Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Matador Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple psychiatric and medical diagnoses, including hallucinations, delusions, and decreased cognition, had a PRN Lorazepam order with no stop date and received 12 doses beyond the 14-day limit without documented prescriber authorization. The DON stated she did not know why the PRN psychotropic order was not dropped after 14 days, despite the facility discussing stopping PRN psychotropic medications after 14 days in morning meetings.
Food Storage and Date Marking Failures: Surveyors found multiple unlabeled and undated food items in the reach-in refrigerator, walk-in refrigerator, pantry, and freezer, along with expired biscuits, condiments, and other foods left in storage. Staff and leadership stated cooks were responsible for labeling, dating, and removing expired food, but practices were inconsistent and the facility policy required containers to be labeled with contents and storage date and cooked foods to be discarded by day 4.
Care Plan Missing AVAPS Order: A resident with heart failure and respiratory failure had an order for AVAPS at HS and PRN, and staff observed the device at her bedside and documented regular use on the TAR. Her care plan addressed O2 therapy and SOB but did not include the AVAPS machine, even though nursing leadership acknowledged it should have been reflected in the plan and that new orders should be updated in the care plan.
A resident with CHF, chronic respiratory failure, pulmonary hypertension, and hypoxia was ordered oxygen at 2-3 L/min via NC to keep sats at 90 or higher, but was observed receiving oxygen at 3.5 lpm on multiple occasions. Her care plan called for oxygen to be administered as prescribed, and staff interviews confirmed nurses were responsible for setting the concentrator flow rate based on the physician order.
A facility failed to conduct required fall risk assessments for a resident with a history of falls and medical conditions such as hemiplegia and hypertension. Despite being identified as high risk for falls, the last assessment was conducted over a year ago, with no quarterly assessments documented. Staff interviews revealed confusion about assessment schedules, and the EHR system did not trigger necessary assessments due to the resident's long-term status.
A resident with Alzheimer's and psychiatric conditions was readmitted to a facility with specific medication orders for Seroquel XR and Trazodone. The facility failed to accurately enter these orders, resulting in incorrect dosages being administered. A nurse identified the error and corrected it, but staff acknowledged the potential harm from such discrepancies. The facility's medication policy was not followed, leading to this deficiency.
The facility failed to employ a certified Dietary Manager (DM) and relied on a contracted dietician for limited hours. The DM, initially hired as a cook, lacked the required certification and training. The owner's wife, who holds a DM certificate, was not involved in kitchen supervision. This deficiency could impact resident satisfaction and dietary management.
The facility failed to serve biscuits as listed on the menu during a lunch meal, which was observed and confirmed by staff interviews. The omission was acknowledged by the RD and DM, who noted the potential nutritional impact. The staff member responsible for meal preparation admitted to forgetting to make the biscuits, contrary to facility policy requiring adherence to the menu.
The facility's kitchen was found to have significant sanitation and food safety deficiencies, including improperly labeled and stored food, unclean conditions, and inadequate hand hygiene practices by staff. Observations revealed unsecured and open food items, trash on floors, and sticky, grimy storage bins. Staff failed to change gloves or wash hands appropriately, and food temperatures were not taken before meal service. Interviews with the DM and RD highlighted the absence of a cleaning schedule and substitution list, contributing to ongoing issues.
The facility failed to conduct timely comprehensive assessments for three residents, resulting in overdue MDS assessments. This was due to the sudden loss of the ADON/MDS nurse, leading to delays in completing assessments and potential issues with care plans and reimbursement. Despite these delays, the CMDS Coordinator believed resident care would not be affected.
The facility failed to review risks and benefits or obtain informed consent for bed rail use for four residents, despite their medical conditions necessitating such equipment. Observations and interviews confirmed the absence of consent forms, contrary to facility policy, potentially placing residents at risk for injuries.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, over several months. Time sheets and interviews with the DON and Administrator revealed that the DON's presence could not be verified for the required duration, and a policy on RN coverage was not provided. This deficiency could lead to inconsistent care for residents.
A CNA in the dining room failed to perform hand hygiene after playing with their hair and before assisting a resident with eating, violating the facility's handwashing policy. This action was observed and confirmed through interviews, highlighting a lapse in the infection prevention and control program.
A facility failed to accurately document a resident's CPAP therapy in the MDS, despite it being part of the care plan and treatment records. The resident, with a history of COPD and sleep apnea, used CPAP nightly, but this was not reflected in the MDS due to staffing issues and oversight. Interviews revealed a lack of knowledge and coordination among staff regarding the MDS process.
The facility failed to complete the required PASRR for two residents before their admission, leading to a delay of several months. One resident, an 81-year-old female with dementia and other conditions, had her PASRR completed four months post-admission. Another resident, a 64-year-old male with diabetes and hypertension, had his PASRR completed two months after admission. The facility's administrator acknowledged the oversight, noting that PASRRs should be done immediately at or before admission, especially for community admissions.
A facility failed to include a smoking care plan for a cognitively intact resident with multiple health issues, despite his smoking 2-5 times daily. The oversight was due to the sudden loss of key staff and lack of training for the DON, as confirmed by the facility's administration. This omission contravenes the facility's policy requiring comprehensive care plans for all resident needs.
The facility failed to store and label medications properly, as observed with two loose pills found in medication carts for Hall 100 and half of Hall 300. LVN B identified the pills as Plavix and Bethanechol Chloride, but their ownership was unclear. Interviews with LVN B and the DON highlighted concerns about potential medication errors and cleanliness issues.
PRN Lorazepam Continued Beyond 14 Days Without Prescriber Authorization
Penalty
Summary
The facility failed to ensure that a PRN order for Lorazepam, a psychotropic anti-anxiety medication, was limited to 14 days unless the prescribing practitioner evaluated the resident and documented an extension. Resident #2, an [AGE]-year-old male admitted with diagnoses including non-Hodgkin lymphoma, psychotic disorder with hallucinations, major depressive disorder, acute respiratory failure with hypoxia, hypertension, benign prostatic hyperplasia, intermittent explosive disorder, urinary tract infection, pulmonary embolism, cellulitis, repeated falls, and a lumbar fracture, had an MDS assessment showing a BIMs score of 12, inattention and disorganized thinking, hallucinations and delusions, and behavior symptoms that interfered with care and social interactions. His care plan also reflected lethargy, decreased cognition, PRN anxiety medication use, transfer to a behavioral hospital for hallucinations, delusions, and paranoid behaviors, and later delirium or an acute confusional episode. On 8/21/25, the physician ordered Lorazepam 0.5 mg by mouth every hour as needed for anxiety with no stop date listed. The medication was then administered 12 times between 9/6/25 and 9/24/25, including multiple doses on several days, without a physician authorization to continue beyond 14 days. During observation on 9/23/25, Resident #2 was asleep in his room in a low bed. The DON stated during interview that she did not know why the PRN Lorazepam order was not dropped after 14 days, and said the facility discussed psychotropic medications in morning meetings and stopping PRN medications after 14 days.
Food Storage and Date Marking Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observations, surveyors found multiple food items in the reach-in refrigerator stored in rectangular plastic tubs without labels or dates, including jelly packets, butter packets, ranch dressing packets, sour cream packets, ketchup packets, and mustard packets. In the walk-in refrigerator, surveyors observed numerous items that were unlabeled, undated, or past date, including open containers and trays of food, sealed packages of meat with varying dates, eggs with no date, potato salad, cobbler crust dough sheet, pineapple, ham, salsa, sliced pickles, whipped topping, shredded cheese, a chocolate nutrition shake with residue around the cap, simple syrup, pimento spread, opened cans of buttermilk biscuits with dried and spotted contents, mayonnaise, mild salsa marked with an expiration date that had passed, sriracha with a best-by date from the prior year, sausage links, scrambled eggs in a zip-top bag with no label or date, pancake mix, liquid eggs, and open sausage links. Surveyors also observed expired food in the pantry and freezer. The pantry contained three boxes of buttermilk biscuit mix with an expiration date that had already passed. The walk-in freezer contained an undated plastic bag with two giant pretzels that had visible round green spots across both pretzels. On a later observation, many of the same items remained in the walk-in refrigerator, including the expired biscuits, expired condiments, unlabeled or undated foods, and meat items with inconsistent labeling and dates. The report also noted that all items observed had a sticky label with a Use By section, but that section was blank. During interviews, the DM stated kitchen staff had been trained in labeling and dating food, but staff were frustrated with others not doing it correctly and training had not been documented. The DM and other administrative staff stated residents could get sick, get a stomach bug, get food poisoning, or be served spoiled or expired food if food was not properly labeled, dated, and discarded. A cook stated cooks were responsible for labeling and dating food and cleaning expired food from the refrigerator and pantry, but there was no specific schedule for cleaning out the refrigerator. Record review showed the facility policy required all containers to be labeled with contents and the date placed in storage, and previously cooked foods held in refrigeration were to be discarded by day 4. The 2022 FDA Food Code excerpt reviewed by surveyors stated food storage containers should be identified with the common name of the food and that date marking is used to ensure safety of refrigerated foods.
Care Plan Missing AVAPS Order
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #24 that included her AVAPS machine, despite the resident having an order for AVAPS to be worn at HS and PRN to improve respiratory function. Her care plan, completed on 07/08/25, addressed oxygen therapy as needed to maintain O2 saturation at 90% or higher and included goals related to oxygenation and shortness of breath, but it did not mention the AVAPS machine. The resident’s record showed diagnoses including heart failure and respiratory failure, and her quarterly MDS indicated she utilized a non-invasive mechanical ventilator while a resident. Record review showed Resident #24 used the AVAPS machine regularly, with TAR documentation reflecting use on multiple dates between 06/02/25 and 09/23/25. During observations, the AVAPS machine was seen on her bedside table, and the resident stated she used it at night to prevent a buildup of CO2 in her lungs. She also stated the machine seemed to be working because her O2 saturations had been between 90 and 100 percent. Staff interviews confirmed the resident had the AVAPS machine in the facility for months to about a year and that nursing staff were aware of its use. Interviews with CNA, LVN, ADON, DON, MDS LVN, and ADM showed that staff knew care plans were their responsibility and that new physician orders should be reflected in the care plan. The ADON stated the AVAPS machine should have been in the care plan and was not sure why it was omitted. The DON stated the team had discussed the resident’s reluctance to use the AVAPS every day as ordered with family at the last care plan conference. The facility policy on Comprehensive Care Plans required a comprehensive person-centered care plan for each resident, and the NIV policy required the care plan to include the type of equipment and when to administer it.
Oxygen Flow Rate Exceeded Physician Order
Penalty
Summary
Resident #8, an [AGE]-year-old female admitted with diagnoses including CHF, chronic respiratory failure, pulmonary hypertension due to lung disease and hypoxia, acute and chronic respiratory failure with hypoxia, and acute pulmonary edema, had a physician order dated 11/18/22 for oxygen at 2-3 L/min via nasal cannula to keep oxygen saturations at 90 or higher. Her quarterly MDS showed a BIMS score of 8, indicating moderately impaired cognition, and documented shortness of breath with exertion and when lying flat. Her care plan identified that she was oxygen dependent and directed oxygen administration as prescribed and keeping oxygen via nasal cannula on to maintain oxygen level. During observations on 09/23/25 and 09/24/25, Resident #8 was seen receiving oxygen via nasal cannula at 3.5 lpm, which was above the ordered range of 2-3 lpm. She was observed seated in her wheelchair and later lying on her back in bed while receiving oxygen at this higher flow rate. Staff interviews confirmed that nurses were responsible for setting oxygen concentrator flow rates and that the physician's order determined the correct rate. The facility's oxygen administration policy also stated that staff should verify a physician's order and review the resident's care plan before administering oxygen.
Failure to Conduct Required Fall Risk Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically by not conducting a fall risk assessment as required by professional standards. The resident, a male with a history of hemiplegia and hemiparesis following a stroke, anemia, and hypertension, was admitted to the facility and had a documented history of falls. Despite being identified as a high risk for falls in his care plan, the last fall risk assessment conducted was a post-fall assessment over a year prior, with no quarterly assessments documented since then. Interviews with facility staff, including the Director of Nursing (DON), revealed that the electronic health record (EHR) system did not trigger the necessary assessments due to the resident's long-term status, and staff were unsure of the required assessment schedule. The facility's policy mandates fall risk assessments upon admission, quarterly, and after any significant change in condition, but these were not completed for the resident, potentially placing him at risk of increased falls.
Medication Order Entry Error for Resident
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident, specifically in the dispensing and administering of medications as per physician orders. The resident, an elderly male with a history of Alzheimer's disease, vascular dementia, and other psychiatric conditions, was readmitted to the facility from a rehab hospital with specific medication orders for Seroquel XR and Trazodone. However, the facility did not accurately enter these orders into their system, leading to the resident receiving incorrect dosages of Seroquel and Trazodone. The resident's discharge orders from the rehab hospital specified that Seroquel XR should be given at bedtime and Trazodone as needed for insomnia. Instead, the facility's records showed that the resident was administered Seroquel twice daily, which did not align with the discharge instructions. This discrepancy was identified by a Licensed Vocational Nurse (LVN) who noticed the mismatch between the discharge orders and the facility's system entries. The LVN reported the issue to the Director of Nursing (DON) and corrected the orders in the system. Interviews with facility staff revealed that the incorrect entry of medication orders was due to a lapse in the process of entering new admission orders. The nurse responsible for the initial incorrect entry was no longer employed at the facility. Staff acknowledged that incorrect medication orders could lead to significant negative outcomes for residents, including potential harm or lethargy. The facility's medication administration policy emphasizes the importance of following the six rights of medication administration, which were not adhered to in this instance.
Deficiency in Dietary Management and Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The Dietary Manager (DM) was hired as a cook and later assumed the role of DM without completing the required certification or possessing any qualifying credentials. The DM admitted to not working on her certification due to financial constraints and the owner's refusal to cover the costs. The facility's policy requires a Director of Food Service to have completed a state agency-approved 90-hour course in food service supervision if a qualified dietician is not employed full-time. However, the DM did not meet these qualifications, and the facility's dietician was only contracted for 20 hours a week. Interviews with various staff members, including the DM, Registered Dietician (RD), and Administrator (ADM), revealed that the owner's wife, who holds a DM certificate, was not involved in supervising or training the kitchen staff. The DM and other staff members confirmed that the owner's wife had never been present in the kitchen. The ADM acknowledged the DM's lack of certification and expressed expectations for the DM to become certified. The absence of a certified DM and the limited involvement of the contracted dietician could potentially lead to issues such as poor resident satisfaction with meals and inadequate knowledge of dietary issues.
Failure to Serve Menu-Listed Bread Products
Penalty
Summary
The facility failed to ensure that the meals served to residents met their nutritional needs as per the established national guidelines. Specifically, during the lunch meal on August 12, 2024, the facility did not serve a biscuit or any bread products to the residents, which was a required component of the meal according to the menu approved by the facility Dietitian. Observations confirmed that no biscuits were present on the serving line, and none were included on the meal trays for residents eating in the dining room or in their rooms. Interviews with the Registered Dietitian (RD) and Dietary Manager (DM) revealed that both were aware of the omission and acknowledged that the biscuits should have been served. The RD emphasized that the absence of menu items could lead to weight loss and nutritional deficiencies. The DM admitted to not knowing why the biscuits were not served, while the staff member responsible for plating the meals stated that she forgot to make the biscuits. The facility's policies require that menus meet the nutritional needs of residents and that any deviations from the planned menu be documented, which was not done in this instance.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. The deficiencies included improperly labeled, dated, and contained stored food, as well as general uncleanliness. Specific observations noted crumbs in a bin holding chips, unlabeled and undated bags of cereal, and a sticky, grimy bin holding powdered milk with an unsecured lid. Additionally, trash, food packets, and crumbs were found on the pantry floor. In the walk-in freezer, several food items were found unsecured, unlabeled, undated, and open to air, with trash and food particles on the floor. Similar cleanliness issues were observed in the walk-in cooler and main kitchen prep area, where bins holding thickener, flour, rice, and sugar were sticky and grimy, with lids that did not seal properly. The facility also failed to ensure proper hand hygiene and glove use among food service staff during meal preparation. An employee, referred to as [NAME] A, was observed not changing gloves or washing hands after touching various surfaces and food items, leading to potential cross-contamination. [NAME] A admitted to not realizing the need to change gloves after touching different surfaces. Furthermore, the facility did not take food temperatures at the beginning of meal service, as required by their policy. [NAME] A was observed serving lunch without taking temperatures of the food on the steam table, and admitted to not taking temperatures before serving, only during cooking. Interviews with the Dietary Manager (DM) and Registered Dietitian (RD) revealed a lack of a substitution list, cleaning schedule, and consistent temperature logs. The RD acknowledged the absence of a substitution list and cleaning schedule, and noted that she only provided limited training due to restricted hours. The DM confirmed the lack of a cleaning schedule and expected staff to clean as they go. Despite being aware of the issues, the facility had not addressed the cleanliness and food storage problems by the following day, as the same conditions were observed during a subsequent walkthrough.
Failure to Conduct Timely Resident Assessments
Penalty
Summary
The facility failed to conduct periodic comprehensive assessments of residents' functional capacity for three residents, leading to overdue assessments. Resident #7, who was admitted with multiple diagnoses including Alzheimer's and major depressive disorder, had her last completed Minimum Data Set (MDS) on 4-26-2024, with the next quarterly assessment due on 7-27-2024, which was three days overdue. Resident #9, with conditions such as chronic obstructive pulmonary disease and osteoporosis, had her last MDS completed on 3-20-2024, with the next due on 6-20-2024, which was 40 days overdue. Resident #20, diagnosed with diabetes and peripheral vascular disease, had his last MDS completed on 3-31-2024, with the next due on 6-30-2024, which was 30 days overdue. The delay in completing these assessments was attributed to the sudden loss of the Assistant Director of Nursing (ADON)/MDS nurse, resulting in the facility outsourcing MDS completion. The Director of Nursing (DON) and the CMDS Coordinator confirmed that the delays were due to waiting for additional information, such as therapy notes, to complete the MDS. The CMDS Coordinator acknowledged that the late MDS assessments could lead to issues like delayed care plans and facility reimbursement, although she believed it would not affect resident care due to the facility owners' commitment to resident needs.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rails with four residents or their representatives and did not obtain informed consent prior to the installation of bed rails. This deficiency was identified during observations, interviews, and record reviews conducted by surveyors. The residents involved were identified as having various medical conditions, including cognitive impairments, arthritis, respiratory issues, and muscle weakness, which necessitated the use of bed rails for bed mobility and positioning. For Resident #5, the clinical record indicated a moderately cognitively impaired individual who required assistance with daily activities. Despite having an active order for a grab-bar for bed mobility, there was no documented consent for the use of bed rails. Similarly, Resident #13, who was also moderately cognitively impaired, used bed rails for turning over in bed, but no consent was obtained. Resident #24, with severe cognitive impairment, and Resident #25, who was cognitively intact, both had bed rails installed without prior consent or discussion of risks and benefits. Interviews with the facility's administrator and Director of Nursing confirmed the absence of proper consent forms for the use of bed rails for these residents. The facility's policy required that risks and benefits be reviewed with residents or their representatives and informed consent obtained before installation, which was not adhered to in these cases. This oversight could potentially place residents at risk for injuries associated with bed rail use.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, for multiple days over a period from May to August 2024. Specifically, the facility did not have RN coverage for 18 days out of 31 days reviewed. The absence of RN coverage was confirmed through a review of the facility's employee roster and time sheets, which showed that on several specified dates, there was no RN present for the required duration. Interviews with the Director of Nursing (DON) and the Administrator revealed that the DON only clocked in for accountability purposes and did not clock out, making it impossible to verify her presence for the full eight hours on the days she was recorded as clocked in. The Administrator admitted that they could not prove the DON was in the facility for the required time. Additionally, a policy regarding RN coverage was requested from the Administrator but was not provided. This lack of RN coverage could potentially lead to inconsistency in care and services for the residents.
Inadequate Hand Hygiene by CNA in Dining Room
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in the dining room, as evidenced by the actions of CNA C. During an observation, CNA C was seen playing with their hair while waiting for a resident's food to be delivered. Subsequently, CNA C did not perform hand hygiene before assisting Resident #32 with eating, which involved touching the resident's napkin and silverware. This lack of hand hygiene was a direct violation of the facility's handwashing policy, which emphasizes handwashing as the most crucial method for preventing the spread of infections. Interviews conducted with CNA C and the Director of Nursing (DON) confirmed the potential negative outcomes of such actions, including the transfer of germs to the resident's food. The facility's handwashing policy, although undated, clearly outlines the necessity for all personnel to adhere to established handwashing procedures to prevent infection spread. The policy specifies that hands should be washed for 20 seconds after activities such as combing hair, which CNA C failed to do, thereby compromising the safety and sanitary conditions expected in the facility.
Failure to Accurately Document CPAP Therapy in MDS
Penalty
Summary
The facility failed to conduct a comprehensive and accurate assessment of a resident using the Resident Assessment Instrument (RAI) as specified by CMS. This deficiency was identified for a resident who was on CPAP therapy, which was not addressed in the Minimum Data Set (MDS). The resident, who had a history of dementia, atrial fibrillation, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and venous insufficiency, was admitted to the facility and had been using CPAP therapy nightly. However, the admission MDS did not reflect this therapy, despite it being documented in the resident's care plan and treatment administration record. The deficiency was further highlighted during interviews with facility staff, where it was revealed that the MDS assessments were being completed offsite due to the sudden loss of the Assistant Director of Nursing (ADON)/MDS nurse. The Director of Nursing (DON) admitted to a lack of knowledge regarding the impact of missing CPAP documentation on the MDS. The Care Management Data System (CMDS) Coordinator confirmed that the CPAP should have been included in the MDS and acknowledged that inaccuracies in the MDS could lead to inaccuracies in the care plan, which drives the resident's care. The facility's policy for the MDS was based on the RAI manual, which specifies the inclusion of CPAP therapy in the assessment.
Failure to Complete PASRR Prior to Admission
Penalty
Summary
The facility failed to perform the required Preadmission Screening and Resident Review (PASRR) for two residents, Resident #18 and Resident #20, prior to their admission. Resident #18, an 81-year-old female with diagnoses including dementia, anxiety, depression, and anemia, was admitted without a PASRR, which was only completed four months after her admission. Her records indicated moderate cognitive impairment and the use of a wheelchair for mobility. Similarly, Resident #20, a 64-year-old male with diabetes, anemia, and hypertension, was admitted without a PASRR, which was completed two months post-admission. His records showed moderate cognitive impairment and the use of a walker for mobility. The facility's administrator acknowledged the oversight, stating that PASRRs should be completed immediately at or before admission, especially for residents admitted from the community rather than a hospital setting. The facility's policy mandates that all residents be screened through the PASRR process as per regulations, but this was not adhered to in these cases. The administrator admitted that the delay in completing the PASRRs could result in residents not receiving necessary services.
Failure to Implement Comprehensive Care Plan for Smoking
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, specifically omitting a care plan for smoking. The resident, a cognitively intact male with multiple diagnoses including dementia, atrial fibrillation, chronic obstructive pulmonary disease, obstructive sleep apnea, and venous insufficiency, was admitted to the facility without a care plan addressing his smoking habits. Despite being independent in some activities of daily living, the resident smoked 2-5 times per day, as noted in his smoking assessment. However, this information was not included in his care plan, which is a requirement to ensure that all aspects of a resident's needs are addressed. The deficiency was acknowledged by the facility's Director of Nursing (DON) and Administrator during interviews. The DON admitted to the oversight, attributing it to the sudden loss of their Assistant Director of Nursing/MDS nurse and her own lack of training in completing care plans. The Administrator also confirmed the absence of a smoking care plan for the resident, noting that while the resident's independence might mitigate immediate concerns, the lack of a care plan could negatively impact residents who are not independent. The facility's policy on comprehensive care plans mandates that all services necessary for a resident's well-being be documented, which was not adhered to in this case.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to currently accepted professional principles. During an observation and interview, it was found that there were two loose pills in the medication drawers of the medication cart for Hall 100 and half of Hall 300. The pills were identified by LVN B as Plavix and Bethanechol Chloride, but it was unclear to whom these medications belonged. This situation could lead to residents not receiving the correct dosage of medication and not being maintained at their best therapeutic level. Interviews with LVN B and the Director of Nursing (DON) highlighted the potential negative outcomes of having loose medications in the medication carts. LVN B noted that the medications could be mistaken for something else, while the DON expressed concern that staff might assume the identity of the pills and administer them to a resident, compromising their cleanliness. The facility's policy on medication storage emphasizes the importance of storing medications in their original containers and ensuring that no discontinued, outdated, or deteriorated medications are available for use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Matador
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crosbyton Nursing And Rehabilitation Center | 34.8 mi | ★★★★★ | 17 | 0 |
| Ralls Nursing Home | 39.4 mi | ★★★★★ | 14 | 3 |
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