Momentous Health at Richfield: Documentation Failures - OH
The incident happened on May 18, 2026, at Momentous Health at Richfield, a 56-bed facility in northeastern Ohio. Inspectors documented the failure to record it as part of a complaint investigation completed May 28.
A certified nursing assistant identified in the inspection report as CNA #212 was the one who noticed something was wrong. She had stepped away to care for another resident and looked back toward the dining room. The woman she had last seen watching television, identified in the report as Resident #57, was gone.
CNA #212 found her in Resident #14's room.
Resident #57 had been living at the facility since April 2025. She had dementia with moderate behavior disturbance, psychosis, Type II diabetes, and chronic obstructive pulmonary disease. A psychosocial assessment in her record described disorganized thinking and inattention as continuously present. Inspectors noted her nursing progress notes ran from April 2025 through her discharge the following day, May 19, 2026, without a single entry about what happened that night.
Resident #14, who had been admitted in January 2026, was living with schizoaffective disorder, bipolar disorder, congestive heart failure, hepatitis C, and diabetes. A formal assessment from April classified her as having severe cognitive impairment and wandering behaviors. Her progress notes for the entire month leading up to the incident, April 28 through May 27, contain nothing about it either.
CNA #212's witness statement, filed as part of the facility's own investigation, described what she found: Resident #57 with her brief and pants around her ankles, Resident #14 wearing no pants or underwear. CNA #212 helped Resident #14 get dressed. A nurse helped Resident #57. When staff tried to assist her, Resident #57 became combative and was taken to her room.
The facility's investigation noted that checks on both residents were being completed every fifteen minutes. Resident #57 was discharged to another facility the following day.
What the investigation did not produce was any entry in either woman's medical record. The Director of Nursing, interviewed by inspectors on May 29, confirmed that gap directly. She said she would expect the nurse involved to have documented the incident in both residents' charts.
Nobody had.
The inspection report classifies the harm level as minimal, and inspectors reviewed three residents total for documentation practices, finding problems in two of them. But the clinical picture behind those two cases is not minimal. One resident had been formally assessed as having severe cognitive impairment and wandering behaviors. The other had continuous disorganized thinking and a history of verbal behavioral disturbances. Both were, by the facility's own records, residents who required close monitoring and careful documentation of anything unusual.
What documentation is supposed to do, in a facility caring for people who cannot reliably speak for themselves, is create a record that nurses and physicians can use to track changes, identify patterns, and make decisions. When a cognitively impaired woman is found in another resident's room at night with her clothing around her ankles, and the other resident has no clothing on at all, that is the kind of event a medical record exists to capture.
Resident #57 left the next morning. Whatever happened in that room on the night of May 18 exists now only in a witness statement buried in a complaint investigation, not in the medical histories of either woman involved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Momentous Health At Richfield from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
MOMENTOUS HEALTH AT RICHFIELD in RICHFIELD, OH was cited for violations during a health inspection on May 28, 2026.
The incident happened on May 18, 2026, at Momentous Health at Richfield, a 56-bed facility in northeastern Ohio.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.