Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Matagorda Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, heart failure, morbid obesity, and total dependence for transfers was care planned to require a Hoyer lift with two staff. During a night shift, a CNA performed a Hoyer transfer alone, despite the two‑person requirement and manufacturer instructions specifying at least two operators. The CNA reported that the lift arms were wobbling, a sling strap slipped off the hook, and the resident fell straight down, striking her head. The resident was found on the floor with her head on a lift leg, in a pool of blood, complaining of head and shoulder pain, and was subsequently transferred to hospitals where she was diagnosed with brain bleeding, including subdural hematoma and subarachnoid hemorrhages. Interviews and record review showed the CNA had not recently been in‑serviced on Hoyer use, another resident reported that Hoyer transfers were often done by one person, and equipment inspections found no mechanical defects, indicating the deficiency stemmed from failure to follow required two‑person transfer procedures.
The facility did not follow its required cleaning schedule for the kitchen ice machine, resulting in visible mold growth inside the machine. Staff interviews and cleaning logs confirmed that the ice machine had not been cleaned or documented as required, placing residents at risk of food contamination and foodborne illness.
A resident with a documented diagnosis of bipolar disorder was admitted with a PASARR Level I screening that failed to indicate a mental illness, despite clear evidence in the medical record. The MDS nurse did not ensure the correction of the inaccurate PASARR received from the hospital, resulting in an incomplete assessment process.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, as three dented cans were found in the dry storage room. Despite in-service training on the risks of using dented cans, the dietary staff overlooked these items, posing a risk to 49 residents.
A resident with a history of hemiplegia and traumatic brain injury was prescribed Prednisone 40 mg daily for pneumonia but only received 20 mg due to a medication aide's error. The DON confirmed the mistake and noted that the facility's medication administration procedures were not followed.
Improper One‑Person Hoyer Lift Transfer Resulting in Resident Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents, specifically related to mechanical lift transfers. An 83‑year‑old woman with dementia, heart failure, morbid obesity, and total dependence on staff for transfers and bed mobility was care planned to require a Hoyer lift with two staff for all transfers. She used a wheelchair and could self‑propel short distances but was otherwise dependent for mobility. The resident’s care plan and MDS documented that she required two‑person total assistance for all transfers, including bed to chair and toilet transfers. On the night of the incident, a CNA who worked the 6 p.m. to 6 a.m. shift initiated a Hoyer lift transfer of this resident from bed to wheelchair alone, despite knowing the resident was a two‑person assist. The CNA reported that she chose to perform the transfer by herself because the other aide was busy and stated that “everybody does it by themselves” at the facility and she did not think anything bad would happen. During the transfer, the CNA described that the Hoyer lift arms attached to the sling were wobbling, the sling on the right side slipped off the hook, and the resident fell straight down, striking her head. The CNA observed blood on the floor and immediately notified the LVN on duty. The LVN documented that the resident fell from the Hoyer lift during a transfer in her room, sustained bleeding to the back of the head, and complained of continuous pain to the back of her head, left shoulder, and left heel. On assessment, the resident’s blood pressure was elevated, she was oriented and obeyed commands, and her pupils were equal and reactive to light. The LVN and other staff found the resident lying on the floor with her head on top of one leg of the Hoyer lift and the other leg bent beneath her body, with a pool of blood around her head. EMS was called, and the resident was transported to a local hospital and then airlifted to a higher‑level facility’s Neuroscience ICU with diagnoses including brain bleeding, a subdural hematoma, and subarachnoid hemorrhages. The resident later reported that she fell during a Hoyer transfer, hit her head, and repeatedly stated that her head hurt. Additional information gathered during the survey showed that the manufacturer’s instructions for the Hoyer lift, updated in November 2025, required at least two people to operate the lift during transfers. The facility’s in‑service records showed Hoyer lift trainings earlier in the year and again on the date of the incident, but the CNA who performed the transfer alone was not listed on those in‑services and could not recall when she last received Hoyer training, stating she might have had training at hire. Other CNAs interviewed stated that Hoyer transfers should always be done with two people, though one resident reported that staff usually performed Hoyer transfers with one person and identified a specific aide by first name as doing so. The Hoyer lift used in the incident had been inspected by the company earlier in the month and again after the fall, with no malfunctions identified; the equipment owner stated that if someone fell due to a wing becoming unbalanced, it would be because the person was not centered in the sling prior to the lift. An Immediate Jeopardy was identified related to these failures.
Failure to Maintain and Sanitize Kitchen Ice Machine
Penalty
Summary
The facility failed to ensure that the kitchen's ice machine was cleaned and sanitized according to the established monthly schedule. Observation of the ice machine revealed the presence of black, fuzzy, raised dots identified as mold within the internal components of the machine. Review of cleaning logs showed that the last recorded cleaning occurred several months prior, and staff interviews confirmed that the cleaning schedule was not consistently followed or documented as required. During interviews, dietary staff acknowledged that the ice machine had not been cleaned or logged in accordance with the posted cleaning schedules. Staff admitted that they may have forgotten to record cleanings, and the logs did not reflect any recent cleaning activity. The facility's cleaning schedules and policies required monthly cleaning and documentation, but these procedures were not adhered to, resulting in visible mold growth inside the ice machine. The deficiency was identified through direct observation, review of cleaning schedules and logs, and staff interviews. The failure to maintain the ice machine in a sanitary condition placed residents at risk of food contamination and foodborne illness, as stated in the report. No contamination of the ice itself was observed at the time of inspection.
Failure to Accurately Complete PASARR Level I Screening for Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-admission Screening and Resident Review (PASARR) Level I assessment for one resident. Specifically, the PASARR Level I screening did not indicate a diagnosis of mental illness, despite the resident having a documented diagnosis of bipolar disorder with an onset date prior to admission. The resident's medical record, including the face sheet and care plan, clearly reflected the diagnosis of bipolar disorder and anxiety, and the resident was receiving antianxiety medication. However, the PASARR Level I screening form marked 'no' for mental illness, resulting in an inaccurate assessment. Interviews with facility staff revealed that the PASARR Level I screening was received from the hospital and was not corrected upon admission, even though the error was identified. The MDS nurse, who was responsible for ensuring the accuracy of PASARRs, acknowledged that the form should have been corrected and that there was no evidence anyone at the facility requested a correction from the hospital. The facility's policy required timely and accurate submission of PASARR forms, but this was not followed in this instance.
Failure to Properly Store and Handle Dented Cans
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the dry storage room, three dented cans were found on the can rack: one 108 oz can of yams with a small dent in the middle, one 66.5 oz can of tuna with a large dent at the top of the seam, and one 104 oz can of fruit cocktail with a small dent at the top of the seam. The Dietary Manager confirmed that these dented cans should have been stored away from the dry storage area with other dented cans. Interviews with the Dietary Manager and dietary staff revealed that they were aware of the risks associated with using dented cans, including the potential for botulism. The Dietary Manager had conducted an in-service training on the issue, and staff were instructed to check for dented cans when groceries were received. Despite these measures, the dented cans in the pantry were overlooked, posing a risk to the 49 residents who received meals from the main kitchen.
Failure to Administer Correct Medication Dosage
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering the correct dosage of Prednisone as per physician orders. The resident, a male with a history of hemiplegia, altered mental status, and traumatic brain injury, was diagnosed with pneumonia and prescribed Prednisone 40 mg daily. However, the medication administration record (eMAR) and the medication aide (MA) only administered 20 mg instead of the required 40 mg. This discrepancy was discovered during a medication cart check, where it was noted that only one 20 mg tablet was missing from the blister pack instead of two. The Director of Nursing (DON) confirmed that the MA did not fully read the physician's order and only administered one 20 mg tablet. The DON also revealed that the facility's staff were in-serviced annually and during onboarding on medication administration, but was unable to find the MA's onboarding competencies and medication checklist. The facility's Medication Administration Procedures policy requires specific orders from the physician to change dosage forms and mandates immediate reporting of medication errors to the physician and DON. However, these procedures were not followed in this instance, leading to the resident not receiving the prescribed therapeutic dose of Prednisone.
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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 Bay City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paradigm At Bay City | 2.2 mi | ★★★★★ | 0 | 0 |
| Avir At Bay City | 2.2 mi | ★★★★★ | 13 | 0 |
| Paradigm At Sweeny | 18 mi | ★★★★★ | 2 | 0 |
| Paradigm At The Prairies | 25.5 mi | ★★★★★ | 15 | 2 |
| Wharton Nursing And Rehabilitation Center | 26 mi | ★★★★★ | 8 | 4 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.