Health inspection·April 23, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with the staff the facility failed to ensure inventions were attempted prior to the use of an as-needed antianxiety medication, and failed to ensure an as- needed lorazepam was not administered more than 14 days without a stop date. This affected one resident (Resident #22) of three residents revealed for behaviors. The facility census was 35. Findings included: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included encephalopathy, end stage renal disease, altered mental status, congestive heart failure, chronic obstructive pulmonary disease, atherosclerotic heart disease, hypertension, dependent on a ventilator, tracheostomy, methicillin resistant staphylococcus aureus, intermittent explosive disorder, anxiety disorders, gastrostomy, anoxic brain damage, foot drop, intracranial hemorrhage, and chronic metabolic acidosis. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident # 22 had intact cognition and received an antipsychotic and antianxiety medications. Review of the April 2024 physician's orders revealed Resident #22 had an order for lorazepam one milligram (mg) intramuscularly (IM) every four hours as needed for anxiety and agitation dated 03/15/24. Review of the March 2024 medication administration record revealed Resident #22 had lorazepam one milligram without any non-pharmacological intervention attempted on 03/14/24 at 6:20 P.M., on 03/15/24 at 11:14 A.M., on 03/16/24 at 9:48 A.M., on 03/17/24 at 9:26 A.M., on 03/18/24 at 8:32 A.M., on 03/19/24 at 3:57 P.M., on 03/21/24 at 7:22 A.M. and 1:18 P.M., on 03/24/24 at 6:07 P.M., and on 03/25/24 at 4:35 A.M. Review of the April 2024 medication administration record revealed Resident #22 had lorazepam one milligram without any non-pharmacological intervention attempted on 04/01/24 at 11:38 P.M. on 4/02/24 at 4:04 A.M., on 04/08/24 at 9:39 A.M., on 04/09/24 at 12:38 A.M. and 12:27 P.M., on 04/15/23 at 7:22 P.M. and on 04/16/24 at 6:10 A.M. On 04/18/24 at 12:05 P.M. an interview with the Director of Nursing verified not all of his as-needed doses of lorazepam administered to him had non-pharmacological intervention attempted prior to administration. (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 2 Event ID: 365977 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 365977 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Circle of Care 1985 East Pershing Street Salem, OH 44460 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)