Matagorda Nursing & Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 of 8 residents (#48 and #59) reviewed for ADL care. The facility failed to ensure Resident #48's fingernails were trimmed, filed, and cleaned on 07/07/2026. -The facility failed on 07/07/2026 to assist Resident #59 to shave his facial hair. These failures could place residents at risk of loss of dignity, risk of infections, and a decreased quality of life.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents or their responsible parties were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment for 1 resident (Resident #1) of 5 residents reviewed for informed consents. The facility failed to ensure Resident #1's responsible party was informed of the risks and benefits prior to anti-psychotic medications being administered. This failure could place the residents at risk of receiving medications with side effects they do not wish.

Inspectors wroteBased on observation and interview, the facility failed to have the most recent survey of the facility posted in a place readily available to resident's, family members and legal representatives. The facility failed to ensure that the previous annual survey results were freely available and visible to the public without having to be requested from staff. This failure could place residents at risk of not being able to exercise their right to be aware of the past history of citations of the facility that they reside in. Findings Include: During an observation on 7/7/2026 at 10:10am, no signs or labels could be located within the halls of the facility that would have indicated where the previous annual survey results would have been located. No binders or folders indicated that it would have contained the records of the results were found. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents hazards and supervision, in that: CNA A failed to perform an appropriate Hoyer Lift transfer with two staff as required, which resulted in Resident #1 sustaining a fall with head injury on 12/30/2025. Resident #1 was transferred from Local Hospital A to City Hospital B's Neuroscience ICU with a diagnosis of a brain bleed and subdural hematoma with subarachnoid hemorrhaging on 12/30/2025. An IJ was identified on 12/31/25. The IJ template was provided to the facility on [DATE] at 4:20 pm. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure the kitchen's ice machine's internal components were cleaned and sanitized, and free from mold, mildew, and soiling. This failure placed residents at risk of food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #13) reviewed for PASARR Level I screenings. 1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #13. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (bipolar disorder with an onset date of 02/25/25) was present upon Resident #13's admission date on 02/26/25. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Three dented cans were on the can rack located in the dry storage room. This deficient practice could place 49 residents who received meals from the main kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 30 residents reviewed for pharmaceutical services The facility failed to administer Resident (#2) scheduled medication (Prednisone 40 mg ) with the correct dosage according to physician orders. This failure could affect the resident by not receiving a therapeutic dose and could prevent the resident from receiving the highest possible benefit from their medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to Store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: -The oil in the deep fat fryer was black. -Dented cans were stored with undented cans. -Foods that are open and not sealed/dated. -Equipment was not cleaned. -There were flies in the Kitchen. These failures could place the residents who ate from the kitchen at risk of risk serious complications from foodborne illness as a result of their compromised health status. Findings Included: Observation of the kitchen on 02/28/23 between 09:15 AM - 10:00 AM revealed the following: 1. In the walk-in-freezer was an open box with sausage patties in an open box not sealed. 2. In the Dry storage room were dented cans of applesauce and Mexican chili beans stored with undented cans. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have assessments that accurately reflect the status of 1one of 15 residents (Resident # 29) reviewed for resident assessments in that:. -Resident #29's Significant Change MDS did not accurately reflect her bowel and bladder incontinent. This failure could affect residents at risk of a decreased quality of care and not having their individualized needs met or communicated accurately to staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's physical, mental and psychosocial needs for 1 of 6 residents (Resident #9) reviewed for care plans. -The facility failed to implement a comprehensive person-centered care plan to address Resident #9's use of indwelling catheter. This deficient practice could place residents at risk of being inappropriately provided care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 5%, based on 6 errors out of 54 opportunities, which involved 3 of 8 residents (Resident's #2, and #33) and 1 of 2 staff (MA A) and ADON, LVN ) observed during medication administration reviewed for medication error, in that: -MA A did not to administer Eliquis tab (apixaban= is a direct -acting oral anticoagulant used to prevent and treat certain types of blood clots), to Resident #33 as prescribed by the physician. -ADON, LVN did not administer Acetaminophen (medication used for pain) and Docusate liquid (medication used for constipation) to Resident #2 as ordered by the physician. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #6) reviewed for significant medication errors. -The facility failed to ensure that Resident #6's blood pressure medications were administered as ordered by his physician. This failure could affect all residents who received blood pressure medications placing them at risk of not receiving the therapeutic effect of the mediations and could result in declining health status.

Inspectors wroteBased on observation, interview and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of two medication carts (1 medication carts ) reviewed for drug labeling and storage, in that: -Medication cart for nurses had 2 Fluticasone propionate nasal spray USP 50 mcg open and 2 Hibiclean 4% Chlorhexidine gluconate Solution open with no date. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a person was designated as the infection preventionist had completed specialized training in infection prevention and control for the facility in that: -The facility Infection Control Nurse was not certified. -The facility Infection Control Nurse was not experienced in infection control and did not have the knowledge to perform the role. This failure could have placed the residents at risk for infectious outbreaks as the Infection Preventionist did not have the knowledge necessary to prevent infections from occurring.