Cimarron Place Health & Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF697Jul 20, 2025

  Based 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.The findings include:1. […]

• No harm, potential for more than minimal, patternF694Jun 26, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF812Mar 9, 2023

  Based 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… […]

• No harm, potential for more than minimal, patternF812Jan 6, 2022

  Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1.The ice machine in the kitchen had a grayish black substance on the inside of the machine above the ice chute. 2. An employee's cell phone on the meal prep table. These deficient practices could place 72 residents who received meals and snacks from the kitchen and place them at risk for food borne illness. Findings Included: 1. […]

• No harm, potential for more than minimal, isolatedF628Jun 3, 2026

  Based 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.Findings include:Review of Resident #1's face sheet date 6/2/2026 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses that included Dementia (A group of thinking an… […]