Health inspection·August 28, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services to include the accurate dispensing and administering of drugs to meet the needs for 1 of 5 residents (Resident #1) reviewed for physician orders. The facility failed to accurately enter physician orders for Seroquel(anti-psychotic medication) and Trazodone(insomnia medication) for Resident #1. The deficient practice could place residents at risk of not receiving medications as prescribed and/or deterioration in their condition. Findings included: Record review of Resident #1's face sheet dated 08/28/24 revealed an [AGE] year old male was originally admitted to the facility on [DATE] and was sent to the hospital and readmitted on [DATE] with diagnoses to include but not limited to Alzheimer's disease(memory loss), atherosclerotic heart disease of native coronary artery(narrowing of arteries), vascular dementia, unspecified severity, without behavioral disturbance(breakdown of thought process), psychotic disturbance, mood disturbance and anxiety, delusional disorder, psychotic disorder with delusions due to known physiological condition, mood disorder due to know physiological condition with major depressive like episode and Vascular dementia, unspecified severity, with other behavioral disturbance(breakdown of thought process causing disruptive behavior). Record review of Resident #1's last completed Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 03 out of 15 indicating that he had severe impairment. Resident #1's functionality was independent from sitting to lying down, sitting to standing and chair/bed transfer with setup assistance with eating, oral hygiene, and upper and lower body dressing. Resident #1 had occasional bowel and urinary incontinence. Record review of Resident #1's care plan start date 08/08/2022 revised on 08/20/2024 revealed that Resident #1 had a history of depression and took antidepressants with interventions to encourage and assist resident to attend activities and provide medication as ordered. Care plan also indicated Resident #1 had a diagnosis of Alzheimer's/Dementia with interventions to encourage and allow resident to verbalize needs and concerns and provide medications as ordered. The care plan did not address Resident #1's insomnia or antipsychotic medication. Record review of Resident #1's discharge orders from the Rehab Hospital dated 08/15/2024, indicated (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 3 Event ID: 676389 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 676389 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Matador Health and Rehabilitation Center 805 Harrison St Matador, TX 79244 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)