Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Pointe Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that confidential medical and personal records for an unidentified number of discharged residents were stored in an unlocked maintenance garage, mixed with general equipment. The DON reported that current residents' records were kept in a locked office but was unsure where discharged records were stored. In the garage, more than 30 banker boxes, many open or unsealed and some damaged, contained resident records such as shower sheets and assessment sheets, with several boxes stacked near the entrance. The DOM stated he had been instructed to move the boxes there and did not know they contained medical records or that they needed to be secured or protected from environmental damage. The facility could not identify which residents’ records were stored in the garage, despite having a confidentiality policy limiting access to authorized staff and business associates.
The facility failed to ensure dietitian oversight of a DT's competency. The contract showed the DT performed the primary clinical nutrition work while the CRD was to supervise and evaluate competency, but the DT's file had no documented performance evaluations or clinical audits. Interviews showed the DT worked at the facility weekly and handled the clinical nutrition work, while the CRD provided support by phone for high-acuity cases and could not identify the last time she had visited the facility.
Multiple residents experienced prolonged environmental discomfort and unclean conditions, including strong cold drafts from windows blocked with tape or pillows, stained and dirty bathroom floors, black buildup around faucets, damaged walls with debris, and a malfunctioning air mattress alarm. One resident remained cold in bed under multiple blankets because a window AC unit was left installed despite repeated requests for removal, while others reported ongoing drafts and unaddressed room damage after notifying staff and maintenance. These issues occurred despite facility policies requiring a safe, clean, sanitary, and homelike environment with comfortable temperatures.
The facility failed to maintain surety bond coverage equal to the total resident fund balance. Review of resident trust balances showed $24,725.31 in resident funds for 29 residents, while the surety bond covered only $15,000.00. An email from the CFO requested an increase in coverage, and HR and the Regional Administrator confirmed the shortfall.
A resident’s comprehensive care plan did not include goals or interventions for an indwelling foley catheter present on admission and was not updated to address anemia or hypokalemia. The record showed critical lab values, a PRBC transfusion, ferrous sulfate, potassium chloride, and weekly CBC/BMP monitoring were ordered, and an LPN confirmed the foley and diagnoses were absent from the care plan.
A resident reported that lunch was not nutritional and consisted only of chicken noodle soup and applesauce, despite receiving a menu and not getting the choice selected. Staff confirmed the meal was not balanced, the menu change was made for resident choice, and the change was not approved by the RD. Resident council minutes did not document the holiday lunch change, and the dietary manager said a separate food committee discussed menu changes but kept no minutes.
A resident with a history of mental health disorders accessed a box cutter left in the activity room by a former maintenance worker and used it to self-harm. The resident, who required assistance with daily activities, took the cutter to her room and inflicted a superficial wrist laceration. The facility's investigation found the cutter had been in the room for some time, leading to the incident.
The facility failed to maintain proper infection control precautions, affecting nine residents and potentially all 56 residents. Observations revealed that EBP and TBP signs were posted, but PPE was not consistently available at room entrances. The Director of Nursing confirmed the deficiencies, acknowledging that rooms were not properly equipped and that infectious waste was improperly stored in hallways. The facility's policy required EBP and contact precautions to prevent MDRO transmission, but these were not followed.
Two residents in an LTC facility experienced significant medication errors due to improper administration and documentation of controlled medications. The facility failed to adhere to physician orders and its own policy, leading to discrepancies in the medication administration record (MAR) and controlled drug records (CDR). The Director of Nursing confirmed these errors were systemic, affecting multiple residents.
The facility failed to maintain residents' dignity by allowing urinary catheter drainage bags to remain uncovered and visible from the hallway. Two residents with urinary catheters were observed with their drainage bags in public view, confirmed by staff during a complaint investigation.
The facility failed to report an allegation of medication misappropriation involving three residents. An RN reported forged signatures on controlled medication records, but the facility did not file a required self-reported incident. Despite the DON and Administrator's awareness, the issue was not reported to the state agency, violating facility policy.
A facility failed to obtain physician orders and provide adequate care for a resident's indwelling urinary catheter. The resident had no documented justification for the catheter's use, and there were no orders for its care. Observations showed the catheter drainage bag was uncovered and visible, and documentation revealed inconsistencies in catheter care provision. The DON confirmed these findings during a complaint investigation.
A facility failed to accurately document the administration of controlled drugs for a resident with chronic pain syndrome, leading to potential medication errors. Discrepancies were found between the medication administration record (MAR) and the controlled drug records (CDR) over several weeks, with instances of morphine being removed but not documented as administered. The Director of Nursing confirmed the requirement for accurate documentation on both records to prevent errors.
Unsecured Storage of Discharged Residents’ Medical Records in Unlocked Garage
Penalty
Summary
Surveyors identified a failure to safeguard and properly store resident medical records, particularly for discharged residents. During an interview, the DON stated that current residents' records were kept in a locked business office area for confidentiality but was unsure where discharged residents' records were stored. An observation of a detached storage garage on the facility grounds, conducted with the DOM, revealed that the garage was unlocked and used for general maintenance storage as well as storage of a large number of banker boxes filled with files. Near the entrance, approximately ten opened and unsealed boxes were piled on top of each other and contained confidential medical and personal information of discharged residents. Additional unsealed banker boxes containing numerous resident medical and personal records, including shower sheets and assessment sheets, were found on multiple wooden shelves at the back of the garage, with the total number of unsecured boxes exceeding 30. The garage was easily accessible to unauthorized individuals and lacked climate control to protect the records from mold, pests, or environmental damage; some boxes near the entrance had damaged corners and were not completely closed. The DOM reported he had been told to move the boxes to the garage, was unaware of their contents, and did not realize the need to lock the garage or secure and protect the files. The DON later acknowledged awareness that some resident records were kept in the garage but not the extent of the volume, and the facility was unable to provide a list of residents whose records were stored there, despite having a written policy stating that access to resident personal and medical records was limited to authorized staff and business associates.
Dietitian Oversight and Competency Monitoring Not Documented
Penalty
Summary
The facility failed to ensure dietitian oversight of a dietetic technician's competency. Review of the contract with the Consultant Registered Dietitian showed that the dietetic technician performed the primary clinical duties, while the consultant dietitian was to supervise, visit quarterly or as needed, and evaluate the technician's competency annually based on documentation and clinical systems reviewed. However, review of the dietetic technician's personnel file showed a resume and associate's degree in applied science in dietetic technology, but no documented initial or ongoing monitoring of competency such as performance evaluations or clinical audits. Interviews showed the dietetic technician worked at the facility once weekly and performed the clinical nutritional work, with the consultant dietitian available by phone for special tube feedings or other high acuity cases. The consultant dietitian stated the technician did most of the work and that she reviewed and approved notes for high acuity cases, but she did not know the last time she had visited the facility and could not provide dates. An email from the consultant dietitian stated that clinical oversight was provided by verbally discussing high nutritional risk and high acuity patients with the technician by telephone on an as-needed basis. Follow-up interviews with the dietetic technician showed she was not sure whether she had received any evaluations and did not think she could locate any.
Failure to Maintain Clean, Comfortable, and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for multiple residents, as evidenced by environmental deficiencies in several rooms. In one shared room, packaging tape had been wrapped around window curtains to block a strong draft of cold air leaking from the window, after residents had complained to maintenance for over a month without resolution. The bathroom in that room had stained and dirty flooring, a black substance around the faucet fixtures, and a bathroom door with a large piece of wood missing and rough, uneven edges with potential for splintering. In the same room, an air pressure mattress alarm continued to sound whether the resident was in or out of bed, and the resident had requested either repair of the alarm or a new mattress. Another resident’s room had two deep wall gashes extending from mid-wall to the floor with wall debris on the floor behind the bed; the resident reported the wall had been in that condition for a couple of months and that staff were aware. Additional observations showed similar environmental issues in other rooms. One resident’s bathroom floor was stained and dirty, with blackened areas, and the mirror and sink were dirty with built-up dirt around the faucets; a heavy draft of cold air leaked from the window, which had a pillow placed over it to reduce the draft, and the resident reported having notified maintenance and administration about the problem one month earlier without any action taken. Another resident was observed in bed covered with three blankets and reported feeling cold because an AC unit remained installed in the window; the resident stated he had been asking staff for two months to have the unit removed as the weather turned cold. A therapy note documented that this same resident had previously reported feeling cold due to the AC unit while lying in bed under multiple blankets. These conditions occurred despite facility policies stating that residents were to be provided a safe, clean, comfortable, sanitary, and homelike environment with comfortable and safe temperatures.
Insufficient Surety Bond Coverage for Resident Funds
Penalty
Summary
Assure the security of all personal funds of residents deposited with the facility was not maintained because the facility failed to keep surety bond coverage at or above the total resident fund balance. Review of the Trust Current Account Balance as of 01/05/26 showed that the combined resident fund balance for 29 residents was $24,725.31, while the facility’s surety bond, signed 10/24/24 and effective from 02/01/25 through 02/01/26, provided only $15,000.00 in coverage. A facility email dated 01/06/26 showed the CFO requested an increase in the surety bond to $25,000.00. Interviews with Human Resources and the Regional Administrator confirmed the bond amount and that it was less than the total resident account balance.
Care Plan Did Not Reflect Foley Catheter, Anemia, or Hypokalemia Needs
Penalty
Summary
The facility failed to ensure Resident #4’s comprehensive care plan reflected the resident’s needs related to diagnoses and medications. Review of the medical record showed the resident was admitted with cellulitis of the left lower limb, septic pulmonary embolism, MRSA, staphylococcal arthritis of the left ankle and foot, neuromuscular dysfunction of the bladder, and iron deficiency anemia. The comprehensive care plan dated 11/04/25 did not include goals or interventions for the resident’s indwelling foley catheter, which was present on admission, and it was not revised to address anemia or hypokalemia. The record also showed the resident had a critical hemoglobin value of 6.8 and received one unit of packed red blood cells, after which ferrous sulfate 325 mg twice daily was added. In addition, a potassium value of 3.1 was documented, potassium chloride extended release 20 mEq twice daily was ordered, and weekly BMP and CBC monitoring was ordered. Interview with an LPN confirmed the foley catheter and the diagnoses of anemia and hypokalemia were absent from the comprehensive care plan. Facility policy stated comprehensive assessments are used to develop, review, and revise the resident’s comprehensive care plan.
Unapproved Holiday Menu Change and Unbalanced Lunch
Penalty
Summary
The facility failed to ensure a well-balanced lunch was served on 12/25/25 and failed to have the menu changes approved by the dietitian. Resident #2, who had diagnoses including osteoarthritis, depressive disorder, congestive heart failure, and anxiety, had intact cognition and required set-up and clean-up assistance with eating. The resident reported that lunch on 12/25/25 consisted of four ounces of chicken noodle soup and applesauce, stated the food was not nutritional, and said they received a menu but did not get what they chose. Review of the 12/25/25 menu showed handwritten homemade chicken noodle soup with coffee/tea and condiments typed below it. The Dietary Manager stated the change to chicken noodle soup and applesauce was made due to resident choice through resident council, but also verified the lunch change was not approved by the dietitian. The Diet Tech stated she was not aware of the change and confirmed it was not a balanced meal. Resident council minutes from 10/02/25, 11/06/25, and 12/04/25 were silent regarding residents' choice for Christmas lunch, and the Dietary Manager stated she kept a separate food committee that met after resident council but did not keep minutes for it.
Failure to Prevent Resident Self-Harm Due to Inadequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment to prevent accidents for a resident with a complex medical history, including paraplegia, traumatic brain injury, and mental health disorders. The resident, who had intact cognition and required assistance with daily activities, was involved in an incident where she self-harmed using a box cutter. The box cutter was taken from the facility's activity room, where it had been left by a former maintenance worker. The resident used the cutter to inflict a superficial laceration on her wrist. The incident occurred when the resident was in the small activity room and took the box cutter, which was dusty and appeared to have been there for some time. The resident placed the cutter in a backpack and returned to her room, where she later used it to attempt self-harm. The facility's staff, including the Activity Director and LPN, were involved in the incident's aftermath, with the LPN providing immediate care and notifying the necessary parties. The facility's investigation revealed that the box cutter had been left in the activity room by a former maintenance worker. The investigation included interviews with staff and residents, as well as searches for other potential self-harm items. The facility's administrative team determined that the box cutter had been in the activity room for an extended period, leading to the resident's access to it and subsequent self-harm attempt.
Inadequate Infection Control Precautions
Penalty
Summary
The facility failed to maintain enhanced barrier precautions (EBP) and transmission-based precautions (TBP) as required, affecting nine residents and potentially impacting all 56 residents in the facility. During a facility tour, it was observed that EBP signs were posted at the entrance of some residents' rooms, but personal protective equipment (PPE) was not consistently available at or near the entrances. For instance, Resident #2 had an EBP sign, but the PPE storage was obstructed by garbage containers. Resident #4 had an EBP sign but no PPE available, and Resident #21 had a TBP sign without specifying the type of precautions, with the PPE bin inaccessible due to a fan placed on top. Further observations revealed that Resident #49 had a TBP sign for contact precautions but lacked available PPE at the entrance. Resident #55, who was receiving antibiotic therapy for a wound, had no EBP sign or PPE available. Similarly, Residents #12, #39, #15, and #24, all with tracheostomies and other medical conditions, had no EBP signs or PPE available at their room entrances. The Director of Nursing confirmed these findings, acknowledging that the rooms were not appropriately equipped with EBP and TBP, and that infectious garbage and soiled linen should not be in the hallways. The facility's policy on Disease-Specific Isolation/Precautions, initiated in April 2024, outlined that EBP should be used to reduce transmission of multi-drug resistant organisms (MDRO) and required gown and glove use during high-contact resident care activities. Contact precautions were intended to prevent transmission of infections spread by direct or indirect contact and required appropriate PPE upon entering the room. The deficiency was identified during a complaint investigation, highlighting the facility's failure to adhere to its own infection control policies.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, identified as Residents #16 and #42, by not properly administering and documenting controlled medications as per physician orders. For Resident #16, the facility's records showed multiple instances where oxycodone was signed out from the controlled drug records (CDR) but not documented on the medication administration record (MAR). Additionally, the medication was administered more frequently than ordered and exceeded the maximum doses prescribed by the physician. This pattern of errors spanned from April 11, 2024, to June 4, 2024, indicating a systemic issue with medication administration and documentation. Resident #42 also experienced similar issues with the administration of oxycodone. The medication was frequently signed out from the CDR without corresponding entries on the MAR, and it was administered more frequently than the physician's orders allowed. These discrepancies occurred between April 30, 2024, and June 6, 2024. The Director of Nursing (DON) confirmed these findings, acknowledging that the nurses were using the CDR instead of the MAR to administer medications, leading to multiple medication errors and inaccurate administration records. The facility's policy on controlled substances, revised in November 2022, required the use of both the MAR and CDR to reconcile the receipt, dispensing, and disposition of controlled substances. However, the failure to adhere to this policy resulted in significant medication errors for the residents involved. The DON verified that these errors were not isolated incidents but occurred with multiple residents receiving controlled medications, indicating a broader issue within the facility's medication administration practices.
Uncovered Urinary Catheter Bags in Public View
Penalty
Summary
The facility failed to maintain the dignity and respect of residents by allowing urinary catheter drainage bags to remain uncovered and in public view. This deficiency was observed in two residents, both of whom had urinary catheters. Resident #15, who has diagnoses including chronic respiratory failure, chronic kidney disease stage III, and obstructive and reflux uropathy, was observed on two occasions with an uncovered urinary catheter drainage bag hanging on the bed frame, visible from the hallway. The Director of Nursing confirmed the observation during the survey. Similarly, Resident #37, diagnosed with diabetes mellitus type II and chronic kidney disease, was also found with an uncovered urinary catheter drainage bag visible from the hallway. This observation was confirmed by a State tested Nursing Assistant. The deficiency was identified during a complaint investigation, indicating a lapse in maintaining residents' privacy and dignity as required by regulations.
Failure to Report Alleged Medication Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation by medication diversion involving three residents. The issue arose when a Registered Nurse (RN) reported that signatures on controlled medication records appeared to be forged, specifically noting a misspelled signature for one resident. Despite the RN's concerns and the removal of the accused Licensed Practical Nurse (LPN) from the schedule, the facility did not file a self-reported incident (SRI) with the state agency as required. The Director of Nursing (DON) and the Administrator were aware of the allegations but did not report them, citing the need for further investigation by the pharmacy, which ultimately did not substantiate the claims of misappropriation. Interviews with facility staff revealed that gossip about controlled medications being misused was circulating, but no concrete details were provided. The DON confirmed that the facility's usual protocol of completing an SRI was not followed due to the involvement of multiple nurses questioning the signatures. The facility's policy mandates reporting all alleged violations of abuse, neglect, exploitation, or misappropriation of resident property to the state survey agency immediately, or within specified timeframes depending on the severity of the allegation. However, this protocol was not adhered to in this case, resulting in a deficiency.
Failure to Provide Adequate Catheter Care and Obtain Physician Orders
Penalty
Summary
The facility failed to obtain physician orders and provide adequate care for an indwelling urinary catheter for a resident. The resident, who was admitted with diagnoses including diabetes mellitus type II with chronic kidney disease and benign prostatic hyperplasia, had an indwelling urinary catheter in place upon admission. However, there was no documented diagnosis or justification for the use of the catheter. Additionally, there were no physician orders for monitoring, maintaining, or caring for the urinary catheter, as evidenced by the review of the medical record, physician orders, and medication and treatment administration records for June 2024. Observations revealed that the resident's urinary catheter drainage bag was left uncovered and visible from the hallway, indicating a lack of privacy and proper care. The baseline care plan noted that catheter care was required daily and as needed, yet documentation showed inconsistencies in the provision of catheter care, with missing records for specific shifts. An interview with the Director of Nursing confirmed these findings and the absence of justification for the continued use of the catheter. This deficiency was identified during a complaint investigation.
Inaccurate Documentation of Controlled Drug Administration
Penalty
Summary
The facility failed to accurately document the administration of controlled drugs for a resident, leading to potential significant medication errors. The resident, who was admitted with a diagnosis of chronic pain syndrome, had physician orders for morphine 15 mg to be administered twice daily and as needed for pain. However, discrepancies were found between the medication administration record (MAR) and the controlled drug records (CDR) over a period of several weeks. Instances were noted where morphine was removed for administration according to the CDR but not documented on the MAR, or where the timing of administration was inconsistently recorded between the two records. The Director of Nursing confirmed these findings, acknowledging that nurses were required to document controlled medication administration on both the MAR and CDR to prevent errors. The facility's policy on controlled substances, revised in November 2022, mandates a system of reconciling the receipt, dispensing, and disposition of controlled substances using these records. Despite this policy, the facility's documentation practices for controlled drug administration were not followed, affecting the accuracy and reliability of medication records for the resident involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Conneaut
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ashtabula County Nursing Home | 7.2 mi | ★★★★★ | 1 | 0 |
| Country Club Ret Center I I I | 11.2 mi | ★★★★★ | 9 | 0 |
| Carington Park | 11.8 mi | ★★★★★ | 0 | 0 |
| Saybrook Landing | 14.5 mi | ★★★★★ | 0 | 0 |
| Jefferson Healthcare Center | 16.5 mi | ★★★★★ | 0 | 0 |
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