indicated Resident #23 refused the influenza vaccination at
an unspecified time; however, there was no evidence of a consent/declination, education, or rationale for it
being declined.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident
#23 did not receive the influenza vaccine as the resident was not in the facility. The assessment also noted
Resident #23 was not up to date on the pneumococcal vaccination as the resident was not assessed.
On 03/13/25 at 7:30 A.M. interview with the Director of Nursing (DON) revealed she was unable to find any
evidence of pneumococcal vaccination being completed as required for Resident #23.
On 03/13/25 at 12:10 P.M. a follow-up interview with the DON confirmed she was unable to locate any
consents or declination for the influenza vaccination for Resident #23.
On 03/27/25 at 10:05 A.M. an interview with Resident #23 revealed the last vaccine she received was prior
to coming to the facility. The resident denied being offered any vaccines or education while she was in the
facility. During the interview, the resident indicated it was likely she would not want to receive an influenza
or pneumococcal vaccination based on the preservatives in them because of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page105of116
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
03/31/2025
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 0883
her low white blood cell count.
Level of Harm - Minimal harm
or potential for actual harm
3. Review of the medical record for Resident #24 revealed an admission date of 06/04/24 with diagnoses
including dementia, hypertension, lymphedema, psychosis, Parkinson's disease, and atherosclerotic heart
disease. The medical record revealed Resident #24 had a guardian and the residents was [AGE] years old.
Residents Affected - Many
Review of the immunizations record revealed no historical records of the resident receiving a
pneumococcal vaccination. There was no evidence of the facility offering, screening, or educating Resident
#24's guardian about pneumococcal vaccinations. The record indicated Resident #24 received the influenza
vaccination on 12/04/24; however, there was no evidence of a consent, screening, or education for the
vaccination.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident
#24 did not receive the influenza vaccine as the resident was not in the facility. The assessment also noted
Resident #24 was not up to date on pneumococcal vaccinations as the resident was not assessed.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) revealed she was unable to find any
evidence of pneumococcal vaccination being completed as required for Resident #24.
Interview on 03/13/25 at 12:10 P.M. with the DON confirmed she was unable to locate any consents or
declinations for the influenza vaccination for Resident #24.
Interview on 03/27/25 at 9:38 A.M. with Resident #24's guardian revealed she had been the resident's
guardian since admission on [DATE] and the facility had never educated or offered immunizations, including
influenza and pneumonia.
A follow-up interview on 03/27/25 at 11:44 A.M. with Resident #24's guardian the guardian revealed the
resident would have taken the vaccines as she usually did get an influenza vaccine every year. It was
unclear during the interview if the guardian was aware that the facility immunization log identified Resident
#24 as a resident who had received the influenza vaccine.
4. Review of the medical record for Resident #25 revealed and admission date of 09/16/24 with diagnoses
including focal traumatic brain injury, vascular dementia, diabetes mellitus, end stage renal disease,
dependence on renal dialysis, and bradycardia. The medical record revealed Resident #25 had an
appointed guardian and the resident was [AGE] years old.
Review of the immunizations record revealed no historical records of the resident receiving a
pneumococcal vaccination. There was no evidence of the facility offering, screening, or educating Resident
#25's guardian about pneumococcal vaccinations. The record indicated Resident #25 received the influenza
vaccination on 12/04/24; however, there was no evidence of a consent, screening, or education for the
vaccination.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident
#25 received the influenza vaccination on 12/04/24. The assessment also noted that Resident #25 was not
up to date on pneumococcal vaccinations as the resident was not assessed.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) revealed she was unable to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page106of116
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
03/31/2025
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 0883
find any evidence of pneumococcal vaccinations being completed as required for Resident #25.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 03/13/25 at 12:10 P.M. with the DON confirmed she was unable to locate any consents or
declinations for the influenza vaccination for Resident #25.
Residents Affected - Many
Interview on 03/27/25 at 10:16 A.M. with the Administrator revealed Resident #25 was younger than [AGE]
years old and she did not think the resident fit the criteria for pneumococcal vaccination.
Interview on 03/27/25 at 10:20 A.M. with MDS Nurse #365 revealed it had been a year or two since he
reviewed the guidance on the MDS section O for vaccines. However, he was educated through American
Association of Nurse Assessment Coordinators (AANAC) that on the question for pneumococcal vaccines,
you would answer yes if the resident had it, and he would look in the medical record to see if they refused
it, then he would mark that, and if they were under 65 he would mark that the resident was not eligible. He
stated that criteria (ineligibility) would apply to Resident #25.
5. Review of the medical record for Resident #38 revealed an admission date of 06/22/24 with diagnoses
including traumatic subdural hemorrhage, chronic obstructive pulmonary disease (COPD), hypertension,
alcohol dependence, and COVID-19 on 12/28/24. The medical record revealed Resident #38 had an
appointed guardian and the resident was [AGE] years old.
Review of the immunizations record revealed no historical records of the resident receiving a
pneumococcal vaccination received. There was no evidence of the facility offering, screening, or educating
Resident #38's guardian about pneumococcal vaccinations. The record indicated Resident #38 refused the
influenza vaccination at an unspecified time; however, there was no evidence of a consent/declination,
education, or rationale for it being declined.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident
#38 did not receive the influenza vaccine as the resident was offered and declined it. The assessment also
noted that Resident #38 was not up to date on pneumococcal vaccinations as the resident was not eligible.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) revealed she was unable to find any
evidence of pneumococcal vaccinations being completed for Resident #38.
Interview on 03/13/25 at 12:10 P.M. with the DON confirmed she was unable to locate any consents or
declinations for the influenza vaccination for Resident #38.
Interview on 03/27/25 at 9:19 A.M. with the Administrator and DON revealed that, per the MDS nurse,
Resident #35 was younger than [AGE] years old and did not fit the criteria for pneumococcal vaccines
during the MDS assessment, based on advice from education at American Association of Nurse
Assessment Coordinators (AANAC).
Interview on 03/27/25 at 10:20 A.M. with MDS Nurse #365 revealed it had been a year or two since he
reviewed the guidance on the MDS section O for vaccines. However, he was educated through American
Association of Nurse Assessment Coordinators (AANAC) that on the question for pneumococcal vaccines,
you would answer yes if the resident had it, and he would look in the medical record to see if they refused
it, then he would mark that, and if they were under 65 he would mark that the resident was not eligible. He
stated that criteria (ineligibility) would apply to Resident #38.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page107of116
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
03/31/2025
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
6. Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses
including paranoid schizophrenia, hypertension, Alzheimer's disease, and hypothyroidism. The medical
record revealed Resident #204 was their own responsible party and the resident was [AGE] years old.
Review of the immunizations record revealed no historical records of influenza or pneumococcal
vaccinations being received by the resident. There was no evidence of the facility offering, screening, or
educating Resident #204 for the influenza or pneumococcal vaccinations.
Review of the Medicare Minimum Data Set (MDS) admission assessment revealed it had not yet been
completed for Resident #204.
Interview on 03/13/25 at 7:30 A.M. with the Director of Nursing (DON) confirmed she had not been able to
locate any historical vaccination information for Resident #204 and confirmed Resident #204 had not been
offered any vaccinations since admission.
Interview on 03/27/25 at 9:19 A.M. with the Administrator and DON confirmed they should offer the
vaccines upon admission.
Interview on 03/27/25 at 11:05 A.M. with Resident #204's family revealed the facility never offered the
vaccines (influenza or pneumococcal) for the resident or provided education related to them.
7. Review of the closed medical record for Resident #55 revealed an admission date of 01/27/23 and
discharge date of 01/09/25. Resident #55 had diagnoses including chronic obstructive pulmonary disease,
peripheral vascular disease, chronic kidney disease, dementia, and nontraumatic intracerebral hemorrhage.
The medical record revealed Resident #55 had an appointed guardian and was [AGE] years old.
Review of the immunizations record revealed Resident #55 was not up to date with pneumococcal
vaccinations as pneumococcal Polysaccharide Vaccine (PPSV) 23 was administered before the age of 65.
Review of the Nurse Practitioner (NP) progress note dated 01/09/25 revealed Resident #55 had complaints
of nausea and loose stools. Stools were noted to be loose and dark tarry colored. Resident #55 reported
not feeling well and not eating due to nausea and abdominal pain. Resident #55 told the nurse he was
having difficulty breathing and he felt like he was dying. Resident #55 had a harsh, moist cough. The NP
ordered to send Resident #55 to the emergency room for evaluation.
Review of the nurse's note dated 01/09/25 revealed Resident #55 was transported to hospital for
complaints of stomach pain for a few days and black stool. Resident #55 was noted to be on a blood
thinner.
Review of the nurse's note dated 01/10/25 revealed Resident #55 was admitted to hospital for pneumonia.
Further review of the medical record for Resident #55 revealed no additional hospital documentation was
available for review.
Interview on 03/17/25 at 8:03 A.M. with the guardian of Resident #55 revealed Resident #55 had passed
away at the hospital. The resident's death certificate was not available as of this date.
Interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page108of116
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
03/31/2025
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Registered Nurse/Infection Preventionist (RN/IP) #374 revealed they were unaware Resident #55 had been
hospitalized for pneumonia and subsequently passed away at hospital despite having symptoms of a
change in condition since testing positive for COVID-19 on 12/27/24. They further confirmed no consents or
refusals for vaccines were able to be located for Resident #55.
8. Review of the medical record for Resident #31 revealed an admission date of 08/13/24 with diagnoses
including diabetes mellitus, bipolar disorder, hypothyroidism, muscle weakness, and unspecified intellectual
disabilities. Resident #31 was hospitalized from [DATE] to 01/08/25. The medical record revealed Resident
#31 was his own responsible party and he was [AGE] years old.
Review of immunizations record revealed no evidence of Resident #31's pneumococcal vaccinations status.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident
#31 had severely impaired cognition and was independent for activities of daily living. The assessment
revealed Resident #31 had not received pneumococcal vaccinations.
Review of a Nurse Practitioner (NP) progress note dated 12/26/24 revealed Resident #31 continued to have
cough and congestion. On 12/23/24 Resident #31 had a chest x-ray with no findings. On 12/24/24 Resident
#31 had four to five watery stools and was ordered Loperamide two milligrams (mg) every six hours as
needed for diarrhea. Resident #31 also complained of nausea and emesis. Laboratory services were
ordered on 12/24/24 and were not obtained. Resident #31's pulse ox was 92 percent on room air and the
resident's heart rate was 109 (tachycardic). While the NP was visiting, she was alerted Resident #31 had
fallen in his room. Resident #31 was trying to walk to bathroom and became dizzy causing a fall. The NP
ordered Resident #31 to be sent to the emergency room for evaluation.
Review of nurse's note dated 12/27/24 revealed Resident #31 had been admitted to the hospital with acute
hypoxic respiratory failure, pneumonia, dehydration, acute kidney injury, and was positive for COVID-19.
Review of a hospital note revealed Resident #31 was admitted to the step-down unit on 12/26/24 for acute
hypoxic respiratory failure and acute kidney injury. Resident #31 was found to have COVID-19 and
pneumonia. Resident #31 had episodes of oxygen desaturation and required oxygen. Resident #31 was
treated with Remdesivir, steroids and antibiotics. Remdesivir had to be stopped due to Transaminitis.
Resident #31 continued to have intermittent coughing while hospitalized .
Review of a NP progress note dated 01/09/25 revealed Resident #31 had re-admitted to the facility from the
hospital on [DATE]. Resident #31 was diagnosed with COVID-19, pneumonia, bilateral pulmonary
embolism, left leg deep vein thrombosis, and acute kidney injury.
Interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and
Registered Nurse/Infection Preventionist (RN/IP) #374 revealed they were unaware Resident #31 had been
hospitalized for treatment of COVID-19 and pneumonia after the resident had been symptomatic since
12/06/24. They further confirmed no consents or refusals for vaccines were able to be located for Resident
#31.
Interview on 03/27/25 at 9:52 A.M. with Resident #31 revealed he was educated regarding the influenza
and pneumococcal vaccines by the facility and he did consent to and received the vaccines, but he could
not remember when he had them or when the education was. Resident #31 stated he knew he had
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page109of116
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
03/31/2025
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
to go to the hospital because he was sick, but he could not remember when it was, and he also could not
remember any treatments or medications he was given prior to the hospitalization. He stated he had poor
memory.
Review of online Centers for Disease Control and Prevention (CDC) information/guidance for
pneumococcal vaccination, dated 10/26/24 revealed the following
•
CDC recommends pneumococcal vaccination for children younger than 5 years and adults 50 years or
older.
•
CDC also recommends pneumococcal vaccination for children and adults at increased risk for
pneumococcal disease.
•
Follow the recommended immunization schedule to ensure that your patients get the pneumococcal
vaccines that they need.
The CDC guidance provides additional information for the types of risk associated with pneumococcal
disease for vaccination of those individuals between the ages of 5 and 49 and also provides guidance on
the type of pneumococcal vaccination/schedule for administration based on an assessment of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page110of116
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
03/31/2025
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 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and
staff after education, and properly document each resident and staff member's vaccination status.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, review of a facility immunization report, review of staff vaccination reports, facility
policy review, review of Centers for Disease Control and Prevention (CDC) guidance and interview, the
facility failed ensure residents and staff were educated, screened, and offered COVID-19 vaccinations as
required. This affected seven residents (#23, #24, #25, #31, #38, #55 and #204) of seven reviewed for
immunizations and the lack of an effective program to manage vaccinations affected all residents in the
facility. The facility census was 54.
Findings include:
1. Review of the Immunizations Report from 01/01/24 to 03/13/25 for COVID-19 vaccinations revealed there
was no evidence of any COVID-19 vaccinations being completed from 01/01/24 to 03/13/25. In addition,
record review revealed there was no documented evidence of consent/declination, screenings, or education
regarding COVID-19 vaccinations for any facility residents during this time period.
Interview on 03/13/25 at 7:30 A.M. with Director of Nursing (DON) revealed she was unable to find any
evidence of COVID-19 vaccinations being completed as required for any residents between 01/01/24 and
03/13/25.
Follow up interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and
Registered Nurse/Infection Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the
facility, but had been assisting the facility with infection control in interim between IPs. They were unaware
of how the previous DON #313 and assistant DON (ADON) #368 had been handling vaccinations and
acknowledged there were a lot of missing vaccination forms.
Follow up interview on 03/19/25 at 2:28 P.M. with COO #300 confirmed she was unable to locate any
additional information on COVID-19 vaccinations for any residents.
Follow up interview on 03/19/25 at 3:37 P.M. with the DON confirmed she was unable to provide any
additional information on COVID-19 vaccinations for any residents.
Review of facility policy Resident COVID-19 Vaccine dated 05/01/22 revealed all residents and employees
who had no medical contraindications will be offered the COVID-19 vaccine. The facility shall provide
education on risks and benefits of vaccine. Administration or declination shall be documented in the
resident medical record and employee personnel record. Vaccines shall be administered in accordance with
current Centers for Disease Control and Prevention (CDC) recommendations.
Review of the CDC guidance titled Staying Up to Date with COVID-19 Vaccines dated 01/07/25 revealed
everyone over six months of age should receive the 2024 to 2025 COVID-19 vaccination to best protect
from currently circulating strains.
Review of the CDC guidance on COVID-19 dated 03/10/25 revealed the COVID-19 vaccination was
recommended for prevention of severe health outcomes.
2. Review of the medical record for Resident #23 revealed an admission date of 06/27/24 and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page111of116
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
03/31/2025
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 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
diagnoses including asthma and pulmonary embolism. The medical record revealed Resident #23 was her
own responsible party.
Review of the immunizations record revealed no historical records of the resident receiving COVID-19
vaccinations. There was no evidence of the facility offering, screening, or educating Resident #23 for
COVID-19 vaccinations.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident
#23 was not up to date on COVID-19 vaccinations.
Interview on 03/13/25 at 12:10 P.M. with the Director of Nursing (DON) confirmed she was unable to locate
any consents or declinations for COVID-19 vaccinations for Resident #23.
On 03/27/25 at 10:05 A.M. an interview with Resident #23 revealed the last vaccine she received was prior
to coming to the facility. The resident denied being offered any vaccines or education while she was in the
facility.
3. Review of the medical record for Resident #24 revealed an admission date of 06/04/24 and diagnoses
including dementia, hypertension, lymphedema, psychosis, Parkinson's disease, and atherosclerotic heart
disease. The medical record revealed Resident #24 had a guardian.
Review of the immunizations record revealed Resident #24 had received doses of COVID-19 vaccinations
prior to admission on [DATE], 08/12/21, and 11/02/22. There was no evidence of the facility offering,
screening, or educating Resident #24's guardian about COVID-19 vaccinations.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident
#24 was not up to date on COVID-19 vaccinations.
Interview on 03/13/25 at 12:10 P.M. with the Director of Nursing (DON) confirmed she was unable to locate
any consents or declinations for COVID-19 vaccinations for Resident #24.
Interview on 03/27/25 at 9:38 A.M. with Resident #24's guardian revealed she had been the resident's
guardian since admission on [DATE] and the facility had never educated or offered immunizations.
4. Review of the medical record for Resident #25 revealed and admission date of 09/16/24 and diagnoses
including focal traumatic brain injury, vascular dementia, diabetes mellitus, end stage renal disease,
dependence on renal dialysis, and bradycardia. The medical record revealed Resident #25 had an
appointed guardian.
Review of the immunizations record revealed no historical records of the resident receiving COVID-19
vaccinations. There was no evidence of the facility offering, screening, or educating Resident #25's
guardian about COVID-19 vaccinations.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident
#25 was not up to date on COVID-19 vaccinations.
Interview on 03/13/25 at 12:10 P.M. with the Director of Nursing (DON) confirmed she was unable to locate
any consents or declinations for COVID-19 vaccinations for Resident #25.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page112of116
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
03/31/2025
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 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
5. Review of the medical record for Resident #38 revealed an admission date of 06/22/24 and diagnoses
including traumatic subdural hemorrhage, chronic obstructive pulmonary disease (COPD), hypertension,
and COVID-19 on 12/28/24. The medical record revealed Resident #38 had an appointed guardian.
Review of the immunizations record revealed no historical records of the resident receiving COVID-19
vaccinations. There was no evidence of facility offering, screening, or educating Resident #38's guardian
about COVID-19 vaccinations.
Review of the Medicare Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident
#38 was not up to date on COVID-19 vaccination.
Interview on 03/13/25 at 12:10 P.M. with DON confirmed she was unable to locate any consents or
declinations for COVID-19 vaccinations for Resident #38.
6. Review of the medical record for Resident #204 revealed an admission date of 03/03/25 and diagnoses
including paranoid schizophrenia, hypertension, Alzheimer's disease, and hypothyroidism. The medical
record revealed Resident #204 was their own responsible party.
Review of the immunizations record revealed no historical records of COVID-19 vaccinations being
received by the resident. There was no evidence of the facility offering, screening, or educating Resident
#204 for COVID-19 vaccinations.
Review revealed the Medicare Minimum Data Set (MDS) admission assessment had not yet been
completed for Resident #204.
Interview on 03/13/25 at 7:30 A.M. with Director of Nursing (DON) confirmed she had not been able to
locate any historical vaccination information for Resident #204 and confirmed Resident #204 had not been
offered any vaccinations since admission.
Interview on 03/27/25 at 11:05 A.M. with Resident #204's family revealed the facility never offered vaccines
to the resident or provided education related to them.
7. Review of the closed medical record for Resident #55 revealed an admission date of 01/27/23 and
discharge date of 01/09/25. Resident #55 had diagnoses including chronic obstructive pulmonary disease,
peripheral vascular disease, chronic kidney disease, dementia, and nontraumatic intracerebral hemorrhage.
The medical record revealed Resident #55 had an appointed guardian and was [AGE] years old.
Review of the immunizations record revealed Resident #55 was not up to date with the COVID-19
vaccinations, with the last dose administered 06/02/22.
Review of the nurse's note dated 12/27/24 revealed Resident #55 tested positive for COVID-19.
Review of the Nurse Practitioner (NP) progress note dated 12/30/24 revealed Resident #55 had nasal
congestion. The NP ordered oxygen via nasal cannula to keep oxygen saturation above 92 percent,
Dexamethasone six mg daily for seven days, and monitor temperature, pulse oximetry (ox), and
respirations every shift for 10 days. The NP noted to continue Eliquis five mg twice per day, Acetaminophen
650 mg every six hours as needed, and Albuterol nebulizer every four hours as needed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page113of116
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
03/31/2025
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 0887
Level of Harm - Minimal harm
or potential for actual harm
Review of the Nurse Practitioner (NP) progress note dated 01/09/25 revealed Resident #55 had complaints
of nausea and loose stools. Stools were noted to be loose and dark tarry colored. Resident #55 reported
not feeling well and not eating due to nausea and abdominal pain. Resident #55 told the nurse he was
having difficulty breathing and he felt like he was dying. Resident #55 had a harsh, moist cough. The NP
ordered to send Resident #55 to the emergency room for evaluation.
Residents Affected - Many
Review of the nurse's note dated 01/09/25 revealed Resident #55 was transported to hospital for
complaints of stomach pain for a few days and black stool. Resident #55 was noted to be on a blood
thinner.
Review of the nurse's note dated 01/10/25 revealed Resident #55 was admitted to hospital for pneumonia.
Further review of the medical record for Resident #55 revealed no additional hospital documentation was
available for review.
Review of the Ohio Department of Medicaid Facility Communication dated 01/16/25 revealed Resident #55
had passed away at the hospital on [DATE].
Interview on 03/17/25 at 8:03 A.M. with the guardian of Resident #55 revealed Resident #55 had passed
away at the hospital. The resident's death certificate was not available as of this date.
Interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and
Registered Nurse/Infection Preventionist (RN/IP) #374 revealed they were unaware Resident #55 had been
hospitalized for pneumonia and subsequently passed away at hospital despite having symptoms of a
change in condition since testing positive for COVID-19 on 12/27/24. They further confirmed no consents or
refusals for vaccines were able to be located for Resident #55.
8. Review of the medical record for Resident #31 revealed an admission date of 08/13/24 with diagnoses
including diabetes mellitus, bipolar disorder, hypothyroidism, muscle weakness, and unspecified intellectual
disabilities. Resident #31 was hospitalized from [DATE] to 01/08/25. The medical record revealed Resident
#31 was his own responsible party.
Review of the immunizations record revealed no evidence of Resident #31's COVID-19 vaccinations status.
Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident
#31 had severely impaired cognition and was independent for activities of daily living. The assessment
revealed Resident #31 was not up to date on COVID-19 vaccinations.
Review of a Nurse Practitioner (NP) progress note dated 12/26/24 revealed Resident #31 continued to have
cough and congestion. On 12/23/24 Resident #31 had a chest x-ray with no findings. On 12/24/24 Resident
#31 had four to five watery stools and was ordered Loperamide two milligrams (mg) every six hours as
needed for diarrhea. Resident #31 also complained of nausea and emesis. Laboratory services were
ordered on 12/24/24 and were not obtained. Resident #31's pulse ox was 92 percent on room air and the
resident's heart rate was 109 (tachycardic). While the NP was visiting, she was alerted Resident #31 had
fallen in his room. Resident #31 was trying to walk to bathroom and became dizzy causing a fall. The NP
ordered Resident #31 to be sent to the emergency room for evaluation.
Review of nurse's note dated 12/27/24 revealed Resident #31 had been admitted to the hospital with acute
hypoxic respiratory failure, pneumonia, dehydration, acute kidney injury, and was positive for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page114of116
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
03/31/2025
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 0887
COVID-19.
Level of Harm - Minimal harm
or potential for actual harm
Review of a hospital note revealed Resident #31 was admitted to the step-down unit on 12/26/24 for acute
hypoxic respiratory failure and acute kidney injury. Resident #31 was found to have COVID-19 and
pneumonia. Resident #31 had episodes of oxygen desaturation and required oxygen. Resident #31 was
treated with Remdesivir, steroids and antibiotics. Remdesivir had to be stopped due to Transaminitis.
Resident #31 continued to have intermittent coughing while hospitalized .
Residents Affected - Many
Review of a NP progress note dated 01/09/25 revealed Resident #31 had re-admitted to the facility from the
hospital on [DATE]. Resident #31 was diagnosed with COVID-19, pneumonia, bilateral pulmonary
embolism, left leg deep vein thrombosis, and acute kidney injury.
Interview on 03/17/25 at 11:27 A.M. with Administrator, Chief Operating Officer (COO) #300, and
Registered Nurse/Infection Preventionist (RN/IP) #374 revealed they were unaware Resident #31 had been
hospitalized for treatment of COVID-19 and pneumonia after the resident had been symptomatic since
12/06/24. They further confirmed no consents or refusals for vaccines were able to be located for Resident
#31.
9. Review of the COVID-19 Vaccination Record Card for Nurse Aid #339 revealed doses of COVID-19
vaccinations were received on 12/23/20, 01/13/21, 02/06/23, and 04/24/23. There was no evidence of
facility offering, screening, or education to Nurse Aid #339 for additional doses of COVID-19 vaccination.
Interview on 03/20/25 at 8:50 A.M. with the Administrator confirmed she was unable to provide any
additional offerings of COVID-19 boosters to Nurse Aid #339 or evidence of any education provided on
COVID-19 vaccination.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page115of116
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
03/31/2025
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 0947
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in
dementia care and abuse prevention.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the personnel files, review of the facility assessment and interviews, the facility failed to ensure
Certified Nursing Assistants (CNA) #305 and #329 received annual performance reviews. This affected two
CNAs of two CNA's personnel files reviewed and had the potential to affect all 54 residents residing in the
facility.
Findings include:
Review of the personnel file for CNA #305 revealed a hire date of 06/03/21. There was no documented
evidence that CNA #305 had an annual performance review.
Review of the personnel file for CNA #329 revealed a hire date of 06/03/21. There was no documented
evidence that CNA #329 had an annual performance review.
Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNAs #305 and
#329 did not have an annual performance reviews in their personnel files.
Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as
determined in nurse aide performance reviews during training and in-services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365370
If continuation sheet
Page116of116
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
41 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F740 - Behavioral health services
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F838 - Facility assessment
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
F841 - Medical director
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
FAQ · About this visit
Common questions about this visit
What happened during the March 31, 2025 survey of MOMENTOUS HEALTH AT RICHFIELD?
This was a inspection survey of MOMENTOUS HEALTH AT RICHFIELD on March 31, 2025. The surveyor cited 41 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MOMENTOUS HEALTH AT RICHFIELD on March 31, 2025?
Yes, 41 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to manage his or her financial affairs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.