Inspection Report Summary
The most recent inspection on March 17, 2026, found one deficiency related to failure to protect residents from misappropriation of narcotic medication, substantiated through a complaint investigation involving diversion by two licensed vocational nurses who were suspended. Earlier inspections showed a pattern of deficiencies involving care planning, medication administration, accident hazard prevention, and infection control, with several substantiated complaints including delayed pain management after a fall and environmental safety issues leading to resident harm. Inspectors frequently cited failures in updating care plans, securing medication carts, and maintaining safe environments, along with issues in medication handling and documentation. Complaint investigations were substantiated in multiple cases, including narcotic diversion and inadequate pain management, but enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with medication security and resident care documentation, with no clear trend of overall improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 17, 2026
Visit Reason
The inspection was conducted based on a complaint investigation regarding drug diversion and misappropriation of resident property involving narcotics at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to protect each resident from the wrongful use of the resident's belongings or money, specifically misappropriation of narcotic medication.
Report Facts
Number of Hydrocodone tablets misappropriated: 23
Fine amount: 200
Instances of undocumented medication: 27
Instances of undocumented medication: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Admitted to stealing narcotics and selling them to LVN B |
| LVN B | Licensed Vocational Nurse | Admitted to purchasing stolen narcotics from LVN A |
| RN K | Registered Nurse | Identified the drug diversion and reported missing narcotics |
| ADON F | Assistant Director of Nursing | Involved in investigation and suspension of nurses |
| ADON/LVN D | Assistant Director of Nursing / Licensed Vocational Nurse | Involved in investigation and interviews related to drug diversion |
| DON J | Director of Nursing | Involved in investigation, interviews, and suspension of nurses |
| DON H | Director of Nursing | Implemented new narcotic auditing procedures and conducted audits |
| CMA G | Certified Medication Aide | Provided information on in-services and narcotic counting procedures |
| LVN E | Licensed Vocational Nurse | Provided information on new narcotic sign-out processes |
| CMA L | Certified Medication Aide | Provided information on narcotic auditing and in-services |
| ADM | Administrator | Reported the incident to the state and provided information on suspensions and terminations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate pain management to a resident following a fall.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide safe, appropriate pain management for a resident who requires such services.
Report Facts
Residents reviewed for pain management: 5
Residents affected: 1
BIMS score: 11
BIMS score: 15
Fall dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Failed to notify nurse of Resident #1's pain during incontinent care |
| RN A | Registered Nurse | Night nurse who was notified late about Resident #1's pain and called 911 |
| RN B | Registered Nurse | Documented Resident #1's fall on 07/13/2025 and initial assessment |
| DON | Director of Nursing | Notified about Resident #1's pain and commented on staff notification failures |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication administration, IV therapy, and medication storage at Cimarron Place Health & Rehabilitation Center.
Findings
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.
Deficiencies (4)
Failure to ensure fall mats were in place on both sides of Resident #62's bed as required by care plan, increasing risk of injury from falls.
Failure to provide timely dressing changes for Resident #231's PICC line, resulting in an outdated dressing that could lead to infection or malfunction.
Failure to prevent significant medication errors for Residents #10 and #21 by administering blood pressure/pulse altering medications when vital signs were outside prescribed parameters.
Failure to ensure medication cart was locked when unattended, risking unauthorized access to medications.
Report Facts
Previous falls: 5
Dates of falls: Falls occurred on 05/18/25, 05/24/25, and 06/01/2025
PICC line dressing change interval: 7
Medication administration errors: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Responsible for unlocked medication cart on 06/25/25 | |
| CNA D | Interviewed about fall mat placement and training | |
| CNA F | Interviewed about fall mat placement and PICC line dressing observations | |
| ADON B | Assistant Director of Nursing | Interviewed about fall mat responsibilities and PICC line dressing oversight |
| RN H | Interviewed about PICC line dressing change attempts | |
| DON | Director of Nursing | Interviewed about PICC line dressing change requirements and medication administration policies |
| MA I | Medication Aide | Administered medication to Resident #10 despite pulse being below parameters |
| MA J | Medication Aide | Failed to administer Resident #21's medication when vital signs were out of parameters |
| MA K | Medication Aide | Interviewed about importance of checking vital signs before medication administration |
Inspection Report
Deficiencies: 1
Date: May 14, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically focusing on the development and implementation of comprehensive, person-centered care plans that include measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs.
Findings
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.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions, specifically failing to update Resident #1's care plan with the DNR code status after the OOH DNR order was signed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Interviewed regarding knowledge of resident code status and importance of updated care plans. |
| LVN B | Licensed Vocational Nurse | Interviewed about checking code status and care plan accuracy. |
| ADON | Assistant Director of Nursing | Interviewed about responsibility for updating code status in care plans. |
| DON | Director of Nursing | Interviewed about procedures for updating code status and care plan accuracy. |
| LMSW | Licensed Master Social Worker | Interviewed about meetings with families and updating code status in care plans. |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning and medical record documentation at Cimarron Place Health & Rehabilitation Center.
Findings
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.
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs, including measurable objectives and time frames, specifically for Resident #1's behaviors and fall mat.
Failed to maintain medical records in accordance with accepted professional standards, including failure to document physician's order and progress notes for Resident #1's CT scan hospital visit.
Report Facts
Residents reviewed for care plans: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS N | Interviewed regarding Resident #1's behaviors and care planning | |
| DON | Director of Nursing | Interviewed regarding Resident #1's behaviors, care planning, and medical record documentation |
| LVN C | Licensed Vocational Nurse | Interviewed about arranging transport for Resident #1's CT scan and documentation |
| LVN D | Licensed Vocational Nurse | Mentioned as previous nurse who did not document CT scan progress notes; no longer employed |
| ADM | Administrator | Interviewed regarding importance of documentation for Resident #1's CT scan |
Inspection Report
Routine
Deficiencies: 5
Date: May 2, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pharmaceutical services, medication administration, medication storage, food safety, garbage disposal, infection prevention and control, and other facility operations.
Findings
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.
Deficiencies (5)
Failed to administer the correct dose of medication (Pramipexole) to Resident #274 as ordered.
Failed to ensure the 500 Hall Medication Cart was locked when left unattended.
Failed to maintain a temperature log and thermometer for the nutrition room freezer and failed to monitor freezer temperatures daily.
Failed to ensure grease barrels had tight fitting lids, secured lids, secured lock rings, and were maintained in good working condition.
Failed to maintain an infection prevention and control program, including proper hand hygiene during wound care for Resident #54.
Report Facts
Residents reviewed for medication administration: 5
Medication carts reviewed: 8
Grease barrels reviewed: 2
Wounds observed for infection control: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Administered incorrect medication dose to Resident #274 and acknowledged the error. | |
| MA B | Left medication cart unlocked and acknowledged the error. | |
| DON | Director of Nursing | Provided statements regarding medication errors and hand hygiene requirements. |
| ADON A | Assistant Director of Nursing | Provided statements regarding medication errors, medication cart security, and hand hygiene. |
| LVN C | Licensed Vocational Nurse | Interviewed regarding nutrition room freezer temperature monitoring. |
| RDM | Regional Director of Maintenance | Interviewed regarding nutrition room freezer temperature monitoring and grease barrel safety. |
| Administrator | Provided statements regarding medication cart security, grease barrel condition, and hand hygiene. | |
| MS | Maintenance Supervisor | Provided statements regarding grease barrel lock rings. |
| Wound Care Nurse | Observed failing to perform adequate hand hygiene during wound care for Resident #54. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure a safe environment free from accident hazards, specifically related to two residents ingesting pieces of soap contained in donated candy bags.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to ensure the resident environment remained free of accident hazards, leading to two residents ingesting soap pieces from donated candy bags.
Report Facts
Residents affected: 2
Date of survey completed: Jul 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Nursing notes documented Resident #1 and Resident #2's conditions and EMS transfers. |
| The Activity Director | Activity Director | Responsible for opening and verifying donated bags; interviewed about the incident and supervision. |
| The Administrator | Administrator | Interviewed regarding the incident, supervision, and staff responsibilities. |
| The DON | Director of Nursing | Interviewed about staff training, supervision, and awareness of the incident. |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to care planning and food service safety at Cimarron Place Health & Rehabilitation Center.
Findings
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.
Deficiencies (10)
Failed to develop and implement a comprehensive person-centered care plan for Resident #59's fluctuating weights due to edema.
Deep fryer full of odiferous grease and inoperable.
Full-size sheet pan with baked-on brown substances.
Steamer oven leaking water.
Undated food and improperly stored food in dry storage area.
Dirty cups in the clean area.
Unlabeled, unidentified paper bag with food in refrigerator.
Marred Teflon pan hanging on pan rack.
Facility not following a cleaning list.
Ice machine cover broken.
Report Facts
Weight changes: -26
Weight measurements: 153.5
Cleaning list items: 19
Initialed boxes on cleaning list: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON/LVN A | Assistant Director of Nursing / Licensed Vocational Nurse | Responsible for weight system and care planning; acknowledged failure to develop care plan for Resident #59's weight variance. |
| MDS Coordinator B | Minimum Data Set Coordinator | Responsible for care plans; admitted to overlooking development of care plans for Resident #59's edema. |
| DON | Director of Nursing | Provided information on care plan development process and acknowledged missing care plan for weight variance. |
| LVN C | Licensed Vocational Nurse | Interviewed regarding awareness of care plans for Resident #59's weight variances. |
| DM T | Dietary Manager | Interviewed about kitchen deficiencies, cleaning practices, and equipment repair processes. |
| DM B | Dietary Manager | Recently started, created cleaning list, and provided information on kitchen operations. |
| MS | Maintenance Supervisor | Interviewed about equipment repairs and maintenance reporting. |
| ADM | Administrator | Interviewed regarding dietary management staffing and certification. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 24, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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