Inspection Reports for Cimarron Place

The complaint investigation substantiated that LVN A stole 23 Hydrocodone-Acetaminophen tablets and sold them to LVN B for $200. Both nurses tested positive for drug use and were suspended. The facility conducted internal investigations, audits, and in-services to address narcotic handling and documentation.

The facility failed to prevent the misappropriation of 23 Hydrocodone-Acetaminophen 10 mg tablets by two licensed vocational nurses (LVN A and LVN B), who diverted and sold the medication for personal use. Both nurses tested positive for drug use and were suspended. The facility implemented new narcotic counting and auditing procedures following the incident.

The complaint investigation found that on 07/14/2025, CNA A failed to alert RN A about Resident #1's pain during incontinent care despite the resident exhibiting signs and symptoms of pain. This delay in notification and assessment led to a right greater trochanter fracture being diagnosed after EMS transport to the emergency room. The complaint was substantiated with actual harm to the resident.

The facility failed to provide safe and appropriate pain management to Resident #1 after a fall on 07/13/2025, resulting in a delayed recognition and response to the resident's pain and injury. Staff failed to promptly notify nursing when the resident exhibited pain during incontinent care, leading to a fracture being diagnosed only after emergency intervention.

The facility was found deficient in ensuring accident hazards were minimized, specifically failure to place fall mats as required for a high-risk resident. Deficiencies were also found in IV dressing maintenance, medication administration errors related to blood pressure and pulse parameters, and failure to secure medication carts properly.

The facility failed to update Resident #1's care plan with the Do Not Resuscitate (DNR) code status after the out-of-hospital (OOH) DNR order was signed by all appropriate parties, potentially placing residents at risk of receiving care inconsistent with their wishes. Interviews with nursing staff and administrators confirmed the importance of accurate and timely updates to care plans to ensure appropriate resident care.

The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1 addressing her behaviors and fall mat use. Additionally, the facility failed to maintain complete and accurate medical records for Resident #1, specifically failing to document the physician's order and progress notes related to a CT scan hospital visit.

The facility was found deficient in multiple areas including medication administration errors, unsecured medication carts, inadequate food storage monitoring, improper garbage disposal, and failure to maintain proper infection control practices such as hand hygiene during wound care.

The investigation was complaint-related, triggered by incidents where Resident #1 and Resident #2 ingested soap pieces from donated candy bags, causing allergic reactions and hospitalizations. Resident #1 had severe cognitive impairment and poor safety awareness, while Resident #2 had moderate cognitive impairment and a history of eating non-food items. The complaint was substantiated based on interviews and record reviews.

The facility failed to prevent two residents from ingesting soap pieces mistakenly included in donated candy bags, resulting in allergic reactions and hospital transfers. Interviews revealed inadequate verification of donated items and insufficient supervision, especially for cognitively impaired residents.

The facility failed to develop and implement a comprehensive person-centered care plan addressing weight variances due to edema for Resident #59, posing minimal harm risk. Additionally, the kitchen failed to meet professional food service safety standards, including issues with equipment, food storage, cleanliness, and lack of a cleaning list.