Inspection·July 3, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and interview, the facility failed to ensure a resident's wish for receipt of cardiopulmonary resuscitation (CPR) was clearly established in the medical record. This affected one (Resident #128) of 24 residents reviewed for code status. Findings include: Review of Resident #128's medical record revealed an admission date of [DATE] with an order for Do Not Resuscitate - Comfort Care - Arrest - Do Not Intubate (DNRCCA - DNI). DNR-CCA orders healthcare providers not to perform cardiopulmonary resuscitation (CPR) and to provide comfort care in case of cardiac or respiratory arrest. Review of an Advance Directive Questionnaire dated [DATE] and signed by Resident #128 revealed she did want CPR provided. Review of a social service progress note dated [DATE] timed 2:15 P.M. revealed Resident #128 requested her advance directive be changed to full measures. Nursing was notified. On [DATE] at 3:44 P.M., the discrepancy between the order for DNRCCA-DNI and the signed Advance Directive Questionnaire, as well as the social service note indicating Resident #128 wished to be a full code were discussed with the Director of Nursing (DON) who stated she would have to clarify Resident #128's code status. During an interview on [DATE] at 4:35 P.M., Resident #128 stated she never fully understood the difference between code statuses. Resident #128 stated she wished to be full code but did not want to be a vegetable. During an interview on [DATE] at 10:59 A.M., Licensed Social Worker (LSW) #813 stated while she was doing admission paperwork with Resident #128 on [DATE], the resident had to go to the bathroom so LSW #813 left the remainder of the paperwork to be signed by Resident #128 in her room. LSW #813 stated she forgot to go back and get the paperwork until [DATE]. When LSW #813 saw Resident #128 signed the full code status she spoke to the floor nurse (refused to provide name of the nurse) but later discovered she should have provided it to the Director of Nursing (DON). During an interview on [DATE] at 9:50 A.M., the DON stated she clarified Resident #128's code status with her on [DATE] and Resident #128 reiterated she wished to be a full code. The order in the medical record had been updated to reflect Resident #128's stated wishes. Review of the facility's Advance Directives policy (revised [DATE]) revealed prior to or upon admission of a resident, the Social Services Director or designee would provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. The plan of care for each resident would be consistent with his or her documented treatment preferences and/or advance directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 2 of 15 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 07/03/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure comprehensive care plans were established. This affected two Residents (#14 and #54) of 18 residents reviewed for care plans. The facility census was 76. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 04/23/23 and diagnoses including congestive heart failure, depression, and chronic kidney disease. Review of the physician's order dated 04/08/24 revealed Resident #14 was on Vistaril 50 milligrams every eight hours for anxiety. Review of the current care plan for July 2024 revealed no evidence Resident #14's anxiety diagnosis or anti-anxiety medication use was addressed in the care plan. Interview on 07/03/24 at 9:41 A.M. with the Director of Nursing confirmed there was no care plan established for Resident #14's anxiety diagnosis or anti-anxiety medication use. 2. Review of the medical record for Resident #54 revealed an admission date of 11/15/23 and diagnoses including fracture of left femur, dementia, adult failure to thrive, and difficulty in walking. Review of Interdisciplinary Fall/Incident Investigation dated 06/13/24 revealed Resident #54 had self-ambulated without use of necessary mobility device and had fallen. Resident #54 was complaining of pain and sent to the hospital. Review of hospital History and Physical assessment dated [DATE] revealed Resident #54 had an unwitnessed fall and sustained left intertrochanteric fracture and left humeral fracture. Review of the current care plan for July 2024 revealed Resident #54's intertrochanteric fracture had been addressed however there was no evidence Resident #54's humeral fracture was addressed in the care plan. Interview on 07/03/24 at 9:41 A.M. with Director of Nursing confirmed there was no care plan established for Resident #54's humeral fracture. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 3 of 15 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 07/03/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. 2. Review of the medical record for Resident #43 revealed an admission date of 09/14/22. Diagnoses included weakness, congestive heart failure and history of falls. Residents Affected - Few Review of Resident #43's care plans initiated on 10/05/22 revealed there was a care plan relating to falls. The care plan had not been updated since 2022. Review of the progress note dated 03/03/24 revealed Resident #43 had an unwitnessed fall. Resident #43 declined to go to the hospital though her arm hurt. A progress note dated 03/04/24 revealed an x-ray was ordered. Resident #43 had a humerus fracture and was sent to the emergency room for treatment. Interview on 07/02/24 at 10:22 A.M. with Minimum Data Set Nurse #811 verified Resident #43's care plan had not been revised since 2022 and revisions should have been made, especially after a fall with injury. Interview on 07/02/24 at 4:58 P.M. with the Director of Nursing revealed a revision should have been added to Resident #43's care plan after the fall. Based on record review and interview, the facility failed to ensure Residents #43 and #55's care plans were revised to reflect all fall interventions. This affected two (Residents #43 and #55) of three residents reviewed for falls. The facility census was 76. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 11/13/23 with diagnoses including syncope and collapse, difficulty in walking and repeated falls. Review of the care plan dated 11/15/23 and last updated on 06/17/24 for Resident #55 revealed the facility did not revise her care plan for the fall on 03/01/24 to reflect a new fall intervention of hipsters (impact absorbing pads that are worn to reduce the risk of fractures). Review of the fall investigation dated 03/01/24 revealed Resident #55 had a fall, and the new intervention was to have the resident wear hipsters. Review of the physician's orders for July 2024 revealed Resident #55 did not have an order for hipsters to be worn as a fall intervention. Interview on 07/03/24 at 10:40 A.M. with the Director of Nursing verified Resident #55's care plan did not have the intervention of hipsters for the fall on 03/01/24. Review of the facility policy titled, Falls and Fall Risk, Managing, revised December 2007, revealed staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 4 of 15 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 07/03/2024 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, review of the facility's activity calendar, and interview, the facility failed to ensure an individualized activity program was provided and group activities were scheduled to permit participation by one (Resident #121) of two residents reviewed for activities. Residents Affected - Few Findings include: Review of Resident #121's medical record revealed diagnoses including anxiety disorder and metabolic encephalopathy. An Exceeding Expectations form indicated Resident #121 preferred group activities. Review of a modification of admission/Medicare five day Minimum Data Set (MDS) assessment revealed Resident #121 was able to make herself understood and was able to understand others. Resident #121 was assessed as cognitively intact with a brief interview for mental status score of 15 (out of a possible 15). The activity preference section of the MDS was completed with input by Resident #121 who indicated it was somewhat important to have reading material, listen to the music she liked, do things with groups of people, and do favorite activities. Resident #121 indicated it was very important to be around animals such as pets and go outside to get fresh air when weather was good. Resident #121 transferred independently and required supervision or touching assistance to ambulate at least 150 feet in a corridor or similar space. Review of a recreation evaluation dated 06/06/24 revealed Resident #121's level of participation in activities was moderate dependent. Current general activity preferences included cards/other games, crafts/arts, walking/wheeling outdoors, watching television, gardening/planting, pets, crosswords/word search, and Bingo. Review of activity participation logs from May 2024 to July 2024 revealed no pet visits and no outdoor activities which Resident #121 had indicated was very important to her. There was no indication of reading and listening to music which Resident #121 had indicated was somewhat important to her. There was no participation in cards/other games, crafts/arts, gardening/planting or Bingo recorded. During interview on 07/01/24 at 12:03 P.M., Resident #121 indicated there were many activities she could not participate in because lunch and dinner came late and activities were scheduled during those times. Resident #121 stated she would also like to sit outside but she was not permitted to sit in the courtyard without staff. Review of the May, June, and July 2024 activity calendars revealed multiple activities were scheduled at 1:00 P.M. and 6:00 P.M. including Bingo, card games, crafts, movies, and games. Review of the facility's listed meal times revealed delivery times for the 200 hall was 12:20 P.M. for lunch and 5:40 P.M. for dinner. Observations of the lunch service on 07/01/24 revealed there were two meal carts delivered to the 200 hall. Resident #121's tray was on the second cart which was delivered to the unit at 12:37 P.M. Resident #121's tray was delivered at 12:54 P.M. Review of the July 2024 activity calendar indicated a paint and sip activity was scheduled for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 5 of 15 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 07/03/2024 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 0679 07/01/24 at 1:00 P.M. Level of Harm - Minimal harm or potential for actual harm On 07/02/24 at 4:10 P.M., Resident #121's recorded interests and activity participation logs and activity calendars were reviewed with Activity Director (AD) #845 who verified multiple activities, including activities Resident #121 indicated she was interested in, were scheduled at 1:00 P.M. and 6:00 P.M. AD #845 stated she had coordinated with kitchen in planning activities. However, kitchen changed their meal times and the activity calendar was not adjusted so as not to conflict with meals. AD #845 verified it was the facility's policy that residents could not go outdoors unless accompanied by staff, regardless of orientation status. One of the reasons residents could not sit in the enclosed patio without staff was because there was a gate which residents could exit. AD #845 stated a visit was made by the lending library two weeks prior to the survey and every resident was supposed to be asked if they wanted to participate. However, she had no record of who was offered the service or who accepted it. Once in a while, staff would take their pets into the facility to visit residents. AD #845 stated about three weeks prior to the survey the facility had pets visit. AD #845 acknowledged there was no evidence Resident #121 was offered a visit with the pets. When asked how the facility tracked/ensured residents got offered activities they were interested, AD #845 stated when staff took daily chronicles around every morning they asked residents if they would like to participate. AD #845 stated activity staff saw her assessments on likes/dislikes/interests but there was no formal tracking of which activities were very important to specific residents and staff went by memory of who liked to attend the activity and then ask other residents. AD #845 verified it would be difficult for residents who just got trays to participate in 1:00 P.M. and 6:00 P.M. activities. AD #845 acknowledged if a resident knew the activity was occurring during meal time they might have expressed they were not interested in participating in the activity so they could eat. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 6 of 15 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 07/03/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on medical record review, interview, and policy review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of an anti-anxiety medication ordered on an as necessary basis. This affected one (Resident #130) of five residents reviewed for medication use. Findings include: Review of Resident #130's medical record revealed diagnoses including Parkinson's disease, neurocognitive disorder with Lewy bodies (Lewy bodies are the inclusion bodies/ abnormal aggregations of protein, that develop inside nerve cells affected by Parkinson's disease, the Lewy body dementias, and some other disorders.), cerebrovascular disease, generalized anxiety disorder, and major depressive disorder. On 06/20/24, an order was written for Ativan (anti-anxiety) one half milligram (mg) every eight hours as needed for anxiety. On 06/21/24, a clarification to the order limited the use to a 14 day duration. Review of the June 2024 Medication Administration Record (MAR) revealed the Ativan was administered on 06/20/24 at 10:56 P.M., 06/21/24 at 11:00 P.M., 06/24/24 at 9:13 P.M., and 06/25/24 at 5:29 A.M. and 9:55 P.M. The June 2024 Treatment Administration Record (TAR) revealed instructions to record unsuccessful non-pharmacological interventions prior to administration of the Ativan ordered on an as necessary basis into the progress notes. A progress note was required if the anti-anxiety medication was administered. No progress note was located indicating any non-pharmacological interventions were attempted prior to the administration of the Ativan ordered on an as necessary basis. During interview on 07/03/24 at 12:01 P.M., the Director of Nursing verified she had been unable to locate any evidence of non-pharmacological interventions being attempted prior to the administration of the Ativan on any of the above dates/times. When a policy was requested regarding the facility's use of psychotropic (including anti-anxiety) medication ordered on an as necessary basis, only a policy regarding antipsychotic medication use was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 7 of 15 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 07/03/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure all medications were secured in an appropriate manner and discarded when expired. This affected three residents (Residents #21, #36 and #37) but had the potential to affect all 25 residents residing on the 200 unit. The facility census was 76. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of [DATE] with diagnoses including diabetes mellitus. Review of the physician's orders for Resident #21 revealed an order for Insulin Glargine (Lantus) (medication for high blood sugar) 15 units one time a day dated [DATE]. Review of the Medication Administration Record for Resident #21 for [DATE] and [DATE] revealed she received the Lantus as ordered. Observation and interview on [DATE] at 11:19 A.M. of the 200 unit medication cart with Licensed Practical Nurse (LPN) #801 revealed a bottle of Lantus for Resident #21 that was dated [DATE] when it was opened. LPN #801 verified the medication was expired and should have been discarded after being opened 28 days. Review of the facility policy titled, Administering Medications, revised [DATE], revealed the expiration date must be checked prior to administering medications. 2. Review of the medical record for Resident #36 revealed an admission date of [DATE] with diagnoses including diabetes mellitus, altered mental status and depression. Review of the physician's orders for [DATE] for Resident #36 revealed there was not physician's orders for Tums (medication to reduce heartburn) or Preparation H (medication for hemorrhoids). Observation and interview on [DATE] at 8:57 A.M. revealed Resident #36 to have Tums and Preparation H on her tray table in her room. Resident #36 stated the facility staff had removed another medication, Excedrin (medication for headaches), from her room. Observation and interview on [DATE] at 10:12 A.M. with Licensed Practical Nurse (LPN) #900 verified Resident #36 had Tums and Preparation H at bedside. She stated Resident #36 did not have a physician's order for those medications. Review of the facility policy titled, Administering Medications, revised [DATE], revealed medications must be administered in accordance with the orders. 3. Review of the medical record for Resident #37 revealed an admission date of [DATE] with diagnoses including diabetes mellitus. Review of the physician's orders for Resident #37 revealed an order for Insulin Aspart (medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 8 of 15 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 07/03/2024 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 0761 for high blood sugar) sliding scale before meals and at bedtime dated [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration Record for Resident #37 for [DATE] and [DATE] revealed she received the Insulin Aspart as ordered. Residents Affected - Some Observation and interview on [DATE] at 2:00 P.M. with Licensed Practical Nurse (LPN) #900 revealed a bottle of Insulin Aspart for Resident #37 that was dated [DATE] when it was opened. LPN #900 verified the medication was expired and should have been discarded after being opened 28 days. Review of the facility policy titled, Administering Medications, revised [DATE], revealed the expiration date must be checked prior to administering medications. 4. Observation and interview on [DATE] at 11:28 A.M. with Licensed Practical Nurse (LPN) #801 of the 200 unit medication storage room revealed three over the counter medications that were expired. These medications included Loratadine 10 milligram (mg) (medication for seasonal allergies) which expired [DATE], Naproxen Sodium 220 (mg) (medication for pain) which expired [DATE] and Melatonin 3 mg (medication for insomnia) which expired [DATE]. LPN #801 verified these medications were expired and should have been discarded. She stated all 25 residents on the 200 unit had the potential to be affected as they were regularly prescribed over the counter medications. Review of the facility policy titled, Storage of Medications, revised [DATE], revealed the facility should not use discontinued, outdated or deteriorated drugs or biologicals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 9 of 15 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 07/03/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on interviews and completion of a test tray the facility did not ensure food was served at palatable temperatures. This had the potential to affect all 59 residents who ate food prepared in the kitchen. Residents Affected - Many Findings include: Interviews on 07/01/24 from 9:00 A.M. through 3:00 P.M. with Residents #3, #13, #14, #119 and #218 during the screening process revealed concerns with palatability of food indicating it was often cold. Observation on 07/02/24 at 11:15 A.M. revealed the food temperatures on the steam table were above 165 degrees Fahrenheit (F). A test tray was requested and plated at 12:22 P.M. The residents' meal trays and test tray were delivered to the floor at 12:31 P.M. Staff began passing the meal trays at 12:32 P.M. At 12:43 P.M., after the last resident received their meal tray, the temperature of the food on the test tray was measured and the food tasted. The BBQ ribs were 98 degrees (F) and the sweet potato fries were 94.3 degrees F. [NAME] #821 verified the temperatures. The food felt cool to touch and tasted luke warm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 10 of 15 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 07/03/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview the facility failed to ensure dishes and eating utensils were sanitized appropriately when the high temperature dish machine was not meeting the hot water temperature required for sanitization. This had the potential to affect all 59 residents who used dishes and cutlery from the kitchen. Findings include: Interview on 07/01/24 at 8:30 A.M. with [NAME] #821 revealed the dish machine sanitized via high temperature. [NAME] #821 also said the kitchen staff noticed the water temperature to the dish machine was lower when the laundry washing machine was running at the same time the dish machine was being used. Laundry staff was to hold running the washing machine until late morning. The facility was waiting for the hot water tank to be replaced. Observation of on 07/01/24 at 8:48 A.M. revealed a dietary aide rinsing and scrubbing dishes in a large grey colored bus tub filled with water and another tub labeled rinse prior to placing plates, cups and trays in a rack then sending the rack through the dish machine. Observation of the digital thermostat on the dish machine during the wash/rinse cycle revealed the temperature reached a high of 147 degrees Fahrenheit (F). [NAME] #821 placed another rack through the dish machine with similar results, temperature between 145-147 degrees F. The bus tubs did not include a sanitizing solution, just a rinse aid to prevent streaks and spots. Observation of the faceplate on the dish machine revealed the following: AM-14 hot water sanitizing Wash temperature of 150 degrees F minimum Rinse temperature 180 degrees F minimum Wash minimum 40 seconds Dwell 13 seconds Rinse minimum 9 seconds Review of the label on the Advance Washing Solutions Rinse Additive container (the rinse aid utlized in the tub labeled rinse) revealed the product was effective at low use rates and provided sheeting to prevent hard water deposits and films, eliminated streaking and was effective in both low and high temperatures. Interview on 07/01/24 at 9:00 A.M. with Maintenance #814 revealed the hot water tank was to be delivered this date. Maintenance #814 was uncertain how long the dish machine had not been reaching the appropriate temperature to sanitize but said it's been awhile. Interview on 07/01/24 at 9:45 A.M. with the Administrator revealed the dish machine temperatures were inconsistent. The Administrator was informed by Dietary Manager #818 that after items were run through the dish machine the dietary staff sanitized the items. It was shared with the Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 11 of 15 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 07/03/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm this was not observed and there were no bus tubs with water and sanitizer observed on the side of the dish machine where the dish racks exited. Interview on 07/01/24 at 10:30 A.M. with Laundry aide #843 revealed she was not told until that morning (07/01/24) to hold off laundry from 10:00 A.M. to 12:30 P.M. Residents Affected - Many Interview on 07/01/24 at 2:58 P.M. with Dietary aide (DA) #833 revaled the temperature of the water in the dish machine was different everyday. DA #833 was not given any instructions on what to do when the water did not meet the proper temperature to sanitize. Follow-up interview on 07/02/24 at 8:45 A.M. with the Administrator revealed she had a copy of what was posted on the dish machine regarding high and low temperatures along with what chemical to use. Review of the information revealed the information was not for sanitation but for appearances (spots and streaks). Interview on 07/02/24 at 10:00 A.M. with Registered Dietitian (RD) #905 revealed when she spoke to the chemical supply technician he said they could use bleach if over 50 parts per million (PPM). Observation at this time revealed RD #905 using a test strip to test the chlorine level of the dish machine; however, the test strip being used was meant to be used for the 3 compartment sink, not the dish machine. Follow-up interview on 07/02/24 at 2:30 P.M. with [NAME] #821 revealed kitchen staff started using bleach to sanitize dishes and cutlery on 07/02/24 when told to by RD #905. Observation on 07/02/24 at approximately 2:30 P.M. revealed RD #905 had the proper chlorine test strip to be used for the dish machine. Additional observation of the dish machine on 07/01/24 at 2:55 P.M. and 07/02/24 at 2:30 P.M. revealed temperatures on the dish machine ranged from 129 degrees to 165 degrees F. Follow up interview with RD #905 on 07/03/24 at 9:00 A.M. revealed the kitchen staff started testing the chlorine levels of the dish machine on 06/08/24. Review of the dish machine temperature logs for April, May and June 2024 revealed the temperatures were low and not hot enough to sanitize starting in May 2024. Review of the chlorine testing log revealed the log was initiated on 06/08/24. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 12 of 15 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 07/03/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure facial protection was available in areas where staff would spray soiled linens, failed to ensure the facility's water management program for legionella prevention was implemented, and failed to utilize the most current tuberculosis rates when reviewing their tuberculosis risk assessment. This had the potential to affect all 76 residents. Residents Affected - Many Findings include: 1. During observations of the laundry room on 07/03/24 at 11:50 A.M. with Housekeeping staff #838, it was verified there was no facial shield available to avoid splatter from soiled linens. On 07/03/24 between 12:05 P.M. and 12:15 P.M., Housekeeper #838 stated there was no need to have a face shield in the laundry room because if laundry was soiled it was sent back to the floor for aides to rinse the laundry out. Observations of two of the four soiled utility rooms revealed hoppers for rinsing laundry but there were no shields for use. This was verified by Housekeeper #838 at the time of observation. Review of the facility's policy, Laundry and Bedding, Soiled (revised July 2009) revealed anyone who handled soiled laundry must wear protective gloves and other appropriate protective equipment. 2. On 07/03/24 at 3:43 P.M. the Water Management Plan Action Items were reviewed with Maintenance Director #814. One of the responsibilities for the facility included checking input temperature to TMV. Maintenance Director #814 indicated he did not know what TMV stood for so he could not provide evidence it was performed monthly per recommendations. Another action the plan indicated was the responsibility of the facility was to measure temperature of water heater outlet and return. Maintenance Director #814 stated the facility was on a circulating pump system at all times so there was no water heater outlet and return to monitor. Maintenance Director #814 stated he had no documented evidence of the shower heads being descaled, cleaned and disinfected quarterly in accordance with the plan. Maintenance Director #814 stated he automatically changed shower heads quarterly. All shower heads had legionella filters. Maintenance Director #814 stated when the company representative who assisted with the water management plan visited to do inspections the shower heads would also be changed upon recommendation. The plan indicated hot water heater tank drains were to be flushed and ensure water quality indicated internal condition quarterly. Maintenance Director #814 indicated the facility did not keep record of when hot water tanks were drained. The plan also indicated the hot water tank exterior condition, insulation, pipe insulation, pipe work and fitting condition were to be inspected for corrosive activity annually. Maintenance Director #814 stated although he did not document annual inspection of the hot water tank exterior condition annually staff viewed it on a routine basis when checking water temperatures. The plan indicated the facility should annually inspect labeling of the hot water heater and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 13 of 15 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 07/03/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm associated valves and note the make and model. Maintenance Director #814 stated he did not document inspection of labeling of the hot water heater and associated valves annually. The plan indicated inspection and service of TMV's was to be conducted annually. Maintenance Director #814 again verified he did not know what TMV referred to. Residents Affected - Many 3. Review of the facility's tuberculosis (TB) risk assessment signed on the bottom by the Administrator on 01/15/24 indicated the TB risk assessment was conducted or updated in the health care setting annually and as needed. The last TB risk assessment was conducted June 2021. The community rate of TB was recorded as two in 2021, the state rate was recorded as 148 in 2021/1.3% per 100000 and 7.86 in 2021 with a 2.4% per 100000. The risk classification for the facility was not designated. A TB risk assessment signed and dated on 05/01/24 indicated the last TB risk assessment was conducted June 2021 and was a copy of the same risk assessment dated [DATE]. Review of the Centers for Disease Control's Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Healthcare Settings, 2005 indicated periodic assessments (annually, if possible) should be conducted. Review of the Ohio Department of Health Tuberculosis and Surveillance data posted 03/24/23 revealed no TB cases were reported for the county in 2022. The Ohio TB rate in 2022 was 1.2 per 100000 people and the US rate was 2.5 per 100000 people. On 07/03/24 at 3:25 P.M., the Administrator provided a face sheet indicating the facility's emergency preparedness program was reviewed and updated on 01/15/24. Included was a TB risk assessment with information from 2021, stating the facility had obtained the TB rate information from the county health department. The administrator had documented the last TB risk assessment was conducted in June 2021. The Administrator stated the information was reviewed every year. The most current information available on the Ohio Department of Health website was reviewed indicating more current information regarding TB rates was available prior to the 05/01/24 TB risk assessment review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 14 of 15 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 07/03/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to offer pneumococcal vaccinations in accordance with recommended vaccination schedules from the Centers for Disease Control (CDC). This affected two (Residents #130 and #226) of five residents reviewed for immunizations. Residents Affected - Few Findings include: 1. Review of Resident #226's medical record revealed an admission assessment dated [DATE] which indicated Resident #226 was up to date on pneumococcal vaccinations with the last date of administration being 01/24/18. Review of Resident #226's immunization records revealed a pneumovax PPV 23 was administered on 01/27/17 when he was [AGE] years old and a dose of Prevnar 13 on 01/24/18 when he was [AGE] years old. During an interview with Licensed Practical Nurse (LPN) #808 on 07/01/24 at 5:35 P.M., she stated she believed since Resident #226 had a history of receiving both the PPV 23 and Prevnar 13 vaccines he was up to date and did not need any further pneumococcal vaccines offered. After reviewing the CDC immunization guidelines, LPN #808 verified the guidelines indicated if a resident had a PPV 23 before the age of 65 and a Prevnar 13 vaccine at 65 years or older and had an immunocompromising condition such as chronic renal failure, one dose of PCV 20 should be administered at least five years after the last pneumococcal vaccine dose or one more dose of PPSV 23 at least eight weeks after the PCV 13 and at least five years after the previous PPSV23. LPN #808 stated nurses working the floor were responsible for getting the consents and getting them to her. LPN #808 verified although Resident #226 was originally admitted [DATE] she was unable to locate any immunization education or consent forms. On 07/02/24, the facility provided a pneumococcal vaccine consent dated 07/01/24 which indicated Resident #226's son requested the pneumococcal vaccine be administered. Review of the facility's Pneumococcal (PPSV23)/Prevnar 13 (PCV13) Vaccination Program: Residents (dated March 2017) indicated on admission, residents would be assessed as to which vaccine they had been previously vaccinated with and staff were to determine which vaccination was required (if any). Prior to immunization the resident and/or resident's legal representative would receive education regarding the benefits and potential side effects. Persons who previously received PPSV23 before the age of 65 years who were now greater than [AGE] years old were to receive PCV 13 at least one year from the date of administration of PPSV23 then they were to receive the PPSV23 again 12 months after receiving the PCV13. 2. Review of Resident #130's medical record revealed an admission date of 06/20/24. On 07/01/24 while reviewing vaccine information with Licensed Practical Nurse (LPN) #808, she verified she did not have evidence of education regarding the pneumococcal vaccination or evidence it was offered to Resident #130. Review of Resident #130's immunization records revealed Resident #130 received the PPSV 23 on 06/13/13 at the age of 66 and again on 02/16/19 at the age of 72. LPN #808 verified CDC guidelines indicated if a resident had received a PPV 23 but not the Prevnar 13, one dose of PCV15 or PCV 20 should be administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365990 If continuation sheet Page 15 of 15