Inspection·June 25, 2024

F 0689 for meals, bedtime, and toileting. Level of Harm - Actual harm Review of the progress notes revealed an incident note dated 05/15/24 detailing that blood was noted on the paddle of the Sara Steady device and Resident #33 sustained a V-shaped skin tear to her right elbow measuring three centimeters (cm) by 1.2 cm while being transferred. The note further revealed the STNA was educated to be more careful when transferring Resident #33 with the device. Residents Affected - Few Review of the progress note dated 06/03/24 revealed the interdisciplinary team (IDT) reviewed bruising to Resident #33's right inner forearm, measuring 10.3 cm by 4.4 cm, which was determined to be the result of the resident being transferred incorrectly and the staff member's elbow contacting Resident #33's right forearm. Review of the progress note dated 06/23/24 revealed the nurse was called to Resident #33's room and found her on the floor with her left leg against the bed frame and her right leg externally rotated as Resident #33 was noted to be screaming in pain. Further review of the progress note revealed the fall occurred as the STNA was transferring Resident #33 into her wheelchair. Resident #33 was transported via ambulance to local hospital for evaluation and treatment after a call was placed to emergency medical services (911). Review of the nursing nursing progress note dated 06/25/24 at 6:18 A.M. revealed an update was received from the resident's son who reported his mother was doing well after her surgery related to a fractured femur. Interview on 06/25/24 at 2:08 P.M. with Resident #34, who was the spouse and roommate of Resident #33 revealed Resident #33 was in the hospital because the aide dropped her and she had to have surgery. During the interview, Resident #34 revealed he informed the STNA Resident #33 required a device to move her, but the STNA (STNA #384) disregarded his suggestion and proceeded to try to pick-up Resident #33 without a device and dropped her before she could place her into her wheelchair. Interview on 06/25/24 at 3:20 P.M. with Therapy Department Manager #383 confirmed Resident #33's transfer status was evaluated by the Therapy Department in December 2023, and it was determined she required a Sara Steady lift for all transfers and a Sit to Stand mechanical lift for transfers as needed, depending on decline in cognitive status or increase in weakness. During the interview, Therapy Department Manager #383 confirmed Resident #33 should not have been transferred without the use of a transfer device and one-to-two-person assistance was to be used with the Sara Steady lift and two-person assistance was required with any type of mechanical lift, such as the Sit to stand or Hoyer lift. Interview on 06/25/24 with the Director of Nursing (DON) at 3:50 P.M. confirmed Resident #33 had an order to use the Sara Steady for all transfers and a sit to stand lift if needed. The DON further confirmed no device was used during the transfer of Resident #33 which led to her fall on 06/23/24, despite evidence of other staff informing STNA #384 a transfer device was required. The DON confirmed Resident #33 sustained a fracture of the right femur as a result of the fall on 06/23/24. Interview on 06/25/24 with the Assistant Director of Nursing (ADON) at 4:00 P.M. confirmed bruising sustained to Resident #33's forearm on 05/31/24 was determined by the IDT on 06/03/24 to be the result of an improper transfer and the fall sustained by Resident #33 on 06/23/24 was the result of STNA #384 not providing a safe transfer by using one of the ordered transfer devices. Further interview with the ADON confirmed STNA #384 was provided an assignment that specified Resident #33 required a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 2 of 3 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 06/25/2024 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)

F 0689 Sara Steady for transfers and a sit to stand as needed for transfers. Level of Harm - Actual harm Review of the Resident assignment sheet for the Appleblossom unit, last updated on 06/20/24, revealed there was written instruction for on-duty staff that Resident #33 required a Sara Steady for transfers or a sit to stand as needed. Residents Affected - Few Review of the facility fall investigation completed 06/25/24 revealed witness statements from three other staff on duty indicating STNA #383 was reminded by staff and by Resident #34, Resident #33's spouse and roommate, that Resident #33 required a lift for transfers. Review of the facility policy titled No Lift last reviewed in September 2023 revealed residents who required increased assistance of one staff member were to be evaluated by the therapy department for the most appropriate type of mechanical lift device. Further review of the policy revealed staff were not to transfer the resident without using the lift recommended by the Therapy Department. This deficiency represents non-compliance investigated under Complaint Number OH00154309. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365793 If continuation sheet Page 3 of 3