Inspection·May 2, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oxygen be applied to the resident due to low oxygen. When the oxygen concentrator was taken to the room, the resident's oxygen saturation was checked and was 95% on room air and his pulse was 89. Oxygen was applied at the son's request. Review of the nursing progress note, dated 04/22/23 at 6:40 P.M., revealed the ambulance arrived to transport the resident to the ER. The family has left the facility at this time. Interview on 05/01/23 at 11:14 A.M., with RN #174, revealed Resident #67's son had complained about several things throughout the day, including about therapy and medication times. The RN stated she confirmed with therapy that he had gotten therapy the day before. The RN stated she gave the resident's Sinemet (medication used to treat Parkinson's disease symptoms) medication just before 5:00 P.M. Approximately ten minutes later, RN #174 stated she was sitting at the nursing station and the resident's son came and said that his dad had vomited. The RN sent STNA #153 to the resident's room to check on him and the STNA said that she didn't believe the resident had vomited but there was a blue substance and saliva coming out of the corner of his mouth. RN #174 confirmed that following the report of the resident vomiting, she did not assess the resident nor observe the saliva coming from his mouth. RN #174 stated that she believed the resident had not swallowed his Sinemet and just spit it out, because the medication was bright blue (the same color as the substance coming from the resident's mouth). RN #174 stated Resident #67's son again came to the nursing station at approximately 6:00 P.M. and reported the resident had an erratic heart rate and low oxygen and demanded she call for an ambulance to have the resident sent to the ER. RN#174 stated that she contacted the ambulance and continued to give report to the oncoming nurse for the next shift. RN #174 stated Resident #67's son again came back to the nursing station and demanded his father receive oxygen. RN #174 stated she continued shift report and approximately five to ten minutes passed from the time that she was first notified of the resident's low oxygen, until she went to check on the resident. RN #174 stated that she checked the resident, and his heart rate was 89 and oxygen saturation was 95%, and then she applied oxygen at two liters per nasal cannula per the son's request. Interview on 05/01/23 at 3:16 P.M. with STNA #153 revealed Resident #67's son came up to the nurse's station and said that his dad had vomited all over himself. STNA #153 stated she went back to check on the resident and he had some saliva and a bright blue substance coming from the corner of his mouth, but it was not vomit, and she performed mouth care. During interview on 05/01/23 at 1:38 P.M., the Director of Nursing (DON) confirmed RN #174 should have assessed Resident #67 following reports of vomiting, low oxygen levels, and erratic pulse. This deficiency represents non-compliance investigated under Complaint Number OH00142274 and OH00142268. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 2 of 4 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 365990 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Dawn Rehabilitation and Healthcare Center 865 East Iron Avenue Dover, OH 44622 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, record review, interview and facility policy review the facility failed to properly destroy controlled substances once removed from the medication cart. This affected one resident (#23) of six residents reviewed for medication administration. The facility census was 64. Findings included: Observation on 05/01/23 at 11:27 A.M. of Licensed Practical Nurse (LPN) #140, during medication administration, revealed LPN #140 removed one half of a tramadol 25 milligram (mg) from the medication blister pack for Resident #23. Each blister had only one half of a tramadol 25 mg, as ordered for the resident. LPN #140 identified Resident #23 was not due to receive the one half of the tramadol 25 mg until later in the day and LPN #140 stated she would need to discard of the controlled substance. LPN #140 walked to the front nurses' station and asked LPN #195 if she would observe the disposal of a controlled substance with her. LPN #195 reported she would, and LPN #140 and LPN #195 walked to the 300 hall where the 300-hall medication cart was located. Observation on 05/01/23 at 11:33 A.M. revealed LPN #140 discarded the one-half of the tramadol 25 mg in the sharp container attached to the medication cart and LPN #195 co-signed the medication was destroyed. An interview at the time with LPN #140 verified she always discards unused medications in the sharp container, even controlled substances. Review of Resident #23's Individual Patient Controlled Substance Administration Record for tramadol 50 mg one-half tablets revealed on 05/01/23 at 11:33 A.M. the medication was wasted. Interview on 05/01/23 at 1:25 P.M. with the DON revealed all controlled substances were not to be put in the sharp container. She reported they are to come to her, and she would destroy them and then mix them with cat litter. Review of the Ohio Administrative Code for Disposal of Controlled Substances (Rule 4729:5-3-01) revealed non-retrievable means the condition or state to which a controlled substance shall be rendered following a process that permanently alters that controlled substance's physical or chemical condition or state through irreversible means and thereby renders the dangerous drugs which are controlled substances unavailable and unusable for all practical purposes. The process to achieve a non-retrievable condition or state may be unique to a substance's chemical or physical properties. A dangerous drug which is a controlled substance is considered non-retrievable when it cannot be transformed to a physical or chemical condition or state as a controlled substance or controlled substance analogue. The purpose of destruction is to render the controlled substance(s) to a non-retrievable state and thus prevent diversion of any such substance to illicit purposes. The method of destruction must render the controlled substances to a state of non-retrievable. Review of the facility policy titled, Discarding and Destroying Medications, revised 10/14, revealed medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. Schedule II, III, and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. The facility may contract with a Drug Enforcement Agency registered collector for proper disposal of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 3 of 4 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 365990 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Dawn Rehabilitation and Healthcare Center 865 East Iron Avenue Dover, OH 44622 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few non-hazardous schedule II, III, IV and V controlled substances. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the Environmental Protection Agency recommend destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substance include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. c. Dispose with the solid waste (i.e., regular trash) in the presence of two witnesses. d. Document the disposal on the medication disposition record. e. Include the signature(s) of at least two witnessed. Destruction of a controlled substance must render it non-retrievable, meaning that the process permanently alters the physical and chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted. This deficiency represents noncompliance investigated under Complaint Number OH00142274 and OH00142268. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 4 of 4