Cimarron Nursing Center

In the surveyor’s words

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

• Actual harm, patternF580Aug 17, 2021

  Based on record review, and family and staff interviews, it was determined the facility failed to notify the physician and family of a change in the resident's condition for three (#53, 54 and #164) of three sampled residents reviewed for notification. Resident #164 had an incident and the physician and family were not notified until four days later. The resident had a fractured tibia and fibula. The facility identified 65 residents resided in the facility. Findings: 1. Resident #164 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 05/01/20, documented, .Transfer using overhead lift and assist of 2 person to reduce risk for falls . […]

• Actual harm, patternF600Aug 17, 2021

  Based on record review and resident and staff interviews, it was determined the facility failed to ensure residents were free from physical abuse and neglect. This affected four (#26, 42, 54, and #164) of four sampled residents who were reviewed for abuse/neglect. Resident #42 sustained a [CONDITION(S)] during an improper transfer. This had the potential to affect 65 residents that resided in the facility. Findings: An abuse policy, revised on 01/2018, documented, .It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person . […]

• Actual harm, patternF684Aug 17, 2021

  Based on record review and staff interviews, it was determined the facility failed to ensure: ~ residents were assessed/monitored after an accident. This affected two (#54, and #164) of three sampled residents who were reviewed for falls/accidents; This resulted in resident #164 sustaining a tibia/fibula fracture. ~residents were assessed/monitored and interventions placed for residents with hypertension, change of condition and notification. This affected one (#54) of three sampled residents whose clinical records were reviewed for changes of condition; ~a resident's venous wound was monitored and treatment provided as ordered for one (#214) of three sampled residents reviewed for wounds; and ~assess/monitor and intervene for finger stick blood sugars for one (#114) of five sampled… […]

• Actual harm, patternF689Aug 17, 2021

  Based on record review and staff interviews, it was determined the facility failed to ensure proper transfers were completed for three (#42, 54 and #164) of three sampled residents who were reviewed for accidents. Resident #164 was improperly transferred which resulted with the resident's tibia and fibula being fractured. The facility identified 65 residents who resided in the facility, ten residents who transferred with a Hoyer lift and three residents who transferred with a sit to stand. […]

• No harm, potential for more than minimal, widespreadF563Aug 17, 2021

  Based on observation, record review, resident, family and staff interviews, it was determined the facility failed to ensure a resident's right to receive unrestricted visitation for seven (#12, 26, 39, 48, 49, 53 and #63) of seven residents and a confidential resident council interview reviewed for visitation. The facility identified 65 residents who resided in the facility. Findings: A visitation policy, dated 03/29/21, documented, .To allow visitation to occur between Residents and outside personnel (family, friends) in a safe manner following designated infection control manners in a controlled environment .Policy .will allow visitation to Residents of our community following the guidelines set forth by CDC [Centers for Disease Control and Prevention] and the Department of Health and… […]