Inspection·November 8, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bad about STNA #464 to STNA #443 so STNA #464 confronted Resident #39 by asking was there a problem with me. Resident #39 started cursing and calling STNA #464 a black [expletive] while demanding STNA #464 leave the room. As STNA #464 continued to pass meal trays, Resident #39 continued to curse and call STNA #464 names in the hall. Resident #39 tried to take the food cart and a tray almost fell, so STNA #464 moved the cart out of Resident #39's way so the dinner trays would not be destroyed. The witness statement dated 08/17/23 from Resident #39 indicated words were had in the hallway with STNA #464, then while in Resident #39's room talking with STNA #443, STNA #464 entered the room yelling and asked what Resident #39's problem was. Resident #39 and STNA #464 yelled and cursed at each other. Resident #39 asked STNA #464 to leave the room three times and STNA #464 responded not having to. Resident #39 then left the room and sat in the hallway. STNA #464 came up behind Resident #39 and said, excuse me. Resident #39 stated, hold on, because of the power chair, then STNA #464 ran the food cart into Resident #39's arm which caused a cut. Resident #39 and STNA #464 yelled and cursed at each other again before both left the area. The witness statement dated 08/17/23 from STNA #443 indicated being in Resident #39's room when STNA #464 entered yelling and getting in Resident #39's face asking if Resident #39 had a problem while swearing at Resident #39 who then told STNA #464 to get out of the room, but STNA #464 continued to yell and swear. STNA #464 continued to yell and swear at Resident #39 while pushing the food cart of dinner trays. The food cart was then pushed into Resident #39 which caused a cut on Resident #39's arm and spilled drinks on the dinner trays while STNA #464 was still yelling and swearing. STNA #443 went to find the (unnamed) nurse. The witness statement dated 08/17/23 from Licensed Practical Nurse (LPN) #423 indicated STNA #443 reported an altercation between Resident #39 and STNA #464. When LPN #423 arrived in the hallway both Resident #39 and STNA #464 were yelling and cursing. Resident #39 reported STNA #464 hit Resident #39 with the food cart. Resident #39's arm had a scant amount of blood, a small skin tear, and scattered bruising. LPN #423 separated Resident #39 and STNA #464 by having them leave the area. The witness statement dated 08/17/23 from STNA #436 indicated while in a substation in the area Resident #39 and STNA #464 were heard arguing followed by a crash in the hallway and continued arguing. Resident #39 reported STNA #464 hit Resident #39 with the food cart. Interviews were conducted with all residents able to answer questions which resulted in no concerns except for Resident #42. The interview with Resident #42 dated 08/18/23 from Resident #42 indicated feeling mistreated by STNA #464 who Resident #42 felt was rude. Review of Resident #39's progress notes for August 2023 revealed after the altercation on 08/17/23, Resident #39 declined law enforcement notification and reported doing well and feeling safe. Resident #39 was apologetic for the incident and reported being upset by STNA #464 for being lazy and doing anything while watching other nursing assistants run around. Interview on 11/07/23 at 3:14 P.M. with Administrator revealed there were no witnesses who saw STNA #464 hit Resident #39 with the cart so it could not be determined if it was purposeful. STNA #464 reported Resident #39 tried to grab the cart, but Resident #39 denied it. Resident #39 was not aggressive, so it was unlikely Resident #39 grabbed the food cart. It was more likely STNA #464 was impatient and did not wait long enough for Resident #39 to move out of the way of the food cart. Administrator verified STNA #464 was an agency aide who was no longer permitted to return to the facility, and due to the altercation on 08/17/23 was terminated from the agency because of poor customer service. Resident #42 was no longer in the facility but reported on the date of the incident, STNA #464 was rude because STNA #464 entered the room, set the dinner tray down and left without speaking to Resident #42. Interview on 11/07/23 at 3:21 P.M. with STNA #443 stated being in Resident #39's room on 08/17/23 talking to Resident #39 about Resident #39 not liking STNA #464's demeanor. STNA #464 barged into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 2 of 6 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 11/08/2023 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 0550 Level of Harm - Minimal harm or potential for actual harm Resident #39's room and asked what Resident #39's problem was. Resident #39 tried to get STNA #464 to leave the room while STNA #464 stated it was [expletive] and [expletive] this but did not witness STNA #464 call Resident #39 any names. This deficiency represents non-compliance investigated under Complaint Number OH00147304. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 3 of 6 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 11/08/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview the facility failed to maintain a clean and homelike environment for Residents #1, #2, #3, #5, #10, #11, #12, #14, #16, #18, #19, #20, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #45, #46, #48, #51, #53, #54, #55, #57, #58, #263 and #264. The facility census was 58. Findings include: Interview on 11/06/23 at 10:02 A.M. with family of Resident #18 stated the window blinds were old, broken, or bent. Throughout the facility the windows were dirty, and several walls required repair or painting. Observation of the environment during a facility tour on 11/08/23 at 8:32 A.M. revealed the following: • Resident #29's room had a large gouge in the lower wall underneath the light fixture. • The exit door adjacent to Resident #31's room, and the right hallway wall by Resident #31's entry door had multiple scuffs, chips in the paint, and deep scrapes in the material. • Doorway frames and entry room doors for the small and large activity areas, and for Residents #2, #11, #19, #29, #31, #38 and #51 had multiple areas of chipped paint, scrapes, and dents. • The center of the hallway wall to the right of Resident #48's room had two large shallow areas of missing wall material. The dry wall was exposed. • The hallway wall across from Resident #48's room had large deep scrapes and one small deep hole with dry wall exposed. • Dirty windows with dirt buildup, dried dirt smudges and smears, window streaks and cloudy appearance were observed in all areas of the large activity room, adjacent to exit doors #8 and #10, and in the rooms of Residents #1, #3, #5, #10, #12, #14, #16, #18, #19, #20, #22, #23, #24, #25, #26, #27, #28, #30, #32, #33, #34, #35, #36, #37, #39, #40, #45, #46, #48, #53, #54, #55, #57, #58, #263 and #264. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 4 of 6 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 11/08/2023 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 0584 • Level of Harm - Minimal harm or potential for actual harm Window blinds with multiple broken, missing or bent slats were observed in the rooms of Residents #1, #10, #12, #14, #18, #20, #22, #32, #33, #37, #40, #48, #55, #57, #58 and #263. Residents Affected - Some Interview on 11/08/23 at 8:59 A.M. with Resident #264 stated he would be able to see outside better if the window was cleaned. Interview on 11/08/23 at 9:04 A.M. with Resident #34 stated the window was very dirty and had been for quite a while. It was difficult to watch the leaves change colors and fall from the trees, which was enjoyable. Interview on 11/08/23 at 9:08 A.M. with Resident #12 stated the window was dirty, and the window blinds break easily when touched because it was so old. Observation and interview on 11/08/23 at 9:16 A.M. during an environmental tour with Maintenance Director #409 verified all the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 5 of 6 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 11/08/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to ensure the garbage/dumpster area was maintained in a clean and sanitary manner. This had the potential to affect all 58 residents residing in the facility. Residents Affected - Many Findings include: Observation of the facility dumpster area with Dietary Manager (DM) #461 on 11/06/23 at 10:28 A.M. revealed a door of the dumpster was open. A mattress, chair, and two wood pallets were stacked beside the dumpster. DM #461 verified the findings at the time of the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365441 If continuation sheet Page 6 of 6