Inspection·April 11, 2024

F 0810 Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #32 had intact cognition. Level of Harm - Minimal harm or potential for actual harm Observations during meal service on 04/04/24 at 5:20 P.M. revealed the meal trays were set up and on the meal cart with regular silverware and glasses. Resident #32 had not received his built-up utensils. This was verified at this time by DA #400. Residents Affected - Few 3. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included left and right below the knee amputation, weakness, depression, anxiety, cerebrovascular accident, chronic obstructive pulmonary disease, pain, cognitive communication deficit, dysarthria, end stage renal disease, and diabetes. Review of the April 2024 physician's orders revealed Resident #24 had an order for two-handles cups and built-up silverware with all meals dated 03/03/23. Review of the plan of care dated 03/14/23 revealed Resident #24 had an activities of daily living self-care performance deficit related to left and right below the knee amputation, weakness, depression, anxiety, cerebrovascular accident, chronic obstructive pulmonary disease, pain, cognitive communication deficit. Intervention included she required built up utensil and a scoop plate for meal. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #24 had moderately impaired cognition. Review of the meal ticket dated 04/04/24 revealed Resident #24 was to receive a two-handled cup with a lid and built-up utensils with her meal. Observations during meal service on 04/04/24 at 5:22 P.M. revealed the meal trays were set up and on the meal cart with regular silverware and glasses. Resident #24 did not receive her two-handles cup or built-up utensils. This was verified at this time by DA #400. Review of the facility policy titled, Adaptive Equipment and accommodation of Needs, dated 08/09, revealed the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physician environment, would be evaluated upon admission and reviewed on an ongoing basis. This deficiency represents non-compliance investigated under Complaint Number OH00151926. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 2 of 5 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 04/11/2024 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 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility did not ensure Resident #17, #40 and #48 had safe and appropriate transportation services provided to them to get to their dialysis treatments at a dialysis center outside of the facility. This affected three residents (#17, #40, and #48) of four reviewed for transportation to dialysis. The facility identified four residents (#17, #24, #40 and #48) who required transportation to dialysis. The facility census was 71. Findings included: Observation was conducted on 04/10/24 at 7:30 A.M. of the distance and path of travel between the facility and the dialysis center. The path exited out the front doors of the facility, through the parking lot and up a road approximately 1000 feet from the facility. The road was a sub-road off of a main road between the facility and the dialysis center and was the road traffic needed to travel to get to various medical buildings spread out within the area. The traffic was light at the time of the observation. There were no edge lines on the road and there was grass and curbs to the sides so anyone being pushed in a wheelchair did not have smooth passage on the road unless on top of the pave road where cars would pass. The road was not lit up by streetlights and the pavement was smooth and free from potholes and obstructions. Closest to the dialysis center the road inclined to a hill that was steep enough that it would require forceful pushing while going up and a firm grip on the wheelchair when going back down the hill. There would be no protection from the rain or snow as there was no awning construction over this path of travel. Additional observations conducted on 04/10/24 throughout the survey process revealed two different transportation company vehicles taking residents to and from dialysis. No additional safety concerns with transportation were identified during the observation. 1. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE]. Diagnoses included fracture of the second cervical vertebra, neoplasm of the bone, anemia, hypothyroidism, anxiety disorder, hypertension, non-rheumatic aortic valve disorder, poly-osteoarthritis, sciatica, chronic kidney disease, wedge compression fracture of thoracic vertebra, and history of falls. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had intact cognition and required dialysis. Review of the April 2024 physician's orders revealed Resident #48 had an order for dialysis on Monday, Wednesday, and Friday with a 4:15 A.M. chair time and a 3:45 A.M. pick up time. On 04/10/24 at 1:00 P.M. an interview with Resident #48 revealed she has had to be pushed up the street in a wheelchair to dialysis three times in the two weeks she had been at the facility because transportation was not available. She stated once it was in the rain, and it was thundering and lightning. She stated the staff gave her an umbrella, but the staff member only had a hoodie on and got wet. She stated they did not take her up the big hill out front; instead, they took her up the side entrance which was not as steep. She stated they left at 3:15 A.M. because she had to be there at 4:15 A.M. She stated then she found out the facility had a van they could have taken. She stated it was an uncomfortable trip because she was in a neck brace for history of a broken neck. She indicated all the jarring and bumps while being pushed on the road were uncomfortable to her back and neck. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 3 of 5 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 04/11/2024 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 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, anemia, diabetes, hypertension, atherosclerotic heart disease, heart failure, atrial fibrillation, respiratory failure, gout, muscle weakness, end stage renal disease with dependence on renal dialysis. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #40 had intact cognition and required dialysis. Review of the April 2024 physician's orders revealed Resident #40 had an order for dialysis on Monday, Wednesday, and Friday with a 9:20 A.M. chair time and a 9:05 A.M. pick up time. On 04/10/24 at 2:30 P.M., an interview with Resident #40 revealed the staff has had to push him up to dialysis three times in a wheelchair. He stated he was not given a reason as to why and one time it was snowing pretty hard. He stated it was bull (expletive). 3. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included gastrointestinal hemorrhage, left humerus fracture, heart failure, pleural effusion, colitis, gastroenteritis, atherosclerotic heart disease, Barrett's esophagus, neuromuscular dysfunction of the bladder, depression, hypertension, diabetes, end stage renal disease, abnormal posture, and spina bifida. Review of the Five-Day MDS 3.0 assessment dated [DATE] revealed Resident #17 had intact cognition and required dialysis. Review of the April 2024 physician's orders revealed Resident #17 did not have an order for dialysis. On 04/10/24 at 2:45 P.M. an interview with Resident #17 revealed the staff has had to wheel her up to dialysis in a wheelchair at least six times since she has been at the facility. She stated they tell her they do not have transportation. She stated it was raining once but not hard. She stated it worried her to be on a road where cars would travel. On 04/10/24 at 12:35 P.M. an interview with State Tested Nursing Assistant (STNA) #403 revealed every once in a while they had to take a resident across the street to the hospital which was no big deal because it was all sidewalks. STNA #403 said they also had to take quite a few people including Resident #17, #40 and #48 to dialysis which was down the street and up a steep hill into their parking lot and it was scary. She stated she was afraid she would lose them coming back down the hill because it had a good size decline. She stated they sometimes must take residents at 4:00 A.M. when it was dark and required pushing them down the street because there were no sidewalks. She stated sometimes it was raining. She stated she knew of one resident (unidentified) they had to put a trash bag over so they would not get wet from the rain while they pushed them in a wheelchair to dialysis. On 04/10/24 at 12:40 P.M. an interview with STNA #407 revealed they had to push residents in wheelchairs over to the hospital but not as much as they do to dialysis. She stated she refused to take residents to dialysis because you had to push them up a big hill into the building. She stated sometimes it was at 4:00 A.M. because they had not gotten transportation set up yet. She stated it was ridiculous and very unsafe for the staff and residents. On 04/10/24 at 12:45 P.M. an interview with STNA #408 confirmed they had pushed residents over in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 4 of 5 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 04/11/2024 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 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchairs to the hospital in and up the road to dialysis. She stated she didn't think the hospital was a big deal because it was right across the parking lot but stated the dialysis center was up the street and up a big hill. She stated it was very hard to push the residents up that hill. She stated sometimes it was even raining and dark out. On 04/10/24 at 1:10 P.M., an interview with the Director of Nursing (DON) confirmed the facility pushed residents in wheelchairs up the road to dialysis. She stated they had pushed them up the road to dialysis when transport did not show up. She stated they scheduled transportation, but transportation did not always show up. She stated the facility does not have a transport vehicle. She stated Resident #48 was the only one who had an early morning chair time of 4:15 A.M. so she left with staff around 3:45 A.M. She stated she was not aware it had been storming the one time. She stated staff should have called her and she would have told them to send her to the hospital. She stated they have tried to reschedule; however, the dialysis center does not always have time available. She stated they did reschedule Resident #48 one time when transportation had not shown up to get her. She stated if the dialysis facility was across town they would just send the resident to the hospital for dialysis if transportation was not set up. This deficiency represents non-compliance investigated under Complaint Number OH00152858. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 5 of 5