Health inspection·October 28, 2021

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few P.M., revealed the Resident #42 was weighed twice with a weight of 122.4 pounds. There was no documented evidence that the physician, dietitian, or the resident's family were notified. Review of the progress note for Resident #42 dated 09/21/21 at 10:30 P.M. written by Registered Nurse (RN) #218 revealed the resident had a tube feeding colored emesis. There was no documented evidence that the physician, dietitian, or the resident's family were notified. Interview on 10/27/21 at 10:26 A.M. with the Director of Nursing (DON) confirmed there was no physician or family notification documented after Resident #42 had an emesis (vomited) on 09/21/21, and no physician or family notification of Resident #42's 15-pound weight loss since his admission. Interview on 10/27/21 at 11:02 A.M. with Dietetic Technician (DT) #249 revealed Resident #42 was on weekly weights, but DT #249 confirmed she was not notified of any weekly weights and was not notified of the fifteen-pound weight loss. DT #249 said she was not notified by nursing services of Resident #42's emesis on 09/21/21. DT #249 said she did not communicate with the physician for Resident #42 related to the resident's condition. Interview on 10/28/21 at 08:57 A.M. with LPN #239 revealed nursing staff documented total tube feeding amount administered in each shift on the treatment administration record (TAR). LPN #239 revealed it was reported that Resident #42 had an emesis on 09/21/21 on the night shift and his tube feeding was turned off by night shift staff. LPN #239 revealed she was not aware if the physician was notified of the emesis. LPN #239 revealed she turned the tube feeding on again when she came in for day shift on 09/22/21. LPN #239 revealed she was not aware of a definite time the tube feeding was turned off and confirmed the tube feed was turned off for a few hours. LPN #239 revealed she weighed Resident #42 on 09/21/21 and obtained a weight of 122.4 pounds. LPN #239 said she notified DT #249 of the weight loss, but there was no documentation of this notification, or of physician notification. Interviews on 10/28/21 at 10:03 A.M. and 12:28 P.M. with the DON confirmed Resident #42 had a documented weight loss of fifteen pounds in two weeks without notification to the physician, the dietitian, or the family members. The DON confirmed Resident #42 had an emesis on 09/21/21 without notification to the physician, the dietitian, or the family members. Review of the facility policy titled Policy/Procedure for Weights dated 01/20/20 revealed the facility policy required weights to be obtained weekly for four weeks following admission. Review of the facility policy titled Enteral Nutrition dated 11/18 revealed the nursing staff and the provider were to monitor the resident for signs and symptoms of inadequate nutrition altered hydration, hypo-hyperglycemia, and altered electrolytes. The policy also revealed staff caring for residents with feeding tubes were also trained on how to recognize and report complications related to the administration of enteral feeding (tube feeding) such as nausea, vomiting, diarrhea, cramping, metabolic abnormalities, and inadequate nutrition. Review of the facility policy titled Lake Pointe Rehabilitation Health Center Notification of Change In Resident Status Policy and Procedure dated 08/03/11 revealed the physician and family were to be notified of significant changes in a resident's health such as deterioration in health and life threatening conditions or clinical complications. This deficiency substantiates Complaint Numbers OH00114831 and OH00114806. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 2 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, record review, and staff interviews, the facility failed to ensure fall interventions were implemented and care planned. This affected two (Residents #15 and #292) of three residents reviewed for falls. The facility census was 39 residents. Findings include: 1. Medical record review for Resident #292 revealed an admission date of 10/19/21 with diagnoses including cardiovascular accident (stroke) and pain. Resident #292 did not have a baseline care plan available in her chart that should have been completed within 48 hours. Review of the nursing progress notes revealed Resident #292 had falls on 10/19/21 (two falls), 10/22/21, and on 10/25/21. The falls on 10/19/21 had fall interventions placed to assist in preventing future falls. However, the falls on 10/22/21 and 10/25/21 revealed the facility staff did not implement new interventions to prevent future falls. Interview on 10/26/21 at 2:00 P.M. with the Director of Nursing (DON) revealed the fall interventions for Resident #292 were to provide a low bed to the resident on 10/22/21, and a scoop mattress on 10/25/21. The DON also verified Resident #292 did not have a baseline care plan or comprehensive care plan in her medical record. Interview on 10/26/21 at 2:40 P.M. with State Tested Nurse Aide (STNA) #236 revealed Resident #292's fall interventions would be listed on the resident's care plan. STNA #236 was unable to state any fall interventions for Resident #292. Observation on 10/27/21 at 8:31 A.M. of Resident #292 revealed the resident was in a regular bed without a scoop mattress. The Director of Nursing (DON) verified Resident #292 was not in a low bed with a scoop mattress. Review of the facility policy titled, Assessing Falls and Their Causes, revised March 2018, revealed information should be recorded in the medical record including appropriate interventions taken to prevent future falls. 2. Medical record review for Resident #15 revealed an admission date of 12/06/20 with diagnoses including difficulty walking, weakness, below knee amputation, and repeated falls. Review of the nursing progress notes revealed Resident #15 had a fall on 10/20/21. Resident #15 was reaching for an item on the floor and fell out of her wheelchair. There were no fall interventions listed in the nursing progress notes to prevent future falls. Review of the care plan dated 12/07/20 revealed Resident #15 had the potential for falls due to unsteadiness and left below knee amputation. There were no interventions listed for the fall on 10/20/21. Review of the facility Post Fall Evaluation dated 10/21/21 revealed the new intervention for Resident #15's fall was to not leave the resident unattended while in her wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 3 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/27/21 at 11:30 A.M. with Licensed Practical Nurse (LPN) #246 verified there were no interventions listed in the nursing progress notes, physician orders or care plan for Resident #15's fall on 10/20/21. LPN #246 did not know the resident was not to be left unattended in her wheelchair. Review of the facility policy titled, Assessing Falls and Their Causes, revised March 2018, revealed information should be recorded in the medical record including appropriate interventions taken to prevent future falls. This deficiency substantiates Complaint Number OH00114831 and Complaint Number OH00114806. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 4 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure one resident, who was dependent on a tube feeding as the sole means of nutritional support, received the tube feeding as ordered by the physician to meet their hydration and nutritional needs. This affected one (Resident #42) of four residents reviewed for nutrition. The facility census was 39 residents. Residents Affected - Some Findings include: Review of the medical record for Resident #42 revealed an admission date of 09/03/21 with diagnoses which included heart disease, cancer of the larynx (throat cancer), dysphagia (difficulty swallowing), absence of part of digestive tract, ileostomy (portion of the small intestine removed with an opening through the abdomen) , encephalopathy (disease affecting the brain), acute respiratory failure with hypoxia (low oxygen), bacteremia (bacteria in the blood), and septic shock. Review of the hospital transfer orders for Resident #42 dated 09/03/21 revealed the resident was ordered to be NPO (he was to have nothing by mouth) and to have all of his nutritional needs met through his feeding tube (a tube which enters through the abdomen and empties directly into the stomach) only. The hospital transfer orders also revealed the resident was ordered tube feeding (a nutritional formula administered through the resident's feeding tube) continuous at 66 milliliters per hour via his feeding tube. Review of the weights in the medical record for Resident #42 dated 09/06/21 revealed the resident weighed 137.4 pounds. Review of the physician orders for Resident #42 dated 09/06/21 revealed the resident was ordered to have nothing by mouth, and a 1.5 calorie per cubic centimeter (cc) tube feeding was to be given at 66 milliliters per hour continuous via his feeding tube. Review of the physician orders for Resident #42 revealed an order for the total milliliters of tube feeding each shift was to be documented. Review of the physician orders for Resident #42 dated 09/07/21 revealed specific tube feeding product was changed to a different 1.5 calorie per cc tube feeding product but remained administered continuous at 66 milliliters per hour Review of Resident #42's medical record revealed there was no documented evidence of the amount of tube feeding administered to Resident #42 on 09/03/21 (from when he was admitted to the facility), 09/04/21, or 09/05/21. Review of the treatment administration record (TAR) for Resident #42 dated from 09/06/21 to 09/23/21 revealed the resident was administered daily tube feeding amounts as follows: On 09/06/21: 150 milliliters of tube feeding administered. On 09/07/21: 1,150 milliliters of tube feeding administered. On 09/08/21: 792 milliliters of tube feeding administered. On 09/09/21: 760 milliliters of tube feeding administered. On 09/10/21: 1,190 milliliters of tube feeding administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 5 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0692 On 09/11/21: 1,574 milliliters of tube feeding administered. Level of Harm - Minimal harm or potential for actual harm On 09/13/21: 792 milliliters of tube feeding administered. On 09/14/21: 1,050 milliliters of tube feeding administered. Residents Affected - Some On 09/15/21: 1,514 milliliters of tube feeding administered. On 09/16/21: 1,526 milliliters of tube feeding administered. On 09/17/21: 1,584 milliliters of tube feeding administered. On 09/18/21: 792 milliliters of tube feeding administered. On 09/19/21: 1,584 milliliters of tube feeding administered. On 09/20/21: 1,386 milliliters of tube feeding administered. On 09/21/21: 1,122 milliliters of tube feeding administered. On 09/22/21: 792 milliliters of tube feeding administered. On 09/23/21: no documented administration of the tube feeding. Review of the progress note for Resident #42 dated 09/09/21 at 2:16 P.M. written by Dietetic Technician (DT) #249 revealed the resident was to have nothing by mouth and was ordered a tube feeding at 66 milliliters each hour through his tube feeding. The progress note revealed Resident #42 required 30-35 kilocalories for each kilogram of his body weight daily, 1.25-1.5 grams of protein for each kilogram of his body weight daily, and 30 milliliters of fluid for each kilogram of his body weight daily. The progress note revealed DT #249 determined that Resident #42 would receive 2376 kilocalories, 106 grams of protein, and 1784 milliliters of total fluid volume daily (which included tube feeding and water flushes) through the amount of tube feed that had been ordered. Review of the plan of care for Resident #42 dated 09/09/21 revealed the resident had a tube feeding to assist in maintaining or improving nutritional status related to diagnoses of dysphagia and malnutrition with goals to maintain adequate nutrition and hydration as evidenced by stable weight and no signs or symptoms of malnutrition and dehydration. Interventions included to administer tube feeding, water flushes, treatments, and medications according to physician orders; monitor for effectiveness and side effects and to report to the physician as needed; monitor for side effects of feed intolerance such as aspiration, diarrhea, nausea and vomiting, increased cough, shortness of breath and report to the physician as needed; and to monitor weight according to policy and orders, record the weight, and notify the physician of significant weight changes as needed. Review of the plan of care for Resident #42 dated 09/16/21 revealed the resident required limited assistance to complete most of his activities of daily living such as transfers, mobility, dressing, bathing, and hygiene and was dependent on staff for eating with interventions which included to provide assistance as needed, to praise efforts at self-care, to encourage the resident to participate in the fullest extent possible, and to monitor for changes in self-care performance, document changes, and report changes to physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 6 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the 5-day admission Minimum Data Set 3.0 assessment for Resident #42 dated 09/10/21 revealed the resident was cognitively intact and exhibited no behaviors. The MDS for Resident #42 revealed the resident was totally dependent on staff for eating and received over 51 percent of his kilocalories needed through tube feeding. Review of the progress note for Resident #42 dated 09/21/21 at 5:17 P.M. written by Licensed Practical Nurse (LPN) #239 revealed the resident was weighed twice with a weight of 122.4 pounds. There was no documented evidence that the physician, dietitian, or the resident's family were notified. Review of the progress note for Resident #42 dated 09/21/21 at 10:30 P.M. nursing note written by Registered Nurse (RN) #218 revealed the resident had a tube feeding colored emesis. There was no documented evidence that the physician, dietitian, or to resident's family were notified. Interview on 10/27/21 at 10:18 A.M. with LPN #245 revealed weekly weights were obtained by the nurse or a state tested nursing assistant (STNA) and were documented in point click care and were not documented anywhere else. Interview on 10/27/21 at 10:26 A.M. with the Director of Nursing (DON) confirmed there was no physician or family notification documented after Resident #42 had an emesis (vomited) on 09/21/21, and no physician or family notification of Resident #42's 15 pound weight loss since his admission. Interview on 10/27/21 at 11:02 A.M. with DT #249 revealed Resident #42 was on weekly weights, however, she was not notified of any weekly weights and was not notified of the 15 pound weight loss. DT #249 revealed she determined Resident #42's tube feeding and fluid need according to protocol. DT #249 revealed Resident #42 was at the highest nutritional risk and required 30 to 35 kilocalories for each kilogram of his body weight daily, 1.25 to 1.5 grams of protein for each kilogram of his body weight daily, and 30 milliliters of fluid for each kilogram of his body weight daily. DT #249 said the total fluid requirement for Resident #42 was 1830 milliliters daily. DT #249 said she was not notified of the abnormal hydration lab results for Resident #42. DT #249 said she was not notified by nursing services of Resident #42's emesis on 09/21/21. DT #249 also said she did not communicate with Resident #42's physician related to the resident's condition. Interview on 10/28/21 at 08:57 A.M. with LPN #239 revealed nursing staff documented the total tube feeding amount administered in each shift on the TAR. LPN #239 said it was reported that Resident #42 had an emesis on 09/21/21 on the night shift and his tube feeding was turned off by night shift staff. LPN #239 said she was not aware if the physician was notified of the emesis. LPN #239 said she turned the tube feeding on again when she came in for day shift on 09/22/21. LPN #239 said she was not aware of a definite time the tube feeding was turned off and confirmed the tube feeding was turned off for a few hours. LPN #239 revealed she weighed Resident #42 on 09/21/21 and obtained a weight of 122.4 pounds. This was a 15 pound weight loss since the last weight on 09/06/21 (15 days). LPN #239 revealed Resident #42 had no other emesis before or after 09/21/21 to her knowledge and the tube feeding had not been turned off at any other time. Interviews on 10/28/21 at 10:03 A.M. and 12:28 P.M. with the DON confirmed tube feeding formula was Resident #42's only form of nutrition. The DON confirmed the skilled nursing note for Resident #42's admission had no documented evidence of tube feeding administration, and there was no documented evidence of tube feed administration until 09/06/21. The DON verified Resident #42 was not receiving the ordered amount of tube feed formula, and Resident #42 had a documented weight loss of 15 pounds in 15 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 7 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Policy/Procedure for Weights dated 01/20/20 revealed the facility policy required weights to be obtained weekly for four weeks following admission. Review of the facility policy titled Enteral Nutrition dated 11/18 revealed the nursing staff and the provider were to monitor the resident for signs and symptoms of inadequate nutrition altered hydration, hypo-hyperglycemia, and altered electrolytes. The policy also revealed staff caring for residents with feeding tubes were also trained on how to recognize and report complications related to the administration of enteral feeding (tube feeding) such as nausea, vomiting, diarrhea, cramping, metabolic abnormalities, and inadequate nutrition. Event ID: Facility ID: 365441 If continuation sheet Page 8 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physician visits for the residents as required. This affected three residents (#15, #24 and #36) of three residents reviewed for primary care physician visits. The census was 39 residents. Residents Affected - Few Findings include: 1. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, hyperglycemia, obesity, dependence on renal dialysis, restless leg syndrome, muscle weakness, hypothyroidism, and dependence on supplemental oxygen. Review of physician progress notes revealed one physician visit dated 08/07/21. There were no additional physician visits available for review in the medical record since the previous annual survey dated 03/14/19. Interview on 10/28/21 at 10:23 A.M. with the Director of Nursing confirmed there was one physician visit dated 08/07/21 documented for Resident #15 in the medical record since 03/14/19. 2. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including acidosis, dysphagia, hyperlipidemia, muscle weakness, dementia without behavioral disturbance, heart failure, and atrial fibrillation. Review of physician progress notes revealed a physician visit on admission which was undated, a second visit after admission dated 11/04/20, and the third physician visit was documented on 06/23/21. There was no physician visit documented between 11/04/20 and 06/23/21 to meet the 30-day requirement for initial visits after admission. Interview on 10/27/21 at 4:12 P.M. with the Director of Nursing confirmed the physician did not visit the resident timely as required after admission. 3. Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, hyperlipidemia, psoriasis, gastro-esophageal reflux disease without esophagitis, diabetes mellitus type 2, sleep apnea, vitamin D deficiency, and osteoarthritis. Review of physician progress notes revealed a physician visit on 08/07/21. There were no additional physician visits available for review in the medical record since the previous annual survey dated 03/14/19. Interview on 10/28/21 at 10:23 A.M. with the Director of Nursing confirmed there was one physician visit dated 08/07/21 documented for Resident #36 in the medical record since 03/14/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 9 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure psychosocial services were provided for the residents. This affected two (Residents #14 and #39) of eight residents reviewed for psychosocial services. The facility census was 39 residents. Findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnosis of morbid obesity and acute respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, and had feelings of depression, hopelessness, and feeling down. The resident was documented as overeating and had trouble concentrating on things like the newspaper and watching TV. The resident rejected care and assessments. Review of the progress notes revealed on 06/02/2021 the resident was irritable and much one-on-one with nursing staff was ineffective. Nursing spoke to social services about concerns and social services indicated they would speak with the resident. There was no documentation that this occurred. A progress note dated 08/10/2021 indicated the resident was having behaviors that shift, and the state tested nursing assistants (STNAs) were trying to meet the residents needs in a timely manner. The resident felt it took to long and turned on his side and had a bowel movement on the floor. Later in the shift the nurse answered the residents call light and he stated he had to go to the bathroom and if she did not hurry up he would s__t on the floor again. There was no documentation in social services notes to indicate that Social Service Designee (SSD) #247 addressed this behavior. A progress note dated 10/01/2021 revealed the nurse removed the residents' nebulizer tubing due to the resident filling the chamber with mouth wash. When the nurse attempted to speak with the resident about this behavior, he started to snore. On 10/07/2021 it was documented that the resident was constantly removing his oxygen, causing his oxygenation level to drop to 80 (normal is between 95 and 100). The resident thought that this would justify asking nursing for a PRN (as needed) narcotic, muscle relaxer, and ibuprofen at one time. A progress note indicated on 10/10/2021, the nurse was giving the resident his morning medications and the resident became agitated because the nurse would not leave the medications at the bedside, and because she put breathing treatment in the machine. The resident began yelling and using foul language towards the nurse. There were no social service notes addressing this behavior. Review of the resident's care plan revealed social services was to discuss the residents' behaviors with him and reinforce why the behaviors were inappropriate and/or unacceptable. Another intervention was to intervene as necessary to protect the rights and safety of others. Interview with Resident #39, who was Resident #14's roommate, revealed he would like to change rooms due to Resident #14 behavior of being on the call light continuously, treating the staff badly, and yelling and cursing at the staff. He said he could not take it and just told social service he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 10 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0742 wants to be moved. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #14 on 10/24/2021 at 9:53 A.M. revealed he was in bed laying on his stomach while using his computer. There were empty wrappers of candy bars and chips, in and/or near the bed. The resident complained about call lights not being answered timely, and not receiving his diabetic diet. He did not speak of his behavior towards staff. Residents Affected - Few On 10/27/2021, interview with the director of nursing revealed Resident #14's behaviors were monitored, but did not indicate that SSD #247 was part of the intervention to help manage the resident's behaviors. 2. Resident #39 was admitted to the facility on [DATE] with the diagnosis of depressive disorders. The admission MDS dated [DATE] indicated the resident was cognitively intact, had feelings of hopelessness, depression, feeling down, feeling tired, feeling bad about himself/or that he was a failure and has let his family down. The resident anticipated his stay to be short term. Review of the care plan dated 10/05/2021 revealed there was no social service documentation. On 10/27/2021 at 10:23 A.M., during interview with the SSD the surveyor asked the SSD if he was providing 1:1 services with the residents as the care plans state was to be done. He did not understand what the term 1:1 meant. The surveyor explained the terminology 1:1 and asked if he attended the interdisciplinary team meetings. The SSD stated no. He further indicated his college degree was in wildlife and had not worked in a setting like the nursing home. The SSD provided no evidence to indicate 1:1 psychosocial services were being provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 11 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure psychosocial services were provided for the residents This affected three (Residents #14, #24, and #39) of eight residents reviewed for behavioral and emotional services. The facility census was 39 residents. Residents Affected - Few Findings include: 1. Resident #14 was admitted to the facility on [DATE] with diagnosis of morbid obesity and acute respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, and had feelings of depression, hopelessness, and feeling down. The resident was documented as overeating and had trouble concentrating on things like the newspaper and watching TV. The resident rejected care and assessments. Review of the progress notes revealed on 06/02/2021 the resident was irritable and much one-on-one with nursing staff was ineffective. Nursing spoke to social services about concerns and social services indicated they would speak with the resident. There was no documentation that this occurred. A progress note dated 08/10/2021 indicated the resident was having behaviors that shift, and the state tested nursing assistants (STNAs) were trying to meet the residents needs in a timely manner. The resident felt it took to long and turned on his side and had a bowel movement on the floor. Later in the shift the nurse answered the residents call light and he stated he had to go to the bathroom and if she did not hurry up he would s__t on the floor again. There was no documentation in social services notes to indicate that Social Service Designee (SSD) #247 addressed this behavior. A progress note dated 10/01/2021 revealed the nurse removed the residents' nebulizer tubing due to the resident filling the chamber with mouth wash. When the nurse attempted to speak with the resident about this behavior, he started to snore. On 10/07/2021 it was documented that the resident was constantly removing his oxygen, causing his oxygenation level to drop to 80 (normal is between 95 and 100). The resident thought that this would justify asking nursing for a PRN (as needed) narcotic, muscle relaxer, and ibuprofen at one time. A progress note indicated on 10/10/2021, the nurse was giving the resident his morning medications and the resident became agitated because the nurse would not leave the medications at the bedside, and because she put breathing treatment in the machine. The resident began yelling and using foul language towards the nurse. There were no social service notes addressing this behavior. Review of the resident's care plan revealed social services was to discuss the residents' behaviors with him and reinforce why the behaviors were inappropriate and/or unacceptable. Another intervention was to intervene as necessary to protect the rights and safety of others. Interview with Resident #39, who was Resident #14's roommate, revealed he would like to change rooms due to Resident #14 behavior of being on the call light continuously, treating the staff badly, and yelling and cursing at the staff. He said he could not take it and just told social service he wants to be moved. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 12 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of Resident #14 on 10/24/2021 at 9:53 A.M. revealed he was in bed laying on his stomach while using his computer. There were empty wrappers of candy bars and chips, in and/or near the bed. The resident complained about call lights not being answered timely, and not receiving his diabetic diet. He did not speak of his behavior towards staff. On 10/27/2021, interview with the director of nursing revealed Resident #14's behaviors were monitored, but did not indicate that SSD #247 was part of the intervention to help manage the resident's behaviors. 2. Resident #39 was admitted to the facility on [DATE] with the diagnosis of depressive disorders. The admission MDS dated [DATE] indicated the resident was cognitively intact, and had feelings of hopelessness, depression, feeling down, feeling tired, feeling bad about himself/or that he was a failure and has let his family down. The resident anticipated his stay to be short term. Review of the care plan dated 10/05/2021 revealed there was no social service interventions for the residents depression. On 10/27/2021 at 10:23 A.M., interview with SSD #247 revealed he did not understand what 1:1 services meant, when asked if he as providing 1:1 services as the care plan indicated. The surveyor then explained the terminology 1:1 and asked if he attended the interdisciplinary team (IDT) meetings. He stated no, he did not attend the IDT meetings. He further indicated his college degree was in wildlife and had not worked in a setting like the nursing home. 3. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including pain, dementia without behavioral disturbance, generalized anxiety disorder, major depressive disorder recurrent, and heart failure. Review of the care plan, initiated 10/07/20, revealed the resident had a diagnosis of depression. Interventions included to monitor, document and report as needed any signs or symptoms of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness. Review of a social service progress note dated 09/02/21 at 1:35 P.M. revealed Resident #24 made comments regarding a desire to be dead without a plan for self-harm or suicide. It was documented nursing staff was informed of the statement and social service would continue to monitor. Review of social service progress note dated 09/24/21 at 2:00 P.M. revealed Resident #24 displayed no evidence of moods and social service would continue to monitor. Review of progress notes from September 2021 and October 2021 revealed no additional social service documentation after 09/24/21. Review of physician orders effective October 2021 revealed orders for memantine 5 milligrams daily for dementia. There were no orders documented for monitoring of mood or behavior. Review of the Medication Administration Record and Treatment Administration Record for September 2021 and October 2021 revealed no documentation for monitoring of mood or behavior. Review of counseling service notes revealed Resident #24 received counseling services on 09/13/21, 09/22/21, 09/29/21, 10/20/21 and 10/25/21. There was no documentation in the counseling service notes regarding the resident's expressed statement made on 09/02/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 13 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0745 Level of Harm - Minimal harm or potential for actual harm Interview on 10/28/21 at 8:22 A.M. with Social Services Designee (SSD) #247 verified there was no documentation SSD #247 communicated the resident's expressed statement made on 09/02/21 with Resident #24's counselor, and confirmed SSD #247 did not provide psychosocial intervention which included monitoring of the resident as SSD #247 indicated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 14 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve food at the proper portion size to meet the residents' nutritional needs. This affected 38 out of 39 residents who received meals prepared in the facility kitchen. Resident #19 did not receive any foods by mouth. The facility census was 39 residents. Findings include: Observation 10/26/21 at 11:31 A.M. of the tray line revealed a serving spoon was going to be utilized for service. Dietary Manager (DM) #206 changed it to a 4 ounce spoodle and prepared two plates with four ounces of pasta [NAME]. DM #206 then portioned eight ounces of pasta [NAME] for the rest of the regular consistency diets. DM #206 had a four ounce number eight scoop for the puree consistency diets and served four ounces of pasta [NAME] on two plates, then served the proper portion for pureed pasta [NAME]. Further observation of trayline on 10/26/21 at 12:00 P.M. revealed that DM #206 had to prepare more pasta [NAME] after 21 residents were served. Interview at the time of observation revealed that DM #206 was not aware what the portion size that should be seved for the pasta [NAME] because he did not review the menu prior to service for regular consistency diets and did not have a spreadsheet available for other consistency and therapeutic diets. Interview on 10/27/21 at 9:04 A.M. with Diet Tech (DT) #249 revealed she was in the facility most Fridays. She stated she spent time in the kitchen during lunch. She stated she set up the spreadsheet book in kitchen. Interview on 10/27/21 at 3:35 P.M. with Registered Dietitian (RD) #250 verified she was consulted by the facility for pediatric residents only and was recently hired in August 2021. RD #250 did not review menus, provide consultation in the kitchen, or sign off on DT #249's notes. Review of the menu revealed that the menu had the portion sizes for the regular consistency menu with no restrictions and stated that eight ounces should be served in regards to the pasta [NAME]. This deficiency substantiates Complaint Number OH00111570. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 15 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on record review and interview, the facility failed to ensure Dietary Manager (DM) #206 met the minimum qualifications to serve as the director of food and nutrition services. This had the potential to affect 38 of 39 residents who received meals prepared in the facility kitchen. Resident #19 did not receive anything by mouth. The facility census was 39 residents. Findings include: Initial tour of the kitchen on 10/25/21 at 8:25 A.M. revealed DM #206 was the only dietary employee that morning due to staffing issues. Interview on 10/26/21 at 2:44 P.M. with DM #206 revealed he was asked to cover the management position while maintaining the role of cook. He stated he did not do the training to become a Certified Dietary Manager (CDM) and verified he was unqualified for the position. He stated he has been acting as cook, aide, and manager for at least a year. Interview on 10/26/21 at 3:06 P.M. with the Administrator verified DM #206 was unqualified as a CDM. The Administrator stated he had been in that position prior to her employment in March 2021. She verified DM #206 stated he only wanted to cook. Review of the personnel record for DM #206 revealed no evidence of qualifications or training for the position of dietary manager or CDM. This deficiency substantiates Complaint Number OH00111570. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 16 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure there was sufficient dietary staff to prepare resident meals and snacks, and to serve resident meals. This affected 38 of 39 residents who received meals and snacks from the kitchen. Resident #19 did not receive anything by mouth. The facility census was 39 residents. Findings include: Initial tour of the kitchen on 10/25/21 at 8:25 A.M. revealed Dietary Manager (DM) #206 was the only dietary employee that morning due to staffing issues. DM #206 stated the dietary aide was off due to COVID-19. Interview on 10/25/21 at 8:26 A.M. with DM #206 verified breakfast was late in being served. He stated there have been many meals that have been late due to staffing issues. Observation on 10/25/21 at 9:17 A.M. revealed the last food cart was delivered to the back hall of the 100 hall unit. Observation on 10/25/21 at 12:45 P.M. revealed the first food cart for lunch was delivered to the 100 hall unit. Interview on 10/26/21 at 2:44 P.M. with DM #206 revealed a dietary schedule was not available. He stated he was working 7:00 A.M. to 7:00 P.M. covering the cook, aide, and dietary manager positions. He stated he has been working as the manager for over a year. Interview on 10/26/21 at 3:06 P.M. with the Administrator verified DM #206 was covering as cook and manager. She stated there are staffing needs in dietary. Review of the mealtimes revealed breakfast was to be served from 7:45 A.M. to 8:15 A.M., and lunch was to be served from 11:45 A.M. to 12:15 P.M. Review of the October 2021 schedule provided by the Administrator on 10/28/21 revealed DM #206 was scheduled as the cook and morning (A.M.) dietary aide on 10/01/21, 10/02/21, 10/03/21, 10/07/21, 10/08/21, 10/09/21, 10/13/21, 10/15/21, 10/21/21, 10/25/21, 10/26/21, 10/27/21, 10/28/21, 10/29/21, 10/30/21, and 10/31/21. DM #206 was scheduled as the A.M. cook and afternoon (P.M.) cook on 10/13/21. Review of the policy titled Staffing, revised October 2017 stated the facility was to provide sufficient staff, including supportive services such as dietary, to ensure the residents' needs were met. This deficiency substantiates Complaint Number OH00111570. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 17 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure a registered dietitian reviewed the menus for nutritional adequacy, and a standardized menu was followed for meal preparation. This affected 38 of 39 residents who received meals prepared in the facility kitchen. Findings include: Observation on 10/25/21 at 12:45 P.M. revealed the posted menu on the 100 hallway was dated July 19, 2021 through July 25, 2021. Interview with Dietary Manager (DM) #206 on 10/26/21 revealed he did not post the menus on the units consistently due to a lack of time related to dietary staffing. He stated he did not have access to the menus until after his food was ordered, stating the meals do not match the current menu at times. Interview on 10/27/21 at 9:04 A.M. with Diet Technician (DT) #249 revealed she was at the facility on most Fridays. She did not check to see if menus were posted. Interview on 10/27/21 at 3:35 P.M. with Registered Dietitian (RD) #250 revealed she has not been to the facility since her hire date in August 2021. She stated she does not check the menus or have anything to do with the kitchen. Review of the current menu revealed the meal to be served on 10/25/21 was braised pork and apples with noodles. The meal observed on 10/25/21 was beef stir fry over rice. This deficiency substantiates Complaint Number OH00111570. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 18 of 19 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 365441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Pointe Rehabilitation and Nursing Center 22 Parrish Road Conneaut, OH 44030 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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm Based on interview and review of the personnel records, the facility failed to ensure the Social Service Designee was appropriately trained and supervised to provide medical behavioral services. This had the potential to affect all 39 residents currently residing in the facility. Residents Affected - Many Findings include: Review of the personnel record for the Social Service Designee (SSD) #247 revealed he was hired on 07/01/21. The application indicated he had a two year degree in wildlife and worked in several occupations, most recently as a Patient Service Representative. The record consisted of training in resident rights, and abuse, but did not contain documentation of his job description. Interview on 10/27/21 at 10:23 A.M. with SSD #247 revealed he received one day of training on social work from the SSD from another facility and was told he would learn as he goes. He stated he was also told to get an LOC for new admissions as he was also the admissions coordinator. When staff asked him where the LOCs were documented he stated he wasn't sure what they were asking him because he thought LOC meant level of consciousness. He was not aware LOC is the acronym used for level of care which is commonly used to determine if a person is eligible for Medicaid-funded, nursing home care. When asked if he was providing 1:1 services for Residents #15 and #39 he asked what a 1:1 was and where was that information found? He was told it was in the plan of care for the residents. When asked if he participated in IDT (interdisciplinary team) meetings. He stated no. Interview on 10/27/21 at 3:45 P.M. with the Administrator revealed she did not have a signed copy of the job description in the SSD's personnel record. There were 28 of 39 Residents identified by the facility as having behaviors eleven (Residents #10, #14, #15, #17, #27, #31, #33, #37, #290, #291, and #292) were not identified as having behaviors. All residents had the potential of needing the psychosocial services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 19 of 19