Crown Center at Laurel Lake

In the surveyor’s words

From the most serious findings on record at Crown Center at Laurel Lake, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 25, 2024

  Based on record review, interview, and review of facility policy, the facility failed to ensure Resident #33 was transferred in a manner that would prevent a fall with major injury. This affected one resident (Resident #33) of three residents reviewed for safe transfers. The facility census was 61. Actual harm occurred on 06/23/24 when Resident #33, who required staff assistance and use of a transfer device due to repeated falls and poor safety awareness, was transferred without the device and sustained a fall and fracture of the right femur. State tested Nurse Aid (STNA) #384 ignored guidance from other staff and Resident's #33's spouse indicating the need to use a transfer device and attempted to transfer Resident #33 independently which resulted in Resident #33 falling. […]

• No harm, potential for more than minimal, widespreadF812Aug 17, 2023

  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. […]

• No harm, potential for more than minimal, widespreadF880Aug 19, 2021

  Based on observation, record review, facility policy and procedure review, review of Centers for Disease Control (CDC) guidance and interview the facility failed to maintain acceptable infection control practices including following contact isolation precautions (wearing a gown and gloves) and using proper hand washing for Resident #30 and utilizing proper infection control practices during a dressing change for Resident #310 to prevent the spread of infection. This affected two residents (#30 and #310) and had the potential to affect all 58 residents residing in the facility. Findings include: 1. Record review for Resident #30 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF641Aug 17, 2023

  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 admitted [DATE] 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. […]

• No harm, potential for more than minimal, isolatedF609Aug 4, 2025

  Based on record review, staff interview, review of facility self-reported incidents (SRIs), and review of the facility policy, the facility failed to ensure allegations of potential abuse and neglect were reported to the State Agency as required. This affected three residents (#57, #58, and #67) of five residents 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. […]