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Complaint Investigation

Marlow Nursing & Rehab

Inspection Date: November 24, 2025
Total Violations 2
Facility ID 375490
Location Marlow, OK
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Inspection Findings

F-Tag F0656

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

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

record review and interview, the facility failed to develop and implement a care plan for illicit substance use for 1 (#58) of 1 sampled resident reviewed for illicit substance use.The DON identified 52 residents resided

in the facility.Findings:A Comprehensive Person-Centered Care Plan policy, dated 12/01/16, showed the care plan should incorporate identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident. A behavior note, dated 01/16/25 at 4:56 p.m., showed at 11:30 a.m., Resident #58 was observed in the hallway, walking quickly, and hollering out loud to staff. The note showed the resident proceeded to a housekeeper inquiring about where the tissue box in their room was at.

The note showed just prior to the resident's encounter with the housekeeper, the housekeeping staff alerted nursing staff about a tissue box that contained what appeared to be a broken glass pipe with a white substance in it. The note showed the tissue box also contained a piece of foil, scissors, and a standard light bulb with a burned area on top of it. The note showed administration was made aware and was given paraphernalia with what appeared to be an illicit drug substance. A quarterly assessment, dated 06/17/25, showed Resident #58's cognition was moderately impaired with a BIMS score of 09. The assessment showed the resident was independent with activities of daily living. The assessment showed

the resident had a diagnosis of cirrhosis of the liver. A care plan, dated 06/18/25, showed no goals or interventions related to illicit substance use.A Discharge summary, dated [DATE REDACTED], showed resident discharged from the facility due to death while on hospice services.On 09/29/25 at 9:48 a.m., the ADON reported no incident report was done related to drug paraphernalia. The ADON reported the drug paraphernalia was taken from the resident, and police were not contacted.On 09/29/25 at 3:44 p.m., the MDS Coordinator reported Resident #58's care plan should have included substance abuse after drug paraphernalia was found in the resident's room.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Marlow Nursing & Rehab

702 South 9th Marlow, OK 73055

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)

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F-Tag F0684

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0684

k.) 09/01/25, 8:00 a.m., B/P 127/65, midodrine given

Level of Harm - Minimal harm or potential for actual harm

l .) 09/03/25, 8:00 a.m., B/P 130/62, midodrine given m.) 09/04/25, 2:00p.m., B/P 121/68, midodrine given

Residents Affected - Some n.) 09/04/25, 8:00 p.m., B/P 121/68, midodrine given o.) 09/06/25, 2:00 p.m., B/P 124/51, midodrine given p.) 09/07/25, 8:00 p.m., B/P 122/64, midodrine given q.) 09/10/25, 8:00 a.m., B/P 129/63, midodrine given r.) 09/12/25, 8:00 a.m., B/P 125/69, midodrine given s.) 09/21/25, 8:00 p.m., B/P 122/70, midodrine given t. ) 09/22/25, 8:00 a.m., B/P 125/49, midodrine given

On 09/24/25, at 01:17 p.m., the DON was asked what the policy for monitoring improvement with medication aides was, after being educated on medication errors. The DON stated they will find out and report back. No policy or practice was presented. The DON verified that the medication should have been held per physician's orders.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

Marlow Nursing & Rehab in Marlow, OK inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Marlow, OK, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Marlow Nursing & Rehab or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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