Cimarron Place Health & Rehabilitation

Inspectors wroteBased on record review and interviews the facility failed to ensure that one (1) residents (Resident #1) of five residents reviewed for transfer or discharge was sent to the Ombudsman to ensure a safe and effective transition of care for the resident. The facility discharged Resident #1 to the hospital for an incident on 5/19/2026 and did not allow the resident to facility The facility discharged Resident #1 on 5/19/2026 without sending notification to the Ombudsman. This failure could place discharged residents at risk of being discharged from the facility causing a disruption in their care and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received their medications as ordered. These failures could place residents at risk of medical complications and prevent them from receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 1 of 4 medication carts (300 Hall Nurse Med-Cart) reviewed for labeling and storage. The facility failed to ensure the 300 Hall Nurse Med-Cart was locked and secured, as well as failed to make sure all medications were labeled appropriately. This failure could have placed residents at risk of gaining access to unlocked medications which were not prescribed to them and could have caused them harm.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the resident's right to be free from misappropriation of resident property for one of four residents (Resident #1) reviewed for drug diversion. The facility failed to prevent the misappropriation of 23 Hydrocodone-Acetaminophen 10 mg tablets from being diverted and sold by LVN A for personal gain to LVN B for LVN B's own personal use. This failure could place residents at risk of misappropriation and not receiving their prescribed pain medication as ordered.

Inspectors wroteBased on interview and record review, the facility failed to provide pain management to one resident (Resident#1), of five residents reviewed for pain management, that was consistent with professional standards of practice, her comprehensive person-centered care plan, and her goals and preferences. On 07/14/2025 the facility staff failed to recognize and address Resident #1's pain while providing incontinent care to Resident #1. On 07/14/2025 CNA A failed to alert RN A of Resident #1's expression and exhibition of pain. CNA A continued to provide incontinent care on 07/14/2025 even when Resident #1 exhibited signs and symptoms of pain. This failure could place residents at risk from receiving prompt pain management.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement resident care policies based upon current professional standards of practice for the preparation, insertion, administration, maintenance and discontinuance of an IV as well as for the prevention of infection at the site to the extent possible for one (Resident #231) of 8 residents review for IV therapy. The facility failed to provide Resident #231 with dressing changes, as ordered by his physician, to his right arm PICC line dressing. The PICC line dressing was dated 06/01/24 and was not changed until 06/24/24, despite the physician orders indicating to change the dressing every seven days. This deficient practice could result in infection or PICC line malfunction and infection.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #62) of eight residents reviewed for accidents and hazards. The facility failed on 06/24/2025 to ensure floor mats were in place both sides of Resident #62's bed, as indicated on her current comprehensive care plan dated 03/27/25, Resident #62 had five previous falls in the last three months on 05/18/25, 05/24/25, and 06/01/2025. This failure could place residents at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for two of six residents (Resident #10 and Resident #21) reviewed for medication errors in that:The facility failed to ensure MA I did not administer Resident #10's blood pressure/pulse altering medications (Metoprolol ER and Amiodarone) on 06/05/25 when her pulse was not within the required parameters per the two physician's orders. The facility failed to ensure MA J did not administer Resident #21's blood pressure/pulse altering medications (Losartan and Nifedipine ER) on 06/01/25, 06/07/25, 06/08/25, 06/09/25, 06/14/25 and 06/21/25 when her blood pressure/pulse was not within the required parameters per the two physician's orders. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments on 1 of 8 medication carts reviewed for storage of drugs. The facility failed to ensure RN A's medication cart located by the nurse's station was locked when not in use on 06/25/2025. This deficient practice could affect residents who have medications on the nurse medication cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. During an observation on 06/25/25 at 11:44 AM, a medication cart by the nurse's station appeared to be unlocked. This surveyor opened the top drawer recognizing the medication cart being unlocked while not in use. Multiple medications in bulk bottles and blister packs were easily assessable for removable. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to update Resident #1's care plan with the DNR code status after the OOH DNR order was signed by all appropriate parties on [DATE]. This failure could place residents at risk of receiving care out of line with their wishes.

Inspectors wroteBased on interviews and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #1) of 4 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 to address her behaviors (e.g. yelling, banging on bed/table, throwing items, removing brief). The facility failed to care plan the fall mat for Resident #1. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs as indicated on the comprehensive care plans.

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for accuracy of records, in that: The facility failed to document in Resident #1's medical record when Resident #1 was sent to the hospital on [DATE] for a CT scan. The facility failed to document the physician's order for the CT scan. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide pharmaceutical services (including the accurate administering of all drugs) to meet the needs of each resident for 1 (Resident #274) of 5 residents reviewed for medication administration. The facility failed to administer the correct dose of Resident #274's scheduled medication (Pramipexole) according to the physician orders. This failure could place residents at risk of not receiving the therapeutic benefits of their prescribed medications.

Inspectors wroteBased on observation and interview the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 8 medication carts (500 Hall Medication Cart) reviewed for medication storage. The facility failed to ensure the 500 Hall Medication Cart was locked when left unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.

Inspectors wroteBased 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 1 of 1 nutrition room reviewed for kitchen sanitation. 1. The facility failed to maintain a temperature log for the nutrition room freezer 2. The facility failed to ensure the nutrition room freezer had a thermometer 3. The facility failed to ensure the nutrition room freezer was monitored daily for correct temperatures These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for 1 of 6 residents (Resident #54) observed for infection control practices during personal care, in that: Wound Care nurse failed to perform hand hygiene for 20 seconds or greater and exposed Resident #54's wound to an uncleaned surface. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on observation, interview and record review, the facility must dispose of garbage and refuse properly for 2 of 2 grease barrels reviewed for garbage disposal. 1. The facility failed to ensure the grease barrels had tight fitting lids 2. The facility failed to ensure the grease barrel lids were secured 3. The facility failed to ensure the grease barrel lock rings were secured 4. The facility failed to ensure the grease barrels, lids, and lock rings were maintained in good working condition These failures could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed in that: The deep fryer was full of odiferous grease and was inoperable A full-size sheet pan had baked-on brown substances The steamer oven was leaking water There was undated food in the dry storage area There was a container of food with a brown substance all over the outside of it in the dry storage area There was improperly stored food in the dry storage area There were dirty cups in the clean area There was an unlabeled, unidentified paper bag with food in it in the refrigerator There was a marred Teflon pan hanging on the pan rack The facility was not following a cleaning list The ice machine cover was broken

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #59) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Residents #59's diagnosis of edema resulting in weight loss and gain. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.