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 (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 05/01/2024 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)