Matlock Place Health & Rehabilitation Center

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

an 81- years-old male that was admitted on [DATE REDACTED]. The resident was diagnosed with: Senile Degenerative of the brain (progressive decline in the brain cognition) and Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen)Record review of Resident #4's Quarterly MDS dated [DATE REDACTED] reflected the resident had a BIMS score of 00, indicating he was severely impaired cognitively. Resident #4 was dependent on staff for all personal hygiene task, toileting, showers, dressing, and meal support for eating.

Sections O special treatments and procedures Resident #4's respiratory treatments were not addressed.

MDS-R and MDS-G signed that the MDS was completed on 10/31/2025.Record review of Resident #4's care plan dated 08/08/2025 reflected he had a terminal illness and received hospice palliative care r/t Senile Degenerative of the brain (progressive decline in the brain cognition). Record review of Resident #4's MAR reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (ipratropium-Albuterol) 3 ml inhale orally three times a day for 7 Days. The order was not dated. Albuterol Sulfate HFA Inhalation Aerosol Respiratory Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally as needed for Shortness of breath.Order for Morphine Sulfate (concentrate) solution 20 MG/ML.give 0.25 ML orally every 1 hours as needed for pain.During an observation on 11/23/2025 at 12:00 PM with Resident #4's was located in the facility dining room sitting in his wheelchair. Resident #4 was not interviewable due to confusion and communication deficit.During an interview on 11/23/2025 at 1:10 PM the DON stated the MDS should be coded for the care that the resident was receiving to reflect on the care plan for care. She stated that the ADON and DON were responsible for reviewing finalized MDS assessment to ensure accuracy. She stated that failing to code the MDS correctly could result in the resident missing care and treatment ordered by the MD. During an interview on 11/23/2025 at 1:20 PM, the Administrator stated that it was her expectation that the MDS reflect the services, care, and treatment that the resident was receiving at the facility. She stated that failing to code correctly could result in the resident missing individualized care. The MDS coordinator was not interviewed nor attempted as the failure was observed on the weekend.

Record review of the facility's Maintain Minimum Data Set Assessments policy, dated 10/01/2023, reflected

it did not address the accuracy of assessments.

Event ID:

Facility ID:

If continuation sheet

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

11/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Matlock Place Health & Rehabilitation Center

7100 Matlock Rd Arlington, TX 76002

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 - Some

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

plans timely to reflect the resident's current care and treatments. The ADM stated that failing to document individualized treatment could result in the resident missing care. Record review of the policy and procedure entitled Comprehensive Person-Centered Care Planning dated 3-2022; 12.2023 read in part .It is the policy of this facility that the interdisciplinary team (IDT) along with the resident, legal representative, and clinical staff develop a comprehensive person-centered care plan includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . to provide effective and person-centered care that meet professional

Event ID:

Facility ID:

If continuation sheet

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

11/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Matlock Place Health & Rehabilitation Center

7100 Matlock Rd Arlington, TX 76002

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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

odor once it was cleaned. She stated once the dressing becomes saturated with the drainage it will start to have an odor. In an interview with the DON on 11/23/25 at 11:15 a.m. she stated they had a Treatment Nurse who worked Monday through Friday, and the weekend nurses were responsible for their wound care.

She stated Resident #3 had chronic wounds with poor prognosis due to her debilitated state. She stated

the wound on her right foot had a lot of drainage due to the edema. She stated the wound care physician had told them once the dressing became soaked it would start to have an odor, but the wound itself did not have an odor. She stated they had an order to change the dressing daily or more often if it became soiled or dislodged. She stated since it did not get changed yesterday she understood why it had an odor. She stated she was not aware of the wound care being missed on 11/22/25 until today (11/23/25). She stated

the Treatment Nurse had not told her of any wound care not being completed on the weekends but stated if

it was not completed on Saturday and done on Sunday, she would not know it was not being completed.

She stated going forward the ADON's were going to have monitor the Treatment administration records. In

an interview on 11/23/25 at 11:40 a.m. with the Wound Care physician he stated he had been providing wound consultation for Resident #3. He stated her wounds were chronic and had poor chances of healing due to her debilitated state, her advanced contractures, and her bedbound status. He stated the wound on her right foot did not have any signs of infection. He stated the drainage would start to have an odor if it was left for an extended period of time, which is why he provided an order for the nurses to change it daily and anytime it became soiled and saturated. He stated it was his expectation for the wound care to be provided as ordered. He stated not keeping the wound clean could lead to more deterioration of the wound bed and

the surrounding skin. Record review of the facility's policy titled, Wound Treatment Management, dated January 2023, reflected, Wound treatments will be provided in accordance with physician orders, including

the cleansing method, type of dressing, and frequency of dressing change.Treatments will be documented

on the Treatment Administration Record or in the electronic health record.

Event ID:

Facility ID:

If continuation sheet

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

11/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Matlock Place Health & Rehabilitation Center

7100 Matlock Rd Arlington, TX 76002

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 0689

manual (gait/transfer belts,.) and mechanical lifting devices.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

11/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Matlock Place Health & Rehabilitation Center

7100 Matlock Rd Arlington, TX 76002

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 0695

The quality-of-care respiratory treatments policy was requested on 11/23/2025 at 12:00 PM and was not provided prior to exiting the building.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Event ID:

Facility ID:

If continuation sheet

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

11/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Matlock Place Health & Rehabilitation Center

7100 Matlock Rd Arlington, TX 76002

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)

Federal health inspectors cited Matlock Place Health & Rehabilitation Center in Arlington, TX for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-11-23.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of Matlock Place Health & Rehabilitation Center.

Correction Status: Deficient, Provider has no plan of correction.