Inspection·May 8, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of fall investigations, and interviews, the facility failed to implement fall interventions for three (Residents #45, #46, and #56) of five residents reviewed for falls. The facility census was 69. Findings include: During general observations on 05/06/24 and 05/07/24, Residents #45 and #46 were observed with mats placed beside their beds, when the residents were lying down in bed. 1. Review of Resident #45's open medical record revealed diagnoses including encephalopathy, restless and agitation, vascular dementia, generalized muscle weakness, abnormal posture and cerebral infarction. Review of Resident #45's fall risk assessment dated [DATE] indicated Resident #45 had one to two falls over the prior six months. Other risk factors for falls included medication use, confusion, total incontinence, confinement to a chair, inability to independently rise to a standing position and need for hands on assistance to move from place to place. Review of care plan interventions revised on 10/20/22 revealed Resident #51 was to have a mat to the bedside as of 08/26/22. On 05/08/24 at 8:42 A.M., Resident #45 was observed lying in bed without the mat placed on the floor to the left side of the bed. The fall mat was folded and leaning against the foot of the bed. On 05/08/24 at 8:42 A.M., State Tested Nursing Assistant (STNA) #170 verified the fall mat was not in place and he placed Resident #45's mat on the floor on the left side of the bed. 2. Review of Resident #46's open medical record revealed diagnoses including dementia, repeated falls, malignant neoplasm of the colon and type one diabetes mellitus with diabetic neuropathy. Review of Resident #46's fall risk assessment dated [DATE] indicated risk factors included a history of multiple falls, medication use, confusion, frequent incontinence of bowel and bladder, confinement to a chair, and need for hands on assistance to move from place to place. Review of an interdisciplinary fall/incident investigation dated 12/07/23 indicated a new intervention was implemented for a mat to bedside for safety. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365990 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 05/08/2024 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)