Matlock Place Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Matlock Place Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Aug 28, 2025

  Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of six residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #2, who had prior behaviors towards others, did not physically abuse Resident #1. On 08/26/25, Resident #2 had her hands around Resident #1's neck and had to be separated by facility staff. An Immediate Jeopardy (IJ) situation was identified on 08/27/25. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. […]

• Immediate jeopardy, patternF656Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #2) reviewed for care plan accuracy. The facility failed to develop and implement a care plan revised on 08/14/25 for Resident #2, which addressed her physically aggressive behaviors towards others between 08/02/25 to 08/26/25. […]

• Immediate jeopardy, isolatedF689Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents and assistance devices to prevent accidents for 1 (Residents #109) of 10 residents reviewed for accidents and hazards.The facility failed on 6/28/26 to ensure Resident #109 was provided with appropriate assistance during incontinent care resulting in Resident #109 falling off the bed, receiving a laceration to his head, which required staples.On 7/07/26 at 7:10 p.m. an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. […]

• Immediate jeopardy, isolatedF726Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 direct-care staff (CNA K) and 1of 1 resident (Resident #109) reviewed for proficiency of nurse aides.The facility failed to ensure CNA K was trained on fall protocol. On 6/28/26, CNA K performed incontinent care independently on Resident #109, which required a 2-person assist, that resulted in Resident #109 falling off the bed and sustaining a laceration to his head. […]

• Immediate jeopardy, isolatedF600Oct 31, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA B transferred her roughly from bed to a geri-chair and then slapped her hand when she attempted to hold onto the bed on 08/31/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/31/24 and ended on 09/03/24. […]