Inspection·August 19, 2021

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility policy and procedure review, review of Centers for Disease Control (CDC) guidance and interview the facility failed to maintain acceptable infection control practices including following contact isolation precautions (wearing a gown and gloves) and using proper hand washing for Resident #30 and utilizing proper infection control practices during a dressing change for Resident #310 to prevent the spread of infection. This affected two residents (#30 and #310) and had the potential to affect all 58 residents residing in the facility. Residents Affected - Many Findings include: 1. Record review for Resident #30 revealed an admission date of 06/15/21 with diagnoses including Clostridium difficile (infection of the large intestine causing diarrhea), urinary tract infection, hypertension (high blood pressure) and congestive heart failure. Review of the physician's order dated 08/10/21 revealed Resident #30 had an order for Vancomycin 125 milligrams, one capsule by mouth one time a day for Clostridium difficile with a stop date of 09/24/21. On 08/16/21 at 8:35 A.M. State Tested Nursing Assistant (STNA) #141 was observed to enter Resident #30's room to deliver his meal tray. Resident #30 had an over the door yellow pocketed divider with personal protective equipment (PPE) including gowns, gloves and masks. There was a bright pink sign on the door stating to report to the nurse before entering, contact precautions, PPE required, gown and gloves. STNA #141 went into the room, did not put on PPE, went to Resident #30's tray table, placed the tray on the table, moved the tray closer to the resident and then opened the items on the resident's tray. STNA #141 then left the room without washing her hands. On 08/16/21 at 8:36 A.M. interview with Licensed Practical Nurse (LPN) #122 verified Resident #30 was on contact isolation for Clostridium difficile and staff should be wearing gowns and gloves in the room as resident was on contact isolation. On 08/16/21 at 8:37 A.M. interview with STNA #141 verified she did not wear PPE in the resident's room. STNA #141 was asked if she washed her hands when she exited and she stated she used hand sanitizer frequently. On 08/17/21 at 1:28 P.M. interview with Physician #140 verified staff should wear PPE while performing personal care for the resident. Physician #140 revealed if you did not touch anything in the room or provide personal care to the resident, staff did not need PPE but had to wash their hands prior to leaving the room. Physician #140 did verify if a staff member touched any item in the room, the staff member should be wearing PPE and washing hands. Review of the facility policy titled Handwashing, revised December 2020 revealed the objective of (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 2 Event ID: 365793 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 08/19/2021 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)