Marlow Nursing & Rehab

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for three (#11, 23 and #37) of twelve sampled residents reviewed for comprehensive care plans. Findings: The corporate RN consultant reported 41 residents reside in the facility. A Care Plans, Comprehensive Person-Centered policy, read in part, A comprehensive, person centered care plan that includes measurable objective's and timetables to meet the resident's physical, psychological, and functional needs is developed and implemented for each resident. 1. Res #11 had diagnoses which included end stage renal failure. A physician's order, dated 02/03/24, documented to obtain Res #11's weight on Monday, Wednesday, and Friday before going to dialysis. A comprehensive assessment, dated 04/23/24, documented Res #11's cognition to be intact and was dependent on staff for activities of daily living. The assessment documented the resident received dialysis services while a resident. A care plan, dated 05/03/24, documented no care area related to dialysis.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure medication regimen reviews conducted by the pharmacist were acted on for two (#15 and #21) of five residents reviewed for unnecessary meds. The corporate RN consultant reported 41 residents resided in the facility. Findings: The facility's Medication Regimen Reviews policy, dated 05/01/23, read in part The Consultant Pharmacist performs a medication regimen review for every resident in the facility receiving medication .The medication regimen review involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities .The attending physician documents in the medical record that the irregularity has been reviewed and what action was taken to address it. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent record . 1. Res #15 had diagnoses which included depression, seizure disorder, and psychotic disorder. Res #15's physician orders, dated 03/01/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the medication was necessary to treat a specific condition indicated in the clinical record and failed to ensure an as needed psychotropic medication was limited to 14 days for one (#20) of five residents reviewed for unnecessary medications. The corporate RN consultant reported 41 residents resided in the facility. Findings: The facility's Medication Regimen Reviews policy, dated 05/01/23, read in part The Consultant Pharmacist performs a medication regimen review for every resident in the facility receiving medication .The medication regimen review involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities. A physician order, dated May 2024, for Res #20, documented, Lorazepam 1 mg tablet give 1 tablet per peg every 6 hours as needed for anxiety. Res #20's diagnosis included unspecified dementia, depression, unspecified, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the medication rate less than 5%. A total of 25 opportunities were observed with two errors. The total medication error rate was 8%. The corporate RN consultant reported 41 residents reside in the facility. Findings: A Medication and Treatment Orders, policy, dated 07/2023, read in part, Orders for medications and treatments will be consistent with principles of safe and effective order writing. A medication pass was conducted on 06/27/24 at 9:03 a.m., with ACMA #1. They administered one Clonidine 0.2 mg tablet to Res #35. They were asked if they already checked the blood pressure. They reported it was not required and their blood pressure ran pretty high and they had discontinued the blood pressure. A physician orders, dated June 2024, for Res #35 documented, Clonidine 0.2 mg tablet give one tablet by mouth twice daily hold if BP less than 100/60 and or pulse is less than 60 for Hypertension .Glipizide 5 mg two tabs to equal 10 mg by mouth daily. The pharmacy card read to administer the medication 30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure blood work was obtained per physician orders for two (#7 and #11) of five residents reviewed for unnecessary meds. The corporate RN consultant reported 41 residents resided in the facility. Findings: The facility's Lab and Diagnostic Test Results-Clinical Protocol policy, read in part The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests . 1. Res #7 had diagnoses which included diabetes mellitus, anemia, and non-traumatic brain dysfunction. Res #7's physician orders, dated 06/01/24, read in part Order date 08/17/23: HGBA1C every 3 months in August, November, February, May. CBC, CMP every 6 months in August and February . A comprehensive assessment, dated 06/03/24 documented Res #7's cognition was not scored due to inability to verbalize. The assessment documented the resident was dependent on staff for activities of daily living. Res #7's clinical record documented no labwork results for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure staff was alerted to implement enhanced barrier precautions for three (#7, 20, and #37) of five sampled residents reviewed enhanced barrier precautions. The Corporate RN consultant reported 41 residents resided in the facility. Findings: 1. Res #7 had diagnoses which included non-traumatic brain dysfunction. Res #7's physician order, dated 10/19/23, read in part Bolus feed - Jevity 1.2 give 237 ml via peg tube .Feed 6 times a day to gravity for meal replacement . A comprehensive assessment, dated 06/03/24 documented Res #7's cognition was not scored due to inability to verbalize. The assessment documented the Res #7 was dependent on staff for activities of daily living and received tube feeding services. On 06/24/24 at 2:19 p.m., Res #7 was observed in bed, peg tube in place, no PPE supplies or enhanced barrier precautions signage in place. On 06/24/24 at 10:06 a.m., Corporate RN reported there was no EBP in the facility, but there probably should be enhanced barrier precautions in place. On 06/26/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accurate coding of a MDS assessment for one (#29) of one sampled resident related to a discharge to the hospital after a reportable fall. The corporate RN consultant reported 41 residents resided in the facility. Findings: A quarterly assessment, dated 04/30/24, documented no upper or lower impairment and independent with transfers. A nurse's note, dated 05/28/24, for Res #29, documented, resident fell in bathroom from toilet. Mobile x-ray confirmed left femur femoral neck fracture. Physician notified. Resident transferred to hospital. A State reportable, dated 05/28/24, documented, self transferring and fell x-ray of left hip acute femoral neck fracture. A nurse's note, dated 05/31/24, read Res #29 returned to facility from hospital per facility van. Alert and oriented x2, cheerful and cooperative, dressing to left hip. On 06/28/24 at 10:50 a.m., MDS coordinator confirmed the MDS assessment recorded Res #29 was discharged on 05/23/24 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to refer a resident with a newly evident or possible serious mental illness to the OHCA for a level II PASRR evaluation for one (#23) of two sampled residents reviewed for PASARR. The corporate RN consultant reported 41 residents resided in the facility. Findings: Res #23 had diagnoses which included dementia, anxiety, depression, psychotic disorder, and schizoaffective disorder. A level I PASRR, dated 07/14/22, documented Res #23 had a primary diagnosis dementia with behavioral disturbances. The PASARR documented no evidence or diagnosis of a serious mental illness. A comprehensive assessment, dated 03/19/14, documented Res #23 had moderate cognitive impairment. The assessment documented the resident had active diagnoses to include dementia, anxiety, depression, psychotic disorder, and schizoaffective disorder. Res #23's physician's order, dated 06/01/24, documented the following medications and orders: 01/17/23 Millennium Mental Health Evaluate and treat. 04/22/24 Melatonin 3 for dementia with behavioral disturbance.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a resident's care plan was reviewed and revised for one (#15) of 12 residents reviewed for care plans. The RN consultant reported 41 residents resided in the facility. Findings: The facility's Care Plans, Comprehensive Person-Centered policy, read in part A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Res #15 had diagnoses which included depression, seizure disorder, and psychotic disorder. A care plan, dated 05/18/23, read in part Antidepressant medication use: At risk for side effects .Antipsychotic drug use: At risk for side effects .Seizure disorder: At risk for side effects . The care plan documented the last date revised was 06/13/23 and last reviewed on 08/18/23. Res #15's clinical record documented an inpatient psych…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide bathing as outlined in their care for one (#6) of one sampled resident reviewed for bathing assistance. The corporate RN reported 41 residents resided in the facility. Findings: Res #6 diagnosis included debility, cardiorespiratory conditions, heart failure and depression. An assessment, dated 06/04/24, for Res #6, documented impairment on both sides and required substantial max dependence for ADL's. On 06/24/24 at 1:53 p.m., Res #6 voiced no complaints, there was a smell of body odor in the room; however, resident reported they received their showers. On 06/27/24 at 3:37 p.m., Corporate RN consultant submitted the shower sheets for resident #6 and reported they had a designated person who did the showers and they may or may not have filled out the ADL book. After they submitted the sheets, they agreed there were still blanks because Res #6 was supposed to be showered on Monday, Wednesday, and Friday and they were not. A shower list, not dated, documented Res #6 showered on Monday, Wednesday, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident was assessed after dialysis treatments per physician's order for one (#11) of two residents reviewed for dialysis. The RN consultant reported three residents that resided in the facility received dialysis services. Findings: Res #11 had diagnoses which included end stage renal failure. A comprehensive assessment, dated 04/23/24, documented resident #11's cognition was intact. The assessment documented the resident received dialysis services. A care plan, dated 05/03/24, documented no dialysis services. A physician's order dated 06/16/24 documented obtain blood pressure and pulse immediately after returning from dialysis appointment. Res #11's dialysis communication forms dated, 06/17/24, 06/19/24, and 06/21/24 documented no blood pressure and pulse readings after returning from the dialysis appointments. A dialysis communication form for Res #11, dated 06/24/24, documented blood pressure 101/79 and pulse 79. On 06/26/24 at 2:43 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were offered the pneumonia vaccination according to policy for three (#4, 20, and #30) of five sampled residents reviewed for immunizations. The corporate RN consultant reported 41 residents resided in the facility. Findings: The facility's Pneumococcal Vaccine policy, dated 08/01/23, read in part: Prior to or upon admission, residents will be assess for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission. Residents/representative have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to: a) notify the resident representative on file for one (#2) of two sampled residents reviewed for change in condition; and b) failed to notify physician for one (#1) of one sampled resident with an abnormal temperature at the time of admission. The administrator identified 42 residents resided in the facility. Findings: 1. Res #2 had diagnoses which included high blood pressure, diabetes, and bradycardia. A nurse note, dated 11/21/23, documented the resident was lethargic with an O2 oxygen saturation of 88% on room air, heart rate of 51 and blood pressure of 117/72 and was hunched over in the wheelchair. The note documented the PA was notified and called the ambulance to send them out to the hospital, they left with the resident at 7:28 a.m. The note documented a family member who was listed as the resident's second contact and left a message. A Patient Transfer Form dated 11/21/23, documented the date of the transfer as 11/21/23, facility name and address, transferring to hospital, and relative or guardian as the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to maintain an accurate clinical record to include the resident's responsibly party contact information for one (#2) of two sampled resident records. The administrator identified 42 residents resided in the facility. Findings: The face sheet, located in the Resident's #2's clinical record, did not identify the responsible party. The face sheet listed a second contact person's name with a phone number, and a third contact person's name without a phone number. On 02/02/24 at 9:46 a.m., the corporate RN identified the DPOA as Res #2's responsible party and identified the third contact person without a phone number on the face sheet as the DPOA. They reported it needed to be updated.

Based on record review, observation, and interview, the facility failed to implement the infection control policy for COVID-19 positive residents. The administrator identified 45 residents resided in the facility. A facility COVID-19 PPE Management Guide, dated 05/15/23, read in part, .a well-fitting facemask will be required at all times and in all departments .resident care encounters: well-fitting facemask and eye protection (goggles or face shield) .care of all quarantined/suspected/positive COVID residents: N95, eye protection, gloves, gown . On 11/14/23 at 10:19 a.m., RN #1 was observed providing wound/ostomy care for Res #5 who had recently tested positive for COVID-19. The resident's door had signage related to transmission based precautions. The nurse was observed without PPE and was noted to come close to the resident's face when leaning over the resident's abdomen while providing care. On 11/14/23 at 10:30 a.m., RN #1 reported they should have been wearing appropriate PPE while providing care for the resident. On 11/20/23 at 2:55 p.m., the administrator reported RN #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received a pneumococcal vaccination for two (#12 and #18) of five residents sampled for immunization compliance. The Resident Census and Conditions of Residents report, dated 05/15/23, documented 41 residents resided in the facility. Findings: The Pneumococcal Vaccine policy, dated 08/01/16, read in parts, .All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections .Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . 1. Resident #12 was admitted to the facility on [DATE]. Resident #12's Consent for Vaccination form, signed 04/02/20, documented, I authorize the Nursing Facility to administer a pneumococcal vaccine. Resident #12's clinical record documented no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to assess residents at least once every three months for two (#1 and #2) of two residents sampled for Quarterly MDS Assessments. The Resident Census and Conditions of Residents report, dated 05/15/23, documented 41 residents resided in the facility. Findings: The facility MDS Completion and Submission Timeframes policy, revised July 2017, documented in part, .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted .Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . 1. Resident #1 was admitted to the facility on [DATE]. The resident's medical record documented the last MDS quarterly assessment was completed on 01/11/23. 2. Resident #2 was admitted to the facility on [DATE]. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure: a) a person-centered baseline care plan was developed for two (#84 and 132), and b) baseline care plans were signed and dated by a nurse, and a summary of the baseline care plan was provided to the resident or representative for three (#84, 132, and #134) of three sampled residents reviewed for baseline care plans. The Resident Census and Conditions of Residents report, dated 05/15/23, documented 41 residents resided in the facility. Findings: The facility Care Plans - Baseline policy, revised December 2016, documented in part, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission .The Interdisciplinary Team will review the healthcare practitioner's orders .including but not limited to .initial goals .physician orders .The resident and their representative will be provided a summary of the baseline care plan that includes .initial goals of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for one (#10) of 12 residents sampled for care plans. The Resident Census and Conditions of Residents report, dated 05/19/22, documented 41 residents resided in the facility. Findings: The Care Plans, Comprehensive Person-Centered policy, dated 12/01/16, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan is developed within seven days of the completion of the required compressive assessment (MDS) . Resident #10 was admitted to the facility on [DATE] with diagnoses which included post-traumatic stress disorder, auditory hallucinations, anxiety disorder and epilepsy. Resident #10's Baseline Care Plan, dated 03/21/23, documented the resident was alert, oriented times three, and independent with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to assess a resident for removal of an indwelling Foley catheter, or ensure an appropriate diagnosis for the use of the catheter, for one (#84) of two residents sampled for urinary catheters. The Resident Census and Conditions of Residents form, dated 05/15/23, documented two residents with indwelling catheters. Findings: The facility Catheter Care, Urinary policy, revised September 2014, read in part, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Review the resident's care plan to assess for any special needs of the resident . The policy did not address verifying a physician's order or having an appropriate diagnosis for the use of a urinary catheter. Resident #84 was admitted to the facility on [DATE] with diagnoses which included dyspnea, osteoporosis, anxiety, and chronic obstructive pulmonary disease. Physician orders for Resident #84 were reviewed and did not include an order for an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.