Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cimarron Place Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found a 300 Hall nurse med-cart parked at the nurses' station with the lock popped and all drawers except the narcotic drawer accessible, while no staff were present and multiple residents were nearby. An unlabeled and undated tube of Permethrin cream was also found in the cart, contrary to the facility’s medication storage policy requiring proper labeling and locked compartments when not in use. The LVN responsible for the cart admitted she had walked away without locking it, and both the ADON and DON stated that nurses were responsible for checking carts each shift for unlabeled medications and for keeping med-carts locked, consistent with facility policy.
A resident's prescribed narcotic pain medication was diverted and sold by an LVN to another LVN for personal use, after the medication and its count sheet went missing. The incident was discovered when a nurse could not locate the medication during a pain request, leading to an internal investigation and suspension of the involved staff. Required procedures for narcotic counts and documentation were not followed, resulting in the misappropriation.
A resident did not receive safe and appropriate administration of IV fluids when needed, as the facility failed to follow required protocols for IV fluid administration.
A resident with severe cognitive impairment and a history of multiple recent falls was found without required fall mats on both sides of the bed, as specified in the care plan. Staff interviews revealed inconsistent understanding and implementation of fall prevention responsibilities, and documentation showed no current physician order or recent fall risk assessment for the resident.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition at the time.
A medication cart was found unlocked and unattended near the nurse's station, with multiple medications in bulk bottles and blister packs easily accessible. An RN responsible for the cart admitted to forgetting to lock it after retrieving items and going to chart, despite regular in-servicing and oversight by the DON. Facility policy requires all medication storage compartments to be locked when not in use, but this protocol was not followed.
A resident with severe dementia and a newly signed OOH DNR order did not have their care plan updated to reflect the change in code status. Despite the DNR order being properly signed and entered into the chart, the care plan continued to indicate that CPR should be performed, and interventions were not revised. Staff interviews confirmed that the care plan should have been updated to match the resident's current wishes, but this did not occur.
A resident with severe cognitive impairment and multiple medical conditions exhibited ongoing behaviors such as yelling, banging, and throwing items, and was at risk for falls, requiring a fall mat. However, the care plan did not address these behaviors or the use of the fall mat, despite staff awareness and facility policy requiring such interventions to be documented and updated as resident needs changed.
A resident with multiple complex diagnoses was sent to the hospital for a CT scan, but staff failed to document the transfer or the physician's order in the medical record. The LPN responsible did not enter a progress note or order, and the DON confirmed that no documentation was made for the verbal order or the transfer, contrary to facility policy requiring immediate recording of such events. The administrator recognized the importance of this documentation for continuity of care.
A resident did not receive the correct dose of Pramipexole as prescribed, due to a medication aide administering only 1 tablet instead of the prescribed 2 tablets. This failure to follow the facility's medication administration policy was observed and confirmed through record review and staff interviews.
A medication aide left a medication cart unlocked and unattended while administering medication to a resident, violating the facility's policy on medication storage. The Administrator, ADON, and DON confirmed that medication carts should always be locked to prevent unauthorized access and ensure resident safety.
The facility failed to maintain proper food storage practices in the nutrition room, specifically regarding the freezer. The freezer lacked a thermometer and a temperature log, and it was not monitored daily as required. Interviews revealed a lack of awareness and adherence to regulations mandating the maintenance and monitoring of temperature-controlled equipment.
A facility failed to maintain an effective infection control program, as a nurse did not perform proper hand hygiene and exposed a resident's wound to an unclean surface during care. The resident had multiple stage 3 pressure ulcers, and the nurse's actions could lead to cross-contamination and infection. Interviews confirmed the importance of proper hand hygiene and preventing cross-contamination, highlighting deficiencies in adherence to facility policies.
The facility failed to ensure proper disposal of garbage and refuse, specifically regarding two grease barrels with ill-fitting, rusted, and bent lids and lock rings. Interviews confirmed the difficulty in securing the lock rings due to their condition, and the facility's policy mandates that all garbage containers must have tight-fitting lids. This failure could place residents at risk of infection from improperly disposed garbage.
Unlocked Medication Cart and Unlabeled Medication on 300 Hall
Penalty
Summary
Surveyors identified a deficiency related to medication labeling and storage on the 300 Hall nurse medication cart. During an observation at the nurses' station, the 300 Hall med-cart was found parked and unlocked, with the cart lock popped out and all drawers accessible except the narcotic drawer. There were no staff present at the cart, and multiple residents were seated in the nearby open area. Additionally, an unlabeled and undated tube of Permethrin cream, a topical medication used to treat scabies, was found in the cart. The facility’s Storage of Medications policy stated that drugs and biologicals must be stored in their original packaging, containers with proper labels, and that drug containers with missing or improper labels must be returned to the pharmacy for proper labeling. The policy also required all compartments containing drugs and biologicals, including carts, to be locked when not in use. In an interview, the LVN assigned to the 300 Hall med-cart acknowledged that the cart belonged to her and admitted she had not realized it was unlocked when she walked away briefly to get something. She stated she knew she was not supposed to leave the cart unlocked when away from it. The ADON reported that it was the responsibility of the nurse using the cart to check each shift for expired or unlabeled medications and confirmed that nurses were expected to lock their med-carts when they walked away. The DON similarly stated that nurses knew not to leave medication carts unlocked and that they had been in-serviced previously on locking carts and checking for expired or unlabeled medications. Despite these expectations and prior in-servicing, the cart was left unlocked and contained an unlabeled medication, in direct conflict with the facility’s written policy and accepted professional standards for medication storage and labeling.
Misappropriation of Resident Narcotics by Nursing Staff
Penalty
Summary
The facility failed to ensure a resident's right to be free from misappropriation of property, specifically regarding the diversion of 23 Hydrocodone-Acetaminophen 10 mg tablets. The incident involved two LVNs, where one LVN diverted and sold the resident's prescribed narcotic medication to another LVN for personal use. The misappropriation was discovered when a nurse was unable to locate the resident's pain medication or the associated count sheet after the resident requested her PRN pain medication. The nurse then medicated the resident from the facility's emergency supply and reported the missing medication to facility leadership. The resident involved was an older adult admitted for a left hip device dislocation, with a history of pain requiring opioid medication, frequent incontinence, and moderate to substantial assistance needed for daily activities. The resident's care plan included interventions to manage pain and monitor for complications related to her surgical wound. Despite these interventions, the resident's prescribed pain medication was diverted, and the medication count and documentation were not properly maintained, leading to the discovery of the missing narcotics. Interviews and record reviews revealed that the two LVNs involved were suspended after drug testing and internal investigation. One LVN admitted to stealing the narcotics, while the other admitted to purchasing them for personal use. The facility's policies required end-of-shift narcotic counts and proper documentation, but these procedures were not followed, resulting in the misappropriation of the resident's medication.
Failure to Ensure Safe IV Fluid Administration
Penalty
Summary
A deficiency was identified regarding the administration of IV fluids to a resident. The facility failed to ensure the safe and appropriate administration of IV fluids when needed for a resident. This indicates that the necessary protocols or procedures for IV fluid administration were not followed or implemented at the time the resident required this intervention.
Failure to Ensure Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards and did not provide adequate supervision and assistance devices as required by the resident's care plan. Specifically, on 06/24/2025, a resident with severe cognitive impairment, left-sided weakness, and a history of multiple recent falls was observed without a floor mat on both sides of the bed, as indicated in the comprehensive care plan. The care plan, initiated on 03/27/2025, required fall mats at the bedside due to the resident's high risk for falls. Despite this, only one mat was present during the survey observation, and there was no current physician order for fall mats or a recent fall risk assessment documented prior to the survey. Interviews with staff revealed a lack of awareness and inconsistent understanding of responsibilities regarding fall mat placement. A CNA who had recently started employment was unaware that a mat was missing, and another CNA stated that all staff were responsible for ensuring mats were in place, but ultimately the charge nurse was accountable. The ADON confirmed that nurses were responsible for correct mat placement and that all staff should check for mats when entering the room. Training on fall prevention varied among staff, with some having received it only at hiring or within the past month. The facility's Fall Prevention Program Policy required staff and physicians to identify and implement interventions to prevent falls, but these were not consistently followed for this resident.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart located by the nurse's station was found unlocked and unattended during an observation. The surveyor was able to open the top drawer and noted that multiple medications in bulk bottles and blister packs were easily accessible. The registered nurse (RN) responsible for the cart was sitting behind the nurse's station and acknowledged responsibility for the unlocked cart. The RN stated that the cart should be locked at all times to prevent unauthorized access but admitted to forgetting to lock it after retrieving items and then going to chart at the nurse's station. Interviews with the RN and the Director of Nursing (DON) confirmed that staff are regularly in-serviced on the requirement to keep medication carts locked when not in use, and that the DON makes frequent rounds to ensure compliance. A review of the facility's Storage of Medications policy also reflected the requirement for all compartments containing drugs and biologicals to be locked when not in use. Despite these policies and procedures, the medication cart was left unlocked and unattended, making medications accessible to unauthorized individuals.
Failure to Update Care Plan with DNR Status
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes to meet the needs of a resident. Specifically, after an Out-of-Hospital Do Not Resuscitate (OOH DNR) order was signed by all appropriate parties, the resident's care plan was not updated to reflect the new DNR code status. The care plan continued to indicate that the resident wished to have CPR performed, and the interventions listed were not revised to align with the updated DNR order. Multiple staff interviews confirmed that the care plan should have been updated to reflect the resident's current code status, and that failure to do so could result in care that does not align with the resident's wishes. The resident involved was an elderly female with a diagnosis of unspecified dementia and a severely impaired BIMS score of 0. She was ultimately discharged due to death. Record reviews showed that the DNR order was properly signed and entered into the resident's chart, but the care plan was not updated accordingly. Staff interviews revealed that updating the care plan with the correct code status was a shared responsibility among the social worker, MDS nurse, and nursing staff, but in this instance, the update did not occur. The facility's policy required that the care plan reflect the resident's expressed wishes regarding care and treatment goals, which was not followed in this case.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Behavioral and Fall Risks
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including traumatic subdural hemorrhage, hemiplegia, muscle wasting, unsteadiness, cognitive communication deficit, type 2 diabetes, unspecified dementia, cerebral infarction, and chronic kidney disease. Despite documentation and staff interviews confirming the resident exhibited behaviors such as yelling, banging on the bed or table, throwing items, and removing her brief since admission, these behaviors were not included in the resident's care plan. The care plan also omitted the use of a fall mat, which was in place due to the resident's history of falls and risk factors, even though the fall mat was used as an intervention during her stay. Interviews with facility staff, including the MDS nurse and DON, confirmed awareness of the resident's behaviors and the use of a fall mat, but these interventions were not documented in the care plan. The facility's policy requires that care plans incorporate identified problem areas, risk factors, and interventions, and be updated as resident conditions change. The omission of both behavioral interventions and the fall mat from the care plan represents a failure to ensure that all of the resident's needs were addressed through measurable objectives and timetables as required by facility policy.
Failure to Document Hospital Transfer and Physician Order for CT Scan
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was sent to the hospital for a CT scan. Specifically, there was no documentation in the resident's medical record regarding the transfer to the hospital for the CT scan, nor was there a physician's order for the procedure recorded. The resident in question had a complex medical history, including traumatic subdural hemorrhage, hemiplegia, muscle wasting, unsteadiness, cognitive communication deficit, type 2 diabetes, unspecified dementia, cerebral infarction, and chronic kidney disease. The resident also had severe cognitive impairment as indicated by a BIMS score of 7. Interviews with staff revealed that the nurse responsible for the resident's care on the day of the transfer did not document a progress note about the CT scan or the transport, citing workload and the need to cover two halls. The previous nurse had left due to a personal emergency and had not documented either. The DON confirmed that the CT scan was ordered verbally by the physician and communicated to the hospital staff, but no order was entered into the resident's chart. The DON also stated that it was not their practice to document such orders or progress notes for in-and-out procedures, and that documentation was typically only completed when the resident returned from the hospital, which did not occur in this case. Facility policies reviewed indicated that verbal orders must be recorded immediately in the resident's chart and that all services provided, as well as changes in the resident's condition, should be documented to facilitate communication among the care team. The administrator acknowledged that documentation of the order and the resident's transfer was necessary for continuity of care and to ensure follow-up on test results, but this was not done in this instance.
Failure to Administer Correct Medication Dose
Penalty
Summary
The facility failed to administer the correct dose of Pramipexole to a resident, leading to a deficiency in pharmaceutical services. Specifically, a medication aide (MA) administered only 1 tablet of Pramipexole 0.125mg instead of the prescribed 2 tablets (0.25mg) to a resident with diagnoses including atrial fibrillation, chronic pain syndrome, restless leg syndrome, and end-stage renal disease. The resident's comprehensive MDS indicated no cognitive impairment, with a BIMS score of 15. The error was observed during a medication administration session and confirmed through record review and interviews with the MA, DON, and ADON. The facility's policy on administering medications, which requires checking the label three times to verify the correct resident, medication, dosage, time, and route, was not followed. Interviews with the MA, DON, and ADON highlighted the potential risks of administering incorrect medication doses, including the lack of therapeutic benefits and possible adverse reactions. The facility's failure to adhere to its medication administration policy resulted in the resident not receiving the prescribed dose of Pramipexole, which could impact the resident's treatment for Parkinson's disease.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys. During a medication administration observation, a medication aide (MA B) left the 500 Hall medication cart unlocked and unattended while entering a resident's room to administer medication. Although there were no residents in the hallway at the time, this action violated the facility's policy on medication storage and posed a risk of unauthorized access to medications. In interviews, MA B acknowledged the mistake, stating that she became nervous and forgot to lock the cart. The Administrator, Assistant Director of Nursing (ADON A), and Director of Nursing (DON) all confirmed that medication carts should be locked at all times when not in use to prevent drug diversion and ensure resident safety. The facility's policy on the storage of medications, dated April 2007, also mandates that compartments containing drugs and biologicals must be locked when not in use and should not be left unattended if open or otherwise potentially available to others.
Failure to Maintain Proper Food Storage Practices
Penalty
Summary
The facility failed to maintain proper food storage practices in the nutrition room, specifically regarding the freezer. During an observation, it was noted that the freezer did not have a thermometer, and there was no temperature log for monitoring. Interviews with the LVN and DON revealed that the night shift was responsible for logging freezer temperatures, but no log was found. The DON acknowledged the absence of a thermometer and a freezer log, and admitted that the freezer was not being used, but also recognized that a malfunction in the freezer could affect the refrigerator. The RDM confirmed that the nursing staff was responsible for checking and logging temperatures, but admitted that the freezer had not been monitored daily as required. Further interviews with the ADM revealed a lack of awareness regarding the regulation that mandates the maintenance and monitoring of all temperature-controlled equipment. The facility's policy on food receiving and storage, which requires the monitoring of refrigeration and food temperatures at designated intervals, was not being followed. This lapse in protocol could potentially lead to foodborne illnesses among residents due to improper food storage conditions.
Inadequate Hand Hygiene and Wound Care Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of the Wound Care Nurse during the care of a resident with multiple stage 3 pressure ulcers. The nurse did not perform hand hygiene for the recommended 20 seconds or greater on multiple occasions, with handwashing times ranging from 5 to 15 seconds. Additionally, the nurse exposed the resident's wound to an unclean surface, which could lead to cross-contamination and infection. These actions were observed during the wound care process for the resident's left lateral heel, left lateral calf, and right lateral foot wounds. The resident involved was an elderly male with a history of cerebral ischemia, atrial fibrillation, and hypertension. The resident had multiple stage 3 pressure ulcers with specific treatment orders for each wound. During the wound care observation, the nurse failed to adhere to proper hand hygiene protocols and allowed the resident's wound to come into contact with the mattress, which was not cleaned. The nurse admitted to being nervous and miscounting the handwashing duration, despite recent in-service training on hand hygiene. Interviews with the Wound Care Nurse, Administrator, ADON, and DON confirmed the importance of proper hand hygiene and preventing cross-contamination during wound care. The facility's policies on hand hygiene and infection control emphasize the need for thorough handwashing and maintaining a safe, sanitary environment to prevent the spread of infections. However, the observed deficiencies in hand hygiene practices and wound care procedures indicate a failure to adhere to these policies, potentially putting residents at risk for healthcare-associated infections.
Improper Disposal of Grease Barrels
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, specifically regarding two grease barrels. Observations revealed that the barrels were partially full, with ill-fitting, rusted, and bent lids. The lock rings, which are supposed to secure the lids, were found on the ground near the barrels and were also bent and rusted. Interviews with the RDM, MS, and ADM confirmed that there was no regulation in place for the oil barrel rings, and the difficulty in securing the lock rings due to their condition was acknowledged. The ADM stated that the lids and lock rings were very hard to place on the barrels because they were bent and rusted, and she was in the process of having them replaced. The facility's policy on food-related garbage and rubbish, revised in December 2008, mandates that all garbage and rubbish containers must have tight-fitting lids or covers and must be kept covered when stored or not in continuous use. The failure to adhere to this policy could place residents at risk of infection from improperly disposed garbage. The MS admitted that the lock rings were supposed to be on the barrels at all times except when pouring old grease into them, and acknowledged the environmental hazard posed by the potential spillage of grease, which could attract rodents and cause cross-contamination.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mirador | 0.8 mi | — | 0 | 0 |
| Corpus Christi Nursing And Rehabilitation Center | 1.2 mi | — | 2 | 0 |
| Wooldridge Place Nursing Center | 1.8 mi | — | 10 | 0 |
| The Palms Nursing & Rehabilitation | 2.9 mi | — | 37 | 0 |
| San Rafael Nursing And Rehabiliation | 5.3 mi | — | 8 | 1 |
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