Inspection·August 4, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LNHA indicated his wife reported tapping him on the bottom to get him to comply. LNHA indicated she did not feel the situation was abusive and his wife was just frustrated. LNHA indicated Resident #57's wife had cared for him for a long time but had a decline and she was experiencing caregiver burn out. LNHA indicated they had offered Resident #57's wife counseling services with their Chaplin and resources for caregiver burnout. Interview on 07/31/25 at 2:28 P.M. with Licensed Practical Nurse (LPN) #242 revealed one of her aides told her Resident #57's wife was toileting Resident #57 on her own and Resident #57 was becoming aggressive with her. LPN #242 indicated his wife also was becoming aggressive. LPN #242 was asked to describe aggressive, and she indicated it was not abuse but she was not there so she could not describe it. LPN #242 stated she inspected Resident#57's skin and there were no red areas on his bottom or injuries. Interview on 08/04/25 at 9:21 A.M. with CNA #221 revealed on 07/24/25 she was assisting Resident #57's wife to get Resident #57 up out of bed to go to the bathroom and Resident #57 punched his wife on the left side of her abdomen. Resident #57's wife reacted and slapped Resident #57 with force on his right facial cheek with her right hand. CNA #221 stated Resident #57's wife instructed her to leave the room and CNA #221 proceeded to leave Resident #57 and his wife alone in the room and went to report the incident to Licensed Practical Nurse (LPN) #242. LPN #242 instructed CNA #221 to fill out an incident report and CNA #221 proceeded to fill out a witness statement and give it to LPN #242. Interview on 08/04/25 at 9:53 A.M. with LPN #242 revealed CNA #221 reported to her that Resident #57 hit his wife while trying to get him up to the bathroom and Resident #57's wife proceeded to slap him in the face. LPN #242 stated she went back in Resident #57's room to see if he and his wife were okay. LPN #242 stated when she entered Resident #57 was sitting on the toilet and his wife was standing next to him, and they were both giggling. LPN #242 confirmed she did not complete an incident report and did not write a statement but did report what was reported by CNA #221 to the Administrator. Interview on 08/04/25 at 9:31 A.M. with the Administrator revealed she talked with Resident #57's wife immediately following the incident being reported by LPN #242. Administrator stated Resident #57's wife stated she tapped him on the bottom and did not hit Resident #57 with force. Administrator confirmed they did not do an investigation, was unable to provide proof of witness statements and did not open a self-reported incident as required. Interview on 08/04/25 at 11:02 A.M. with Resident #57's wife revealed while assisting CNA #221 to get Resident #57 up to the bathroom, Resident #57 hit his wife, and she patted him on the butt to get him to listen. Resident #57's wife stated she did not slap Resident #57 and did not ask CNA #221 to leave the room. Review of the facility incident logs from 04/25 to 07/25 revealed the allegation of abuse was not listed. Review of the Ohio Department of Health's Gateway system revealed no facility SRI related to the allegation of abuse reported by Certified Nurse Aide (CNA) #221 on 07/24/25 related to Resident #57.2. Review of the medical record for Resident #58 revealed an admission date of 01/25/23. Diagnoses included but were not limited to displaced intertrochanteric fracture of right femur, urinary tract infection, anxiety disorder, dementia, Alzheimer's dementia, and macular degeneration. Review of the 07/24/25 discharge Minimum Data Set (MDS) 3.0 for Resident #58 revealed severe cognitive impairment, resident was rarely understood and had noted wandering behavior almost daily. Review of the 07/14/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #58 revealed severe cognitive impairment, wandering was indicated four to six days of seven assessed, and was independent to walk 150 feet. Resident #58 was noted to have a wander guard. Review of Resident #58's care plan revealed risk for wandering/elopement related to disorientation to place, history of attempts to leave facility unattended while previously living in the assisted living facility. Resident #58 was noted to have almost daily attempts to push or slam her walker through doors to get to assisted living. (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 08/04/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interventions were to encourage activity when resident was observed in the front areas by the exit doors. Review of the 04/06/25 nursing progress note for Resident #58 revealed the nurse was notified by activity staff resident had got out of the exit doors toward the Al and was brought back by activity staff. Review of the 04/06/25 nursing progress note for Resident #58 revealed resident was seen walking towards the AL entrance door and used her hands to pry open the door and was redirected by staff. Review of the 04/07/25 nursing note revealed the interdisciplinary team discussed the 04/06/25 incident for Resident #58 and decided it was not an elopement since it was still inside the facility. Review of the 04/30/25 nursing progress note for Resident #58 revealed the nurse heard the alarm and started searching for Resident #58. Nurse found Resident #58 outside the facility entrance lobby and brought her back into the facility without injury. Review of the 05/07/25 nursing progress note for Resident #58 revealed she was found outside of the facility under the pavilion front entrance. Nurse was able to bring her back without injury. Resident #58 was noted to pry open door with hands to exit. Review of the 05/17/25 nursing progress note for Resident #58 revealed the nurse heard the front door alarm around 4:15 P.M. with a quiet beeping noise. Nurse went to investigate and found Resident #58 standing outside the facility entrance under the pavilion in front of the facility. Resident #58 brought back into facility by staff. Review of the 05/17/25 nursing progress note for Resident #58 revealed Resident #58 continued to have exit seeking behaviors and became agitated and attempted to hit staff when they attempted to redirect her away from the facility front door. Review of the 06/06/25 quarterly elopement assessment for Resident #58 revealed a score of 5 which indicated high risk for elopement. Review of the facility incident log from 04/25 through 07/25 revealed three elopements listed for Resident #58 on 04/06/25, 05/07/25, and 05/17/25. The elopement listed in the nursing progress note dated 04/30/25 was not listed on the incident log. Interview on 07/31/25 with Administrative Assistant (AA) #215 revealed on 05/07/25 she was walking back towards her desk and heard the front door alarm going off. AA #215 went outside and found Resident #58 standing outside the facility under the pavilion and brought her back into the facility. Interview on 07/31/25 at 9:29 A.M. with the Director of Nursing (DON) revealed she would not consider a resident outside of the facility an elopement unless a resident made it to the road. DON stated she would report abuse, neglect, or injury of unknown origin, but has never reported an elopement. DON confirmed they had four elopement incidents listed on the incident log from 04/25 through 07/25 but had not reported them to the state. Interview on 07/31/25 at 11:52 A.M. with the Assistant Director of Nursing (ADON) revealed she would consider a resident outside of the external doors of the facility to be an elopement. Interview on 07/31/25 at 12:41 P.M. with the Administrator revealed an elopement is a resident going to an unsafe area without authorization, unsafe area would be resident getting out of the facility close to the road. If a resident elopes, staff are to notify the DON and Administrator and start searching the premise. Administrator confirmed she would report abuse or neglect but had never reported elopement to the stated agency. Interview on 07/31/25 at 4:06 P.M. with Licensed Practical Nurse (LPN) #241 revealed when she came on shift on 05/17/25 she was told by staff that Resident #58 had already been outside the facility once earlier in the day and to be on high alert due to her being exit seeking. LPN #241 was walking from the nurse station towards the front entrance and heard a faint beeping and began to check rooms for alarms. When LPN #241 got to the front door she heard the alarm beeping and looked outside to see Resident #58 outside on the sidewalk at the edge of the walkway under the portico. Resident #58 was confused, unsure of why she was out there. LPN #241 brought Resident #58 back into the facility. LPN #241 reported the incident to Registered Nurse (RN) #279. Interview on 07/31/25 at 4:25 P.M. with RN #279 revealed on 05/17/25 Resident #58 had a wander guard on, but (continued on next page) 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 08/04/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was able to pull the front door open and got outside onto the sidewalk in front of the facility. LPN #241 found Resident #58, brought her back inside and reported it to RN #279 and she reported it to the Administrator and DON. Interview on 07/31/25 at 4:36 P.M. with the DON confirmed Resident #58 had been outside of the facility on 05/17/25 without staff supervision and staff were not aware she had left the facility. DON stated she was unable to recall if Resident #58 had gotten outside of the facility earlier in the day. DON confirmed she did not do an SRI and did not complete an investigation. 3. Review of the medical record for Resident #67 revealed an admission date of 07/03/24. Diagnoses included but were not limited to fracture of left pubis, dementia with psychotic disturbance, and cognitive communication deficit. Review of 06/26/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #67 revealed a Brief Interview of Mental Status (BIMS) score of 06 which indicated severe cognitive impairment. Resident #67 was noted to have behaviors of wandering one to three days of the review period. Resident #67 was noted to be independent to walk 150 feet. Review of the 06/06/25 elopement evaluation revealed score of six which indicated high risk of elopement. Resident #67 was noted to have a history of elopement or attempts to the leave the facility without informing staff, had verbally expressed a desire to go home, stayed near the exit doors, and frequently wandered without a purpose. Review of the Resident #67's care plan revealed she was an elopement risk related to impaired safety awareness related to her dementia. Review of the 07/05/25 nursing progress note timed at 4:29 P.M. revealed Certified Nursing Assistant (CNA) had last checked on resident at 11:48 A.M. who was getting out of bed for lunch. When CNA went back to check on Resident #67 at 12:03 P.M. she found Resident #67 on the floor on her back with her walker in front of her. Resident #67's left leg had external rotation and was unable to straighten her leg without pain. Resident #67 was sent out for evaluation. Review of the 07/05/25 nursing progress note timed at 5:38 P.M. revealed Resident #67 had a pelvic fracture and was admitted to the hospital. Review of the 07/09/25 nursing progress note timed at 6:37 P.M. for Resident #67 revealed she was readmitted without surgery and was weight bearing as tolerated. Review of the 07/09/25 elopement evaluation revealed a score of five which indicated a high risk for elopement. Review of the 07/17/25 elopement evaluation revealed a score of one due to Resident #67 being non-ambulatory and unable to self-propel in wheelchair. Review of nursing progress notes revealed no note related to Resident #67 being found outside of the facility by a resident family member on 07/23/25. Review of the 07/23/25 elopement evaluation revealed a score of 8 which indicated a high risk of elopement. Review of the physician orders dated 07/23/25 for Resident #67 revealed an order for a wander tag to left ankle to alert staff to unassisted exit from facility. Review of the facility incident log from 04/25 through 07/25 revealed no entry related to Resident #67 getting outside of the facility unattended. Interview on 07/30/25 at 1:05 P.M. with LPN #254 revealed Resident #67 got outside of the facility on 07/23/25 and was found in the parking lot by another resident's wife who brought her back into the facility. LPN #254 stated she had entered a progress note that a wander guard was added following the elopement incident but did not enter a progress note or complete a skin assessment as it was at shift change. Interview on 07/30/25 at 2:47 P.M. with Resident #57's wife revealed she was walking into the facility from her car and found Resident #67 out in the parking lot on the side walk between the front entrance and blueberry unit entrance door and brought her back into the facility to staff. Interview on 07/30/25 at 3:46 P.M. with LPN #217 revealed she was coming into work around 2:20 P.M. on 07/23/25 and saw Resident #67 sitting in her wheelchair in the parking lot outside of the facility. LPN #217 went inside and told LPN #254. LPN #217 stated she did not enter a progress note or complete a skin assessment as she figured LPN #254 would complete it. Interview on 07/31/25 at 12:41 P.M. with the Administrator confirmed following Resident (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 08/04/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #67 getting outside of the facility without staff supervision, the facility did not do an incident report, complete an investigation or report it to the state agency. Review of the 06/01/25 revised facility policy called Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed abuse means the willful infliction of injury, harm, pain or mental anguish. Physical abuse includes but is not limited to slapping, punching, biting and kicking. Under the section titled response to allegations or suspicions of abuse, mistreatment, neglect, exploitation, and/or misappropriation of resident property, staff shall report all incident immediately to their direct supervisors, the director of nursing, and the administrator. Staff are not to leave the resident unattended unless it is absolutely necessary to summon assistance. A nurse supervisor should perform an initial assessment of the resident which should include range of motion, full body assessment for signs of injury and vital signs. If a third party is accused or suspected of abuse, the facility will take immediate action to protect the resident including but not limited to contacting the third party and addressing the issue directly with him/her, preventing access to the resident during the investigation and/or refer the matter to the appropriate authorities. The incident will be documented in the nurses' notes and should include an accurate description of the incident, the results of the range of motion (ROM), body assessment, vital signs, the notification of the physician and the responsible party, and treatment provided. Appropriate quality assurance documentation should also be completed as well. All allegations of abuse or neglect that do not result in bodily injury must be reported to the Administrator immediately and the State Survey and Certification Agency within 24 hours. Once notifications are made, an investigation will be conducted using the quality assurance form used by the facility. The investigation shall begin upon learning of the incident and final disposition of the incident shall be made to the Ohio Department of Health (ODH) within five working days. Investigation shall include the following; interview the resident, the accused, and all witnesses who work closely with the resident the day of the incident. Obtain written statement from the resident, if possible, the accused, and each witness. This deficiency represents non-compliance investigated under Complaint Number OH002574199 and Complaint Number OH002572009. 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 08/04/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to complete an investigation into allegations of physical abuse for Resident #57 and failed to complete an investigation into potential neglect for Residents #58 and #67. This affected three residents (#57, #58, and #67) of four reviewed for abuse and neglect. The facility census was 70.Findings include:1. Review of the medical record for Resident #57 revealed an admission date of 07/19/25 and diagnoses including delirium due to known physiological condition, vascular dementia, anxiety disorder, aphasia, cognitive communication deficit, cerebral infarction, and persistent atrial fibrillation.Review of the 07/19/25 care plan for Resident #57 revealed the resident had the potential for physically aggressive behavior related to dementia. Interventions included monitoring and documenting any signs and symptoms of the resident posing danger to self and others.Review of a behavior note dated 07/21/25 revealed Resident #57 had grabbed the nurse's arm and started yelling. Resident #57 was also noted to make several attempts to get out of bed on his own and when staff intervened, he would become aggressive. Resident #57 was noted to become aggressive towards his wife as well.Review of a Psychiatric Evaluation dated 07/23/25 revealed Resident #57 had history of insomnia, anxiety, depression, and vascular dementia. Resident #57 admitted to the facility following hospitalization for a cardiac procedure. Resident #57 was noted to be combative coming out of anesthesia and had been experiencing delirium related to anesthesia. Resident #57 was noted to have intermittent agitation and aggression since admission and was not getting along with his roommate. Resident #57's wife did not wish for medication changes at this time. Review of physician progress note dated 07/23/25 revealed Resident #57 was status post-procedure. The procedure was noted to be uncomplicated, however, Resident #57 had noted delirium following the procedure with waxing and waning of mental status and confusion.Review of a nursing note dated 07/23/25 revealed Resident #57 was combative with staff during care. It was also noted Resident #57's wife appeared to be the only consoling factor and only person able to re-direct him. Resident #57 required one-on-one care while his wife was away.Review of nursing note dated 07/24/25 revealed Resident #57 was being aggressive with his wife during toileting, and it was observed by staff that the wife became aggressive back. Social services and the Administrator were made aware. There were no noted injuries or effects to Resident #57.Review of Brief Interview for Mental Status (BIMS) evaluation dated 07/25/25 revealed Resident #57 scored 4.0 indicating severe cognitive impairment.Interview on 07/31/25 at 1:37 P.M. with the Administrator revealed Resident #57 and his wife normally resided in the independent living (IL) together. The Administrator indicated Resident #57 had come to the facility for a rehabilitation stay following a hospitalization. The Administrator indicated Resident #57 needed psychiatric services while admitted for behaviors. The Administrator indicated on 07/24/25, staff found Resident #57's wife attempting to toilet him. Resident #57 was being resistive, and his wife was getting angry and frustrated with him. The Administrator indicated her staff reported their concerns with the situation to her and she brought his wife into her office to talk about it. The Administrator indicated his wife reported tapping Resident #57 on the bottom to get him to comply. The Administrator stated she did not feel the situation was abusive and his wife was just frustrated. The Administrator indicated Resident #57's wife had cared for him for a long time but had a decline and she was experiencing caregiver burn out. The Administrator reported they had offered Resident #57's wife counseling services with their Chaplain and resources for caregiver burnout.Interview on 07/31/25 at 2:28 P.M. with Licensed Practical Nurse (LPN) #242 revealed one of her aides told her Resident #57's wife was toileting Resident #57 on her own and Resident #57 was becoming aggressive with her. LPN #242 indicated the resident's wife Residents Affected - Few (continued on next page) 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 08/04/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few also was becoming aggressive. LPN #242 was asked to describe aggressive, and she indicated it was not abuse but she was not there, so she could not describe it. LPN #242 stated she inspectedInterview on 08/04/25 at 9:21 A.M. with Certified Nursing Assistant (CNA) #221 revealed on 07/24/25 she was assisting Resident #57's wife to get Resident #57 up out of bed to go to the bathroom and Resident #57 punched his wife on the left side of her abdomen. Resident #57's wife reacted and slapped Resident #57 with force on his right facial cheek with her right hand. CNA #221 stated Resident #57's wife instructed her to leave the room and CNA #221 proceeded to leave Resident #57 and his wife alone in the room and went to report the incident to Licensed Practical Nurse (LPN) #242. LPN #242 instructed CNA #221 to fill out an incident report and CNA #221 proceeded to fill out a witness statement and gave it to LPN #242.A follow up interview on 08/04/25 at 9:53 A.M. with LPN #242 revealed CNA #221 reported to her that Resident #57 hit his wife while trying to get him up to the bathroom and Resident #57's wife proceeded to slap him in the face. LPN #242 stated she went back in Resident #57's room to see if he and his wife were okay. LPN #242 stated when she entered Resident #57 was sitting on the toilet and his wife was standing next to him, and they were both giggling. LPN #242 confirmed she did not complete an incident report and did not write a statement but did report what was reported by CNA #221 to the Administrator.Interview on 08/04/25 at 9:31 A.M. with the Administrator revealed she talked with Resident #57's wife immediately following the incident being reported by LPN #242. Administrator stated Resident #57's wife stated she tapped him on the bottom and did not hit Resident #57 with force. Administrator confirmed they did not do an investigation, was unable to provide proof of witness statements and did not open a self-reported incident as required.Interview on 08/04/25 at 11:02 A.M. with Resident #57's wife revealed while assisting CNA #221 to get Resident #57 up to the bathroom, Resident #57 hit his wife, and she patted him on the butt to get him to listen. Resident #57's wife stated she did not slap Resident #57 and denied asking CNA #221 to leave the room. Review of the facility incident logs from 04/25 to 07/25 revealed the allegation of abuse was not listed.Review of the Ohio Department of Health's (ODH) Certification and Licensure System (CALS) revealed no facility self-reported incident (SRI) had been reported related to the allegation of abuse reported by Certified Nurse Aide (CNA) #221 on 07/24/25 regarding Resident #57.2. Review of the medical record for Resident #58 revealed an admission date of 01/25/23. Diagnoses included but were not limited to displaced intertrochanteric fracture of right femur, urinary tract infection, anxiety disorder, dementia, Alzheimer's dementia, and macular degeneration.Review of Resident #58's care plan revealed risk for wandering/elopement related to disorientation to place, history of attempts to leave facility unattended while previously living in the assisted living facility. Resident #58 was noted to have almost daily attempts to push or slam her walker through doors to get to assisted living. Interventions were to encourage activity when the resident was observed in the front areas by the exit doors.Review of the 04/06/25 nursing progress note for Resident #58 revealed the nurse was notified by activity staff that Resident #58 had gotten out of the exit doors toward the assisted living (AL) and was brought back by activity staff.Review of the 04/06/25 nursing progress note for Resident #58 revealed resident was seen walking towards the AL entrance door and used her hands to pry open the door and was redirected by staff.Review of the 04/07/25 nursing note revealed the interdisciplinary team discussed the 04/06/25 incident for Resident #58 and decided it was not an elopement since the resident was still inside the facility.Review of the 04/30/25 nursing progress note for Resident #58 revealed the nurse heard the alarm and started searching for Resident #58. Nurse found Resident #58 outside the facility entrance lobby and brought her back into the facility without injury.Review of the 05/07/25 nursing progress note for Resident #58 revealed she was found outside of the (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 08/04/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility under the pavilion front entrance. Nurse was able to bring her back without injury. Resident #58 was noted to pry open door with hands to exit.Review of the 05/17/25 nursing progress note for Resident #58 revealed the nurse heard the front door alarm around 4:15 P.M. with a quiet beeping noise. The nurse went to investigate and found Resident #58 standing outside the facility entrance under the pavilion in front of the facility. Resident #58 was brought back into the facility by staff.Review of the 05/17/25 nursing progress note for Resident #58 revealed Resident #58 continued to have exit seeking behaviors and became agitated and attempted to hit staff when they attempted to redirect her away from the facility front door.Review of the 06/06/25 quarterly elopement assessment for Resident #58 revealed a score of 5 which indicated high risk for elopement. Review of the facility incident log from 04/25 through 07/25 revealed three elopements listed for Resident #58 on 04/06/25, 05/07/25, and 05/17/25. The elopement listed in the nursing progress note dated 04/30/25 was not listed on the incident log.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #58 revealed severe cognitive impairment, wandering was indicated four to six out of seven days assessed, and was independent to walk 150 feet. Resident #58 was noted to have a wander guard.Interview on 07/31/25 with Administrative Assistant (AA) #215 revealed on 05/07/25 she was walking back towards her desk and heard the front door alarm going off. AA #215 went outside and found Resident #58 standing outside the facility under the pavilion and brought her back into the facility.Interview on 07/31/25 at 9:29 A.M. with the Director of Nursing (DON) revealed she would not consider a resident outside of the facility an elopement unless a resident made it to the road. The DON stated she would report abuse, neglect, or injury of unknown origin, but has never reported an elopement. The DON confirmed they had four elopement incidents listed on the incident log from 04/25 through 07/25 but had not reported them to the state. Interview on 07/31/25 at 11:52 A.M. with the Assistant Director of Nursing (ADON) revealed she would consider a resident outside of the external doors of the facility to be an elopement.Interview on 07/31/25 at 12:41 P.M. with the Administrator revealed an elopement is a resident going to an unsafe area without authorization and further explained an unsafe area would be resident getting out of the facility close to the road. If a resident elopes, staff are to notify the DON and Administrator and start searching the premises. The Administrator confirmed she would report abuse or neglect but had never reported elopement to the State Agency. Interview on 07/31/25 at 4:06 P.M. with Licensed Practical Nurse (LPN) #241 revealed when she came on shift on 05/17/25 she was told by staff that Resident #58 had already been outside the facility once earlier in the day and to be on high alert due to her being exit seeking. LPN #241 was walking from the nurse's station towards the front entrance and heard a faint beeping and began to check rooms for alarms. When LPN #241 got to the front door she heard the alarm beeping and looked outside to see Resident #58 outside on the sidewalk at the edge of the walkway under the portico. Resident #58 was confused and unsure of why she was out there. LPN #241 brought Resident #58 back into the facility. LPN #241 reported the incident to Registered Nurse (RN) #279.Interview on 07/31/25 at 4:25 P.M. with RN #279 revealed on 05/17/25 Resident #58 had a wander guard on but was able to pull the front door open and got outside onto the sidewalk in front of the facility. LPN #241 found Resident #58, brought her back inside and reported it to RN #279 and she reported it to the Administrator and DON.Interview on 07/31/25 at 4:36 P.M. with the DON confirmed Resident #58 had been outside of the facility on 05/17/25 without staff supervision and staff were not aware she had left the facility. DON stated she was unable to recall if Resident #58 had gotten outside of the facility earlier in the day. DON confirmed she did not do an SRI and did not complete an investigation. 3. Review of the medical record for Resident #67 revealed an admission date of 07/03/24. Diagnoses included but were not limited to fracture (continued on next page) 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 08/04/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of left pubis, dementia with psychotic disturbance, and cognitive communication deficit.Review of the Resident #67's care plan revealed she was an elopement risk related to impaired safety awareness related to her dementia.Review of the elopement evaluation dated 06/06/25 revealed score of six which indicated high risk of elopement. Resident #67 was noted to have a history of elopement or attempts to the leave the facility without informing staff, had verbally expressed a desire to go home, stayed near the exit doors, and frequently wandered without a purpose.Review of 06/26/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #67 revealed a Brief Interview of Mental Status (BIMS) score of 06 which indicated severe cognitive impairment. Resident #67 was noted to have behaviors of wandering one to three days of the review period. Resident #67 was noted to be independent to walk 150 feet.Review of the nursing progress note dated 07/05/25 and timed at 4:29 P.M. revealed an unnamed CNA had last checked on Resident #67 at 11:48 A.M. The resident was getting out of bed for lunch. When CNA went back to check on Resident #67 at 12:03 P.M., she found Resident #67 on the floor on her back with her walker in front of her. Resident #67's left leg had external rotation and was unable to straighten her leg without pain. Resident #67 was sent out for evaluation.Review of the nursing progress note dated 07/05/25 and timed at 5:38 P.M. revealed Resident #67 had a pelvic fracture and was admitted to the hospital.Review of the nursing progress note dated 07/09/25 and timed at 6:37 P.M. for Resident #67 revealed she was readmitted without surgery and was weight bearing as tolerated.Review of the elopement evaluation dated 07/09/25 revealed a score of five which indicated a high risk for elopement.Review of the 07/17/25 elopement evaluation revealed a score of one due to Resident #67 being non-ambulatory and unable to self-propel in wheelchair.Review of nursing progress notes revealed no note related to Resident #67 being found outside of the facility by a resident family member on 07/23/25.Review of the 07/23/25 elopement evaluation revealed a score of 8 which indicated a high risk of elopement.Review of the physician orders dated 07/23/25 for Resident #67 revealed an order for a wander tag to left ankle to alert staff to unassisted exit from facility. Review of the facility incident log from 04/25 through 07/25 revealed no entry related to Resident #67 getting outside of the facility unattended. Interview on 07/30/25 at 1:05 P.M. with LPN #254 revealed Resident #67 got outside of the facility on 07/23/25 and was found in the parking lot by another resident's wife who brought her back into the facility. LPN #254 stated she had entered a progress note that a wander guard was added following the elopement incident but did not enter a progress note or complete a skin assessment as it was at shift change.Interview on 07/30/25 at 2:47 P.M. with Resident #57's wife revealed she was walking into the facility from her car and found Resident #67 out in the parking lot on the side walk between the front entrance and blueberry unit entrance door and brought her back into the facility to staff.Interview on 07/30/25 at 3:46 P.M. with LPN #217 revealed she was coming into work around 2:20 P.M. on 07/23/25 and saw Resident #67 sitting in her wheelchair in the parking lot outside of the facility. LPN #217 went inside and told LPN #254. LPN #217 stated she did not enter a progress note or complete a skin assessment as she figured LPN #254 would complete it.Interview on 07/31/25 at 12:41 P.M. with the Administrator confirmed following Resident #67 getting outside of the facility without staff supervision or knowledge, the facility did not complete an incident report, an investigation, and the incident was not reported to the State Agency.Review of the 06/01/25 revised facility policy called Abuse, Neglect, Exploitation and Misappropriation of Resident Property revealed abuse means the willful infliction of injury, harm, pain or mental anguish. Physical abuse includes but is not limited to slapping, punching, biting and kicking. Under the section titled response to allegations or suspicions of abuse, mistreatment, neglect, exploitation, and/or misappropriation of resident property, staff shall report all incident immediately to their direct (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 08/04/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete supervisors, the director of nursing, and the administrator. Staff are not to leave the resident unattended unless it is absolutely necessary to summon assistance. A nurse supervisor should perform an initial assessment of the resident which should include range of motion, full body assessment for signs of injury and vital signs. If a third party is accused or suspected of abuse, the facility will take immediate action to protect the resident including but not limited to contacting the third party and addressing the issue directly with him/her, preventing access to the resident during the investigation and/or refer the matter to the appropriate authorities. The incident will be documented in the nurses' notes and should include an accurate description of the incident, the results of the range of motion (ROM), body assessment, vital signs, the notification of the physician and the responsible party, and treatment provided. Appropriate quality assurance documentation should also be completed as well. All allegations of abuse or neglect that do not result in bodily injury must be reported to the Administrator immediately and the State Survey and Certification Agency within 24 hours. Once notifications are made, an investigation will be conducted using the quality assurance form used by the facility. The investigation shall begin upon learning of the incident and final disposition of the incident shall be made to the Ohio Department of Health (ODH) within five working days. Investigation shall include the following: interview the resident, the accused, and all witnesses who work closely with the resident the day of the incident. Obtain written statements from the resident, if possible, the accused, and each witness. This deficiency represents non-compliance investigated under Complaint Numbers 2574199 and 2572009. Event ID: Facility ID: 365793 If continuation sheet Page 10 of 10