Matagorda Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Matagorda Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 1, 2026

  Based on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents hazards and supervision, in that: CNA A failed to perform an appropriate Hoyer Lift transfer with two staff as required, which resulted in Resident #1 sustaining a fall with head injury on 12/30/2025.Resident #1 was transferred from Local Hospital A to City Hospital B's Neuroscience ICU with a diagnosis of a brain bleed and subdural hematoma with subarachnoid hemorrhaging on 12/30/2025. An IJ was identified on 12/31/25. […]

• No harm, potential for more than minimal, widespreadF812May 29, 2025

  Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure the kitchen's ice machine's internal components were cleaned and sanitized, and free from mold, mildew, and soiling. This failure placed residents at risk of food contamination and foodborne illness. Findings included: Observation of the exterior of the kitchen ice machine on May 27, 2025, at 9:14 AM, revealed a printed event log adhered to the outside of the ice machine. The event title on the form read Ice Machine. The form contained a table in which kitchen staff log events related to the ice machine. […]

• No harm, potential for more than minimal, widespreadF812Oct 26, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation and storage. The facility failed to ensure Cook E provided clean and sanitary conditions while preparing food. This failure could place residents at risk of exposure to cross contamination and foodborne illness. Findings included: Observation on 10/25/22 at 2:50 p.m. revealed the two - compartment prep sink had dirty dishes socking in one compartment of the sink and a container with soap and sanitizer solution for cleaning was in the other compartment of the sink where a calendar (container with holes) that contained cooked tortellini was sitting. […]

• No harm, potential for more than minimal, widespreadF908Dec 9, 2021

  Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 or 1 automatic dishwasher. -The facility failed to ensure the automatic dishwasher temperature gauge was in working condition to measure the water temperature. This deficient practice placed the residents at risk of exposure to foodborne illnesses. Finding included: Observation on 12/8/2021 at 11:30 a.m. of the automatic dishwasher revealed the temperature gauge read 115 degrees F. At 11:36 a.m. the dishwasher was ran and the temperature gauge read 118 degrees F. Interview on 12/8/2021 at 11:40 a.m. with DS B said we run the dishwasher over and over until it gets hot enough. DS B said, It does not get hot enough. […]

• No harm, potential for more than minimal, patternF677Jul 9, 2026

  Based on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 of 8 residents (#48 and #59) reviewed for ADL care. The facility failed to ensure Resident #48's fingernails were trimmed, filed, and cleaned on 07/07/2026. -The facility failed on 07/07/2026 to assist Resident #59 to shave his facial hair. These failures could place residents at risk of loss of dignity, risk of infections, and a decreased quality of life.Findings included: Record review of the Face Sheet revealed Resident #48 was an [AGE] year-old male whose original admission date was 04/07/2025 with a readmission date of 02/26/2026. […]