Inspection·May 2, 2019

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Residents #1, #20 and #55 and the representatives for these residents were notified in writing of the reason for the discharge to the hospital in an easily understood language. This finding affected three (Residents #1, #20 and #55) of four residents reviewed for hospitalization. Findings include: 1. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, difficulty in walking, muscle weakness and heart failure. Review of Resident #1's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #1's progress note dated 04/22/19 at 3:53 P.M. indicated the resident's silent alarm was going off and the nurse entered the room. The resident was observed on his knees in front of the toilet in the bathroom and the resident was yelling. The staff observed a moderate amount of bright red blood in the shower stall, on the resident's head, left arm and left knee. The resident was covered in stool and stated he had tried to wipe himself, fell forward and into the wheelchair that was in the shower stall. The resident was observed with a gash on his forehead, a gash on his left elbow and left knee. Resident #1 was transported to the hospital. Review of Resident #1's progress note dated 04/27/19 at 2:48 P.M. indicated report was obtained from the hospital, the resident returned to facility and the resident was in a recliner chair with dinner provided. Interview on 04/30/19 at 3:07 P.M. with Social Services #808 confirmed Resident #1 and the resident's representative were not notified in writing of the reason for the discharge to the hospital in an easily understood language as required. 2. Record review was conducted for Resident #20 who was admitted to the facility on [DATE] with diagnoses that included leg amputation, prostate cancer and chronic blood clots. The Minimum Data Set assessment dated [DATE] revealed he had intact cognition, needed the assistance of staff for mobility, transfers, toileting and hygiene. Review of a Progress Note dated 01/13/19 at 10:59 A.M. revealed Resident #20 was admitted to the hospital and the admitting diagnosis was unknown at that time. A progress note dated 01/21/19 at 10:40 P.M. revealed he was readmitted to the facility. Interview on 04/30/19 at 3:07 P.M. with Social Services #808 confirmed the resident and the resident and resident's representative were not notified in writing the reason for the discharge to the hospital in a language the resident and the resident's representative could understand. 3. Record review was conducted for Resident #55 who was admitted to the facility on [DATE] with diagnoses that included right femur fracture and dementia. The Minimum Data Set assessment dated [DATE] revealed she had severe cognitive impairment and needed staff assistance for her activities of daily living. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 2 of 7 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 365793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Center at Laurel Lake 200 Laurel Lake Dr Hudson, OH 44236 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a Progress Note dated 03/01/19 revealed Resident #55 was being sent to the hospital to be evaluated for a right femur fracture. A Progress Note dated 03/04/19 revealed she was readmitted to the facility following the surgical repair of the fracture. Interview on 04/30/19 at 3:07 P.M. with Social Services #808 confirmed the resident and the resident and resident's representative were not notified in writing the reason for the discharge to the hospital in a language the resident and the resident's representative could understand. Event ID: Facility ID: 365793 If continuation sheet Page 3 of 7 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 365793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Center at Laurel Lake 200 Laurel Lake Dr Hudson, OH 44236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to assist Resident #37 with routine showering/personal care. This affected one of two residents reviewed for choices. The facility census was 72. Residents Affected - Few Findings included: Record review was conducted for Resident #37 who was admitted on [DATE] with diagnoses including type two diabetes mellitus, generalized muscle weakness and depression. The Minimum Data Set assessment dated [DATE] revealed she had no cognitive impairment and needed extensive assistance from staff for bed mobility, transfers, toileting and hygiene. Review of the facility document titled, Shower task for the month of April 2019, revealed Resident #37 last had a shower on 04/16/19. Review of progress notes from 04/10/19 to 04/27/19 revealed no documented shower refusals by Resident #37. Observation and interview was conducted on 04/29/19 from 10:05 A.M. to 10:40 A.M. of Resident #37 lying in her bed. She was dressed in a hospital gown, had silver hair that looked unwashed and had a foul body odor that was evident from a three foot distance. She explained that she preferred showers on Tuesday and Friday but had not received her shower in over a week. She explained the staff had not offered her a bed bath either in the last two weeks. Interview conducted on 05/02/19 at 1:26 P.M. with Stated Tested Nursing Assistant (STNA) #804 verified Resident #37 last had a shower on 04/16/19 and had missed showers on 04/19/19, 04/23/19 and 04/26/19. Interview was conducted on 05/02/19 at 3:59 P.M. with the Director of Nursing (DON) who revealed she did keep some documents titled, Bathing Monitoring tool, for Resident #37. The DON verified Resident #37 had been showered on 04/09/19, 04/16/19 and 04/30/19 however she had indeed gone without receiving a shower from 04/17/19 to 04/29/19, 13 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 4 of 7 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 365793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Center at Laurel Lake 200 Laurel Lake Dr Hudson, OH 44236 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain Resident #65's urinary catheter in a manner to prevent contamination. This affected one of three residents reviewed for catheters and urinary tract infections. The facility census was 72. Findings include: Review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including gastrostomy status, irritable bowel syndrome with diarrhea and dysphagia (trouble swallowing). Review of Resident #65's urinary catheter care plan dated 03/28/19 indicated the resident had a sixteen French catheter with a 10 cubic centimeters (cc's) balloon and to position the catheter bag and tubing below the level of the bladder and away from the entrance of the room door. Review of Resident #65's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #65's physician orders revealed an order dated 04/17/19 to change the catheter drainage bag on night shift on the seventeenth of the month and as needed. Observation on 04/30/19 at 3:17 P.M. revealed Resident #65's urinary catheter drainage bag was hanging on the resident's left side of the bed and the catheter bag was observed in direct contact with the floor. Interview on 04/30/19 at 3:19 P.M. with Licensed Practical Nurse (LPN) #803 confirmed Resident #65's urinary catheter drainage bag was on the floor and appropriate infection control measures were not maintained. Observation on 05/01/19 at 10:13 A.M. revealed Resident #65's urinary catheter drainage bag was on the right side of the bed and the catheter bag was observed directly in contact with the fall prevention safety mat on the floor. Interview on 05/01/19 at 10:15 A.M. with Registered Nurse (RN) #807 confirmed Resident #65's urinary catheter drainage bag was on the floor mat on the floor and appropriate infection control measures were not maintained. Observation on 05/01/19 at 2:01 P.M. revealed Resident #65's urinary catheter drainage bag was hanging on the resident's right side rail and the catheter bag was observed in direct contact with the floor. Interview on 05/01/19 at 2:05 P.M. with Social Services Designee (SSD) #808 confirmed Resident #65's urinary catheter drainage bag was on the floor and appropriate infection control measures were not maintained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 5 of 7 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 365793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Center at Laurel Lake 200 Laurel Lake Dr Hudson, OH 44236 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to administer medications as ordered by the physician and with an error rate of less than 5 percent (%). This affected Resident #1, one of six residents observed for medication administration. There were two errors in 28 medication opportunities observed resulting in a medication error rate of 7.14%. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, essential hypertension, pain in the right shoulder and atrial fibrillation (irregular heart beat). Review of Resident #1's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Observation of medication pass for Resident #1 was completed with Registered Nurse (RN) #807 on 04/29/19 at 9:34 A.M. Resident #1 received eight medications including an Eliquis tablet (an anticoagulant to prevent blood clots) and a Salonpas Lidoderm (lidocaine), a topical pain patch, which was to be applied on the day shift and and removed at bedtime. When applying the Lidoderm pain patch, RN #807 was observed removing a another, undated Lidoderm patch from the resident's right shoulder. Review of Resident #1's physician orders revealed an order dated 04/27/19 for Eliquis 2.5 mg (milligrams) give one tablet by mouth two times a day for atrial fibrillation (irregular heart beat) and lidocaine patch 4% (percent) to the right shoulder topically two times a day for pain, to be applied in the morning and removed at bedtime. Review of Resident #1's medication administration records from 04/01/19 to 04/29/19 revealed the Eliquis anticoagulant tablet was due at 8:00 A.M. and 9:00 P.M. and the lidocaine patch was to be applied at 8:00 A.M. and was to be removed at 8:00 P.M. Interview on 04/29/19 at 11:45 A.M. with RN #807 confirmed the Eliquis was not administered timely and the previous lidocaine patch was not dated and had not been removed by the nurse at bedtime the night before as ordered by the physician. These two medication errors were identified out of 28 medications observed, resulting in a 7.14 % medication error rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 6 of 7 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 365793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Center at Laurel Lake 200 Laurel Lake Dr Hudson, OH 44236 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** Based on record review, observation and interview the facility did not ensure facility staff followed appropriate transmission based precautions to prevent the spread of infection while cleaning Resident #62's room. This affected one of one residents reviewed for respiratory care and had the potential to affect all of the other 71 residents residing in the facility. Residents Affected - Many Findings included: Record review was conducted for Resident #62 who was admitted to the facility on [DATE] with diagnoses that included vascular dementia. The Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired and needed extensive assistance of one staff person for dressing, toileting and hygiene. The plan of care dated 04/26/19 indicated he had a respiratory infection and interventions included him being placed on droplet precautions and for staff to maintain universal precautions when providing care. An observation was conducted on 04/30/19 at 4:19 P.M. of Resident #62 resting in his bed with his eyes closed. On the entrance door to the room hung a bag of blue masks, yellow gowns and disposable gloves. An interview was conducted on 04/30/19 at 4:38 P.M. with Registered Nurse (RN) #905 who explained that Resident #62 had an upper respiratory infection and anyone entering the room needed to wear a gown, gloves and mask and follow universal precautions with hand washing. An observation was conducted on 05/01/19 at 9:59 A.M. of Resident #62 sitting in his room talking to Housekeeper #810 who was in his room wiping off his bed side table. Housekeeper #810 was wearing only gloves and a mask, but no gown. Interview was conducted on 05/01/19 at 10:01 A.M. with Licensed Practical Nurse (LPN) #809 who verified Housekeeper #810 had not worn a gown while in Resident #62's room. Interview conducted on 05/01/19 at 10:05 A.M. with Housekeeper #810 verified she was responsible for cleaning all the resident rooms on Resident #62's unit and she had not worn a gown while cleaning his room. Housekeeper #810 stated she did not think a gown was necessary since she was not touching the resident. Interview was conducted on 05/02/19 at 3:25 P.M. with LPN #951 who revealed on 04/26/19 Resident #62 was started on droplet precautions since he tested positive for a respiratory infection which was contagious. LPN #951 explained that although a physician order had not been written for the resident to be on droplet precautions, they place him on droplet precautions. LPN #951 said anyone entering the room needed to wear a gown, mask and gloves to avoid potentially spreading the infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 7 of 7