Health inspection·May 1, 2024

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 medical record review, interview and facility policy review, the facility failed to report an injury of unknown origin to the state agency as required. This affected one resident (#2) of three residents reviewed for injury of unknown origin. This had the potential to affect all residents residing at the facility. The facility census was 73. Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/05/23. Diagnoses included but were not limited to Alzheimer's dementia, stage III chronic kidney disease, anxiety disorder, and dementia with behaviors. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed a Brief Interview of Mental Status (BIMS) score of 03 which indicated severe cognitive impairment. Review of activities of daily living (ADL) revealed Resident #2 required maximum assist for toileting, dressing, personal hygiene, chair transfer, toilet transfer, and was dependent for bathing, sit to stand, tub transfer and wheeling 50 feet. Review of nursing progress note dated 03/28/24 timed at 12:08 P.M. revealed the State Tested Nurse Aide (STNA) found Resident #2 sitting on the floor in front of his recliner with his back against the recliner and his feet still on the leg rest. Resident #2 denied hitting his head or pain. Review of nursing progress noted dated 04/09/24 timed at 8:47 A.M. for Resident #2 revealed the STNA notified the nurse Resident #2 had bruising on his right hand and forearm and had swelling in his bilateral arms. Resident #2 denied falling or injury. Resident #2 was noted to have edema in the arms from the fingers to the elbows, bruising on the right arm from his thumb to mid forearm and one plus pitting edema to his bilateral legs from the toes to the groin. Review of nursing progress note dated 04/10/24 timed at 10:22 A.M. revealed Resident #2 was assessed by the Director of Nursing (DON) and stated the bruising was latent bruising secondary to the fall on 03/28/24. Review of nursing progress notes dated 04/25/24 timed at 2:20P.M. revealed an interdisciplinary note stating Resident #2 had an injury of unknown origin with bruising to right hand and forearm. Interview on 05/01/24 at 10:13 A.M. with the Medical Director confirmed Resident #2 had a fall on 03/28/24 but did not feel the bruising identified on 04/09/24 was related to the 03/28/24 incident Page 1 of 2 365793 365793 05/01/2024 Crown Center at Laurel Lake 200 Laurel Lake Dr Hudson, OH 44236

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and thought the bruising would have presented prior to 04/09/24 and thought another incident occurred later to cause the bruising. Interview on 05/01/24 at 1:46 P.M. with the DON confirmed a complete fall investigation had not been completed on 03/28/24 following Resident #2's unwitnessed fall. The DON stated she only got a witness statement from the STNA who found Resident #2 but did not get statements from any other employees working that day. The DON confirmed when the bruising was identified on 04/10/24 for Resident #2 she attributed the injury of unknown origin to the 03/28/24 fall, did not gather witness statements, do an investigation, or submit a self-reported incident (SRI) to the state agency. Review of the 01/16/20 revised facility policy Abuse, Mistreatment, Neglect and Misappropriation of Resident Property revealed an injury of unknown origin is when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury, the location of the injury or the incidence of injuries over time. This deficiency represents non-compliance investigated under Complaint Number OH00152967. 365793 Page 2 of 2