Inspection·August 17, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family interview, review of the medical record, and review of the facility policy for restraints, the facility failed to assess the use of a body pillow which was tucked underneath of Resident #42's fitted sheet to prevent the resident getting out of bed without staff assistance. This affected one resident (#42) of one resident reviewed for physical restraints. The facility census was 57. Residents Affected - Few Findings include: Review of Resident #42's medical record revealed an admission date of 10/19/20. Diagnoses included Parkinson's disease, dementia, anxiety, history of falling, hypertension, overactive bladder, and hallucinations. Review of Resident #42's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance of two staff for bed mobility and transfers. The resident was documented as having no physical restraints. Review of the fall risk assessment dated [DATE] revealed Resident #42 was at risk for falls. Review of Resident #42's current plan of care, initiated 08/13/20, revealed the resident was at risk for falls related to confusion, deconditioning, gait/balance problems, history of falls, Parkinson's disease, dementia, and poor safety awareness. An intervention initiated on 12/21/20 included a body pillow while in bed to help establish boundaries. Review of Resident #42's current physician orders identified an order for a body pillow while in bed to help establish boundaries. Review of Resident #42's medical record revealed no assessment had been completed to support the use of the body pillow. Observation on 08/14/23 at 3:36 P.M. revealed Resident #42 was lying in bed. Directly to the resident's left, the bed was against a wall. Directly to the resident's right, a body pillow covering most of the length of the bed was tucked underneath of the fitted sheet located on the resident's bed. The resident was struggling to sit up and was unable to do so due to the wall on one side and the body pillow on the other. Observation on 08/15/23 at 3:24 P.M., revealed Resident #42 was sleeping in her bed in a supine position. The left side of the resident's bed remained against the wall. Directly to the right of the resident and in alignment with her body, the body pillow was tucked underneath of the fitted sheet. Interview on 08/15/23 at 3:27 P.M. with Licensed Practical Nurse (LPN) #324, confirmed the body pillow was in place whenever the resident was in bed. LPN #324 reported the body pillow was in place to prevent the resident from falling. Observation on 08/16/23 at 2:32 P.M., revealed Resident #42 was lying in bed and was awake. The resident was lying on her back, with her right leg over the body pillow, which was tucked underneath of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 2 of 10 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 08/17/2023 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the fitted sheet and to the right of the resident. Resident #42 would place her leg back inside of the perimeter created by the body pillow and would then attempt to put her leg over it. Interview on 08/16/23 at 4:19 P.M. with Resident #42's daughter, revealed the resident had the body pillow in place to help prevent falls. Resident #42's daughter reported the body pillow was not supposed to be underneath of the fitted sheet, but staff had probably tucked it in so the resident couldn't move it or get out of the bed. Resident #42's daughter further stated the facility did not allow bolsters, so the body pillow was the best they could do. Interview on 08/16/23 at 4:26 P.M. with Agency State Tested Nursing Assistant (STNA) #377, revealed the body pillow was tucked under the fitted sheet so it would stay in place and so the resident could not push it off or get out of the bed. Review of the facility policy titled Restraints, revised January 2016, revealed the facility supported the belief that all residents had the right to be free from chemical and physical restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 3 of 10 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 08/17/2023 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 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** 3. Review of Resident #61's medical record revealed an initial admission date of 06/30/23 from an acute care hospital following diagnosis and treatment of UTI (urinary tract infection). Diagnoses included acute cystitis without hematuria, benign prostatic hyperplasia, atherosclerotic heart disease, paroxysmal atrial fibrillation, hypertension, and malignant neoplasm of hepatic flexure. Resident #61 was a short-term resident in the facility and was discharged back to his Independent Living apartment on 07/12/23. There was no hospitalization during his brief stay. Residents Affected - Some Review of the Resident #61's discharge MDS 3.0 assessment dated [DATE] revealed Resident #61 was able to verbalize his needs, understood others, made himself understood and had no apparent cognitive deficit. The assessment indicated a BIMS score of 15 out of 15. Review of the plan of care revealed Resident #61 was to be discharged to home setting upon completion of therapies. Interventions included to allow choices related to daily care, encourage involvement in activities, involve family in discharge planning as needed, offer opportunity to verbalize feelings related to placement, and to provide information regarding community resources available, and have support needed in place for discharge. Further review of A2100 Discharge Status under Section A of the discharge MDS dated [DATE] indicated Resident #61 was discharged to an acute hospital. Review of the nurse progress note dated from 06/30/23 through 07/08/23 revealed no transfers, admissions, or discharge to an acute care hospital. Nurse progress note dated 07/08/23 indicated Resident #61 was discharged with home going instruction, personal belongings, and medications to his Independent Living Apartment at approximately 4:00 P.M., accompanied by his daughter. During interview on 08/17/23 at 10:02 A.M., MDS Nurse #303 confirmed Resident #61 was discharged back to his apartment and was not discharged to an acute hospital. MDS Nurse #303 confirmed the discharge MDS was coded incorrectly. Based on observation, interview, and record review the facility failed to ensure Resident's #34, #36, #50 and #61 had accurate Minimum Data Set (MDS) assessments recorded in their medical records. This affected four residents (#34, #36, #50 and #61) out of five residents reviewed for accurate MDS assessments. The facility census was 57. Findings include: 1. Review of Resident #36's medical record revealed an admission date of 10/12/22 and diagnoses including Sjogren's syndrome with inflammatory arthritis, cerebral infarction, and rheumatoid arthritis. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was cognitively intact. Resident #36 required supervision and set-up help only for eating. Review of Resident #36's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #36's Brief Interview for Mental Status (BIMS) was not assessed. Resident #36 required extensive assistance of one staff member for bed mobility, transfers, eating, and toilet use. Resident #36 was frequently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 4 of 10 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 08/17/2023 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 0641 incontinent of urine and bowel. Level of Harm - Minimal harm or potential for actual harm Review of Resident #36's care plan revised 01/18/23 included Resident #36 required extensive assistance with activity of daily living (ADL) due to difficulty walking, muscle weakness associated with a recent fall sustaining a laceration to the head requiring stitches. Resident #36 would improve current level of function and have all care needs met through the review date. Interventions included Resident #36 required set-up help with supervision for meals, snacks, and allow Resident #36 to perform any aspect of the meal she was able. Residents Affected - Some Observation on 08/15/23 at 12:21 P.M. of Resident #36 revealed she was sitting in an upholstered chair in her room and State Tested Nursing Assistant (STNA) #372 walked in the room carrying Resident #36's lunch tray. STNA #372 prepared the meal tray for Resident #36 to eat, then walked out of the room and did not assist Resident #36 to eat the lunch meal. Resident #36 proceeded to eat her meal without assistance. Interview on 08/16/23 at 12:06 P.M. of Director of Rehab (DOR) #378 revealed she was not aware Resident #36 had a decline in eating from 04/2023 through 07/2023. Interview on 08/16/23 at 12:22 P.M. of STNA #372 revealed Resident #36 required set-up for her meals. STNA #372 stated Resident #36 did not need assistance with eating. Observation on 08/16/23 at 12:22 P.M. of Resident #36 revealed she was sitting in a chair in her room eating lunch and had no difficulty feeding herself. Interview on 08/16/23 at 12:41 P.M. of DOR #378 and MDS/Registered Nurse (MDS/RN) #303 revealed MDS/RN #303 stated Resident #36's information pulled over wrong from the aide charting in the electronic record when she was completing Resident #36's quarterly MDS assessment dated , 07/11/23. MDS/RN #303 indicated as a result of the aide charting not pulling over correctly, Resident #36's MDS was not accurately documented for eating. MDS/RN #303 stated Resident #36's assessment should be documented as supervision of one staff member for eating and she would need to complete a modification for the quarterly MDS completed on 07/11/23. 2. Review of Resident #50's medical record revealed an admission date of 04/27/22 with diagnoses including pulmonary fibrosis, depression, anxiety disorder, and cerebral infarction. Review of Resident #50's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #50 had moderate cognitive impairment. Resident #50 required limited assistance of one staff member for bed mobility and transfers and required extensive assistance of one staff member for eating. Resident #50 did not have pain or difficulty when swallowing. Review of Resident #50's care plan revised 04/13/23 included Resident #50 had deficits related to decreased mobility secondary to recent hip fracture with surgical repair. Resident #50 would improve current level of function and have all her care needs met through the review date. Interventions included Resident #50 required set-up assistance of one staff member for eating. Observation on 08/15/23 at 12:13 P.M. of Resident #50 revealed she was sitting in an upholstered chair in her room watching television, dressed in clean clothes, groomed appropriately, and said she was waiting for her lunch tray to be delivered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 5 of 10 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 08/17/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 08/15/23 12:24 P.M. of Resident #50 revealed STNA #370 walked into Resident #50's room carrying her lunch tray, prepared the tray for Resident #50 to eat, then walked out of the room. STNA #370 did not stay in the room and assist Resident #50 to eat. Observation on 08/15/23 from 12:24 P.M. through 12:52 P.M. did not reveal Resident #50 received staff assistance with eating her lunch. Interview on 08/15/23 at 12:57 P.M. of STNA's #370, #372, and #395 revealed Resident #50 did not require assistance eating. STNA #395 stated she needed her meal prepared, then she was able to feed herself without help. Interview on 08/16/23 at 12:45 P.M. of MDS/RN #303 confirmed Resident #50's quarterly MDS assessment dated [DATE] included Resident #50 required extensive assistance of one staff member for feeding. MDS/RN #303 stated Resident #50's aide charting in the electronic record pulled over wrong when she was completing Resident #50's quarterly MDS assessment dated [DATE] and the assessment would need to be modified. MDS/RN #303 stated Resident #50's MDS assessment dated [DATE] needed modified to read Resident #50 required supervision of one staff member for eating. 4.Review of medical record for Resident #34 revealed an admission date of 05/23/23. Diagnoses included acute respiratory failure with hypoxia, pneumonitis due to inhalation of food and vomit, dysphagia (difficulty swallowing), collagenous colitis (inflammatory bowel disease affecting the colon), and bowel syndrome with diarrhea. Review of quarterly 06/02/23 MDS assessment revealed Resident #34 had no significant weight changes, was not on a mechanical or therapeutic diet, received 51 percent or more of her calories from a tube feeding product, and average fluid intake per day was 501 cubic centimeter (CC) or more from intravenous or tube feeding. Review of the physician orders reveled during the reference range for the 06/02/23 MDS assessment, Resident #34 had an order dated 05/25/23 for Vital 1.5 one can (250 milliliters) via peg (percutaneous endoscopic gastrostomy) four times a day. Review of abbottnutrition.com revealed Vital 1.5 was a peptide based therapeutic nutrition product for patients who required a tube feeding and were experiencing malabsorption, maldigestion, or impaired gastrointestinal function and/or gastrointestinal intolerance. Interview on 08/17/23 at 9:01 A.M. with Registered Dietitian (RD) #369 stated Resident #34 had a history of loose stool and required a special tube feeding product, which was why Resident #34 had been on Vital 1.5. RD #369 confirmed therapeutic diet was not identified, and should have been, for the quarterly 06/02/23 MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 6 of 10 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 08/17/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, and staff interview the facility failed to monitor the placement and function of an assistive device (Wanderguard) to ensure Resident #32 did not elope from the facility. This affected one resident (#32) of three residents reviewed for elopement. The facility census was 57. Findings include: Review of Resident #32's medical record revealed an initial admission date of 03/02/23 with admitting diagnoses including nondisplaced intertrochanteric fracture of right femur, dementia, iron deficiency anemia, depression, paroxysmal atrial fibrillation, malignant of esophagus, cardiac pacemaker, chronic kidney disease, hypertension, hypothyroidism, and gastroesophageal reflux. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had a BIMS (Brief Interview of Mental Status) score of 3 out of 15 and was not always able to verbalize his needs or understand others. Resident #32 exhibited behaviors including verbal behavioral symptoms directed as others, rejection of care, and wandering. The assessment indicated the resident required extensive assistance of one staff for most activities of daily living (ADL) including bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Resident #32 had experienced a decline in mobility since his initial admission MDS performed 03/08/23. Review of Elopement Risk Assessments dated 03/02/23 and 06/06/23 indicated Resident #32 was at no risk for elopement. Elopement Risk assessment dated [DATE] revealed Resident #32 was at risk for elopement. Clinical suggestions included to apply personal safety alarm device, monitor location frequently, utilize exit alarms, utilize check in/check out log, personalize room with familiar objects and/or photographs, and to notify staff of elopement risk. Review of the revised plan of care dated 08/04/23 revealed Resident #32 was a wanderer and at risk for elopement related to disorientation to time/place and impaired cognition related to safety awareness. Interventions included frequent cues and redirection from staff, distract resident from wandering with pleasant diversions, structured activities, food, conversation, television, or book. Additionally, an assistive device - Wanderguard was ordered and placed on Resident #32 on 08/01/23 for safety. The plan of care indicated to maintain and check function of the Wanderguard per facility protocol. On 08/15/23 at 4:43 P.M., observation of Resident #32 revealed the Wanderguard in place securely on his left ankle. This was confirmed at that time by both the Director of Nursing (DON) #304 and the resident's wife. Review of the physician's orders and the Treatment Administration Record (TAR) for August 2023 did not reveal documentation to confirm that staff maintained and checked the function of the Wanderguard device since implementation. On 08/15/23 05:05 P.M., interview with DON #304 verified there was no order for staff to check placement and function of the Wanderguard device every shift and there was no documentation on the August 2023 TAR that indicated the device had been maintained and checked every shift per facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 7 of 10 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 08/17/2023 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 0689 protocol. 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: 365793 If continuation sheet Page 8 of 10 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 08/17/2023 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 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, staff interview, and facility policy, the facility failed to ensure food was labeled and dated appropriately, and failed to ensure the kitchen was clean and sanitary. This had the potential to affect 56 of 57 residents who received meals from the facility kitchen. The facility identified one resident (#34) who received no food by mouth. The facility census was 57. Findings include: The following concerns were observed during the main initial kitchen tour conducted on 08/12/23 between 8:22 A.M. and 8:50 A.M with Kitchen Coordinator #374: • The service cooler had one opened and resealed one-fourth full bag parmesan cheese undated, one open and resealed full bag of whipping cream undated, one opened one-half full quart of curdled heavy whipping cream with a sell by dated of 08/02/23, seven small disposable clear plastic containers with lids of dill sauce undated and unlabeled. At the time of observation, Kitchen Coordinator #374 confirmed the parmesan cheese and whipping cream should have been dated when opened, the dill sauce should have been labeled and dated, and the quart of whipping cream should have been thrown out. • The one door freezer had one open and resealed half full bag of hash browns undated, one open to air and undated one fourth full bag of egg rolls, one open to air and undated half full bag of chicken wings, one open to air and undated one fourth full bag of gyro meat undated, and one open and resealed one fourth full bag of fish patties undated. At the time of observation, Kitchen Coordinator #374 confirmed opened items need to be resealed and dated. • Observation of the griddle top on the stove top revealed a buildup of debris in the corners of the griddle, and the floor mixer had an accumulation of splash marks on the base of the unit. Observation of the bulk storage containers for flour, gluten free flour, white sugar, and breadcrumbs revealed a buildup of debris on the outside and base of the containers. At the time of observation, Kitchen Coordinator #374 confirmed the griddle needed cleaned, and the floor mixer was dirty from the mashed potatoes from the previous night, and the bulk containers were dirty and needed cleaned. • Observation of the walk-in cooler revealed a buildup of debris on the floor under the shelves around the perimeter of the unit. There were four cooked pork loins in a rectangular metal pan covered with film wrap which was undated and unlabeled and one quarter of a ham log wrapped in film wrap, undated. At the time of observation, Kitchen Coordinator #374 confirmed the pork loins should have been labeled and dated and the ham should have been dated. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 9 of 10 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 08/17/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Observation of the milk/produce walk in cooler revealed a dirty floor with bits of watermelon and lettuce on the floor in the middle of the unit and a buildup of dirt and debris under the shelving located around the perimeter of the unit. Two large puddles of dried milk were observed under the shelves where the milk was stored. Kitchen Coordinator #374 at the time of observation confirmed the floor was dirty and needed cleaned. Residents Affected - Many • Observation of the dried storage area revealed one fifty-pound cardboard box parboil white rice open to air with a clear plastic cup stored in the bulk rice. At the time of observation, Kitchen Coordinator #374 confirmed the rice should have been resealed, and no scoop should have been stored it the box. Review of the facility policy Floor Sanitation, dated 07/01/96, revealed floors would be kept clean and sanitary. Review of the facility policy Food Storage, revised 04/13/12, revealed scoops were not to be stored in the food containers; prepared and leftover food items would be labeled and dated; and all food items would be stored in original packages, covered containers, or wrapping. Review of the facility policy Infection Control: Equipment, revised 10/22/20, revealed equipment would be thoroughly sanitized between use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 10 of 10