Health inspection·March 1, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 7 of 7 rooms (Rooms #605, #607, #608, #703, #704, #801, and #805) reviewed for infection control. Residents Affected - Some The facility failed to ensure that staff had appropriate Personal Protective Equipment (PPE) readily available to wear when entering rooms (Rooms #605, #607, #608, #703, #704, #801, and #805) on droplet precautions to prevent the spread of infection. This failure placed all residents, as well as employees and visitors, at risk of communicable diseases. Findings included: Observation of Hall 600 on 03/01/25 at 11:15 AM revealed Rooms #605 and #608 were on droplet precautions. Both rooms had PPE bins outside of the door, but there were no face shields or goggles available. Observation of Hall 700 on 03/01/25 at 11:18 AM revealed Rooms #703 and #704 were on droplet precautions. Both rooms had PPE bins outside of the door, but there were no face shields or goggles available. Observation of Hall 800 on 03/01/25 at 11:20 AM revealed rooms #801, #805, and #607 were on droplet precautions. Both rooms had PPE bins outside of the door, but there were no face shields or goggles available. In an interview on 03/01/25 at 1145 AM, LVN A stated she was administering medications on Hall 800. LVN A stated there were residents with COVID-19 on that hall, and they were on droplet precautions. She stated she wore gloves and a mask when entering the rooms. LVN A stated she did not wear face shields and only wore her eyeglasses. She stated there were no face shields in the PPE bins outside of the room and she did not know where they were kept. In an interview on 03/01/25 at 1:35 PM with the Administrator and DON, the DON stated the protocol for staff providing care to residents on isolation was to wear PPE appropriate for the precautions in place. The DON stated PPE for droplet precautions included a N95 mask, face shield, gloves, and a gown if providing direct care. The Administrator stated all staff were expected to wear appropriate PPE when entering isolation rooms and the risk not wearing it could cause the spread of infection. The DON stated the facility currently had 7 residents with COVID-19. The DON stated all PPE bins should be stocked with all PPE, including face shields and she and the ADON were responsible for (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 2 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 03/01/2025 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)