Inspection·January 8, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one of five residents (Resident #1) reviewed for accuracy of assessments. Residents Affected - Some The facility failed to ensure Resident #1's medications were correctly documented on his quarterly and annual MDS assessments. This failure could place residents at risk of inadequate care due to inaccurate assessments. Findings included: Record review of Resident #1's face sheet, printed on 01/08/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included metabolic encephalopathy (brain dysfunction caused by an imbalance of chemicals in the blood), chronic embolism and thrombosis of other specified veins (blood clots), end stage renal disease (a permanent condition where the kidneys can no longer function properly), acute and chronic respiratory failure with hypoxia (condition where the lungs are not effectively delivering oxygen to the body, causing a lack of oxygen in the bloodstream), quadriplegia (the loss or severe impairment of motor function, sensation, and autonomic functions in all four limbs (arms,legs and the torso), hypotension (low blood pressure), cerebral infarction (a medical condition where brain tissue dies due to a disruption in blood flow to the brain), chronic pain, anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy (a condition that occurs when high blood sugar levels damage nerves in the body), peripheral vascular disease (a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked), schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors), and essential (primary) hypertension(a condition where a person has high blood pressure without a clear cause). Record review of Resident #1's annual MDS assessment, dated 11/12/24, reflected Resident #1 had a BIMS of 13, which indicated Resident #1 was cognitively intact. Question N0415. High-Risk Drug Classes: Use and Indication, indicated Resident #1 had taken none of the above listed medications by classification in the last seven days (prior to assessment). Record review of Resident #1's quarterly MDS assessment, dated 12/12/24, reflected Resident #1 had a BIMS score of 11, which indicated a moderate cognitive impairment. Question N0415. High-Risk Drug Classes: and Indication, indicated Resident #1 had taken antipsychotic, antianxiety, and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 676141 Printed: 05/15/2026 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 676141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2025 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)