Inspection·July 8, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few section titled Physical Exam Detail which stated, There Is significant soft tissue swelling with nonpitting edema of the upper and lower lips as well as the tongue and floor of the mouth. Record review of Resident #2's face sheet, dated 07/08/23, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Rhabdomyolysis (breakdown of muscle tissue that releases a damaging protein into the blood), Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), Parkinson's disease ( brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness and difficulty with balance and coordination), and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly.) Record review of Resident #2's Medicare 5 day MDS, dated [DATE], revealed Resident #2 had BIMS score of 12, indicating she had a moderate cognitive impairment. MDS also revealed, Resident #2 required supervision for eating. Record review of Resident #2's care plan, retrieved 07/08/23 with a revised date of 07/05/23 and initiated date of 05/08/23, revealed, Resident #2 has impaired cognitive function/impaired thought processes HX (history) of eating items that appear to (be) food items 7/3/23 bit packaged and labeled soap. Record review of Resident #2's nursing note dated 07/04/23 at 12:08AM by LVN A stated, entered room to find resident lying in bed with swelling to bottom lip. Nursing note also stated, EMS came to transfer resident to local hospital. Record review of Resident #1's emergency room visit notes dated 07/03/23 at 11:23PM revealed a section titled Physical Exam Detail which stated, There Is significant soft tissue swelling with nonpitting edema of the upper and lower lips as well as the tongue and floor of the mouth. LVN A was attempted to be reached via telephone on 07/08/23 at 12:40pm, 1:05PM, 2:21PM and 6:05pm with no answer, and voicemail left detailing who was calling and reason for call. No phone call was returned as of 07/20/23 by LVN A. During an interview with Resident #2 on 07/08/23 at 12:45pm she stated she got a bag of candy and there was a piece of soap that she ate and made her sick. She stated had not been made aware that there was a piece of soap in the bag, she stated it looked like a donut and she ate the entire piece of soap. Resident #2 stated her lips got real big and stated the facility had to call an ambulance. She stated staff took the bag away from her. During an interview on 07/08/23 with The Activity Director at 1:57PM she stated on 07/03/23 residents were given bags with chips and candy donated from a youth group. The Activity Director stated that her department was responsible for opening donated bags or boxes to verify the contents. The Activity Director stated that before handing out the bags on 07/02/23 she went through only 1 bag to verify contents and saw chips and candy in the bag. The Activity Director stated she did not see any donut shaped pieces of soap in the one bag she checked. The Activity Director stated she believed only some bags contained pieces of soap in them. The Activity Director stated any staff member should have been able to verify the contents of the donated bags and stated she did look in 1 bag and assumed they were all the same. The Activity Director stated she was not aware or made aware that there was soap in the bags donated. The Activity Director stated because staff was not aware of soap in bags (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676087 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cimarron Place Health & Rehabilitation Center 3801 Cimarron Corpus Christi, TX 78414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the residents were not made aware either. When asked if any residents had eaten pieces of soap she stated none in her presences but stated she had been made aware that Resident #1 and Resident #2 had an allergic reaction and were sent to the emergency room. The Activity Director stated Resident #1 was so so cognitively impaired and had poor safety awareness. The Activity Director stated she did not know if Resident #1's care plan stated she had impaired thought process due to dementia. When asked if it was safe for Resident #1 to receive a bag the Activity Director stated she only saw chips and candy and nothing hazardous which was okay for Resident #1 to receive. When the Activity Director was asked if Resident #2 was cognitively impaired she stated, I would say with certain things stating that in some situations yes and in others no. The Activity Director stated Resident #2 was not aware of any dangers. The Activity Director stated if she were to look in Resident #2's care plan she's aware it would mention that resident had impaired cognitive function. The Activity Director stated she had previously been trained over preventing accidents and keeping residents free of hazards and stated staff was also in serviced after this incident. The Activity Director stated nursing leadership was responsible for providing the training. The Activity Director was asked how she monitored and supervised residents to prevent accidents and to ensure their environment was free of hazards, The Activity Director stated by making sure residents were free from any items that were hazardous or were a hazard. When the Activity Director was asked what negative impact not appropriately monitoring and supervising residents to ensure they are from hazards could have on the residents, she stated, if you do not then anything can happen. During an interview with Resident #1 on 07/08/23 at 3:39pm when she returned from the hospital Resident #1 stated she thought she had gotten a bag with chips and candy but did not recall a donut, she stated she ate the entire bag and did not get sick. Resident #1 stated she thought she ate something small last week but did not get sick. Resident #1 was unable to recall where she had previously been. During an interview on 07/08/23 at 7:23PM with The Administrator she stated on 07/03/23 residents were provided bags of candy. The Administrator stated she was not aware of anyone checking contents of all bags and stated the Activity Director only checked a couple of bags and did not notice anything in them and assumed the rest were the same. The Administrator was not sure why the Activity Director did not check all the bags. The Administrator stated the Activity Director was responsible for verifying items in bags before handing them out to residents and should have done so. The Administrator stated she was not made aware of pieces of soap in bags and stated she did not know if residents were made aware. The Administrator stated the bags did not contain a piece of soap that looked like a donut but did contain a circular piece of bath soap that was labeled bath soap. The Administrator stated there were 2 residents Resident's #1 and #2 that attempted to eat the soap. The Administrator stated Resident #1 was cognitively impaired, had poor safety awareness and was not able to make her own decisions. The Administrator stated she and staff were aware of Resident #1's care plan stating she had impaired thought process. The Administrator stated Resident #2 was cognitively aware and stated when it came to safety awareness and ability to make her decisions Resident #2 did know it was soap one she took a bite. The Administrator stated she was later made aware by Resident #2's family that she had a history of eating items that look like food. The Administrator stated Resident #1 should not have received on of the bags as it was not safe for her. The Administrator stated she thought Resident #2 was okay to receive bag before she was made aware of her history of eating items that looked like food. The Administrator stated staff was in serviced after the incident and stated her self and DON were responsible for providing training to staff. The Administrator was asked how she monitored and supervised residents to prevent accidents and to ensure their environment was free of hazards, the Administrator stated by making (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676087 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676087 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cimarron Place Health & Rehabilitation Center 3801 Cimarron Corpus Christi, TX 78414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursing rounds, having managers perform rounds to check the environment for safety, going over incident and accident reports during their morning meetings, and checking for any new orders. When the Administrator was asked what negative impact not appropriately monitoring and supervising residents to ensure they are from hazards could have on the residents, she stated, you could have an accident. During an interview on 07/08/23 at 8:19PM with The DON stated she was not aware of what date the bags had been given to residents, stating she was out that day and was made aware after the fact. The DON stated the contents of the bags should have been checked by activities. The DON stated no staff member verified the contents of the bags before handing them out to residents and she did not know why. The DON stated staff should have verified bags before handing the out to residents. The DON stated she was told there was a piece of soap but did not know if staff or residents were made aware previously as she was not working that day. The DON stated there were 2 residents Resident's #1 and #2 that attempted to eat the soap. The DON stated Resident #1 was cognitively impaired, had poor safety awareness and was not able to make her own decisions. The DON stated she and staff were aware of Resident #1's care plan stating she had impaired thought process. The DON stated Resident #2 was cognitively aware, was able to make her own decisions and a still had some safety awareness intact. The DON stated her, and her staff were aware of Resident #2's care plan stating she had impaired cognitive function. The DON stated she was later made aware by Resident #2's family that she had a history of eating items that looked like food. When asked if it was safe for Resident #1 and #2 to receive one of the bags, the DON stated, the majority of items in the bag were fine for them. The DON stated staff had previously been in serviced over incidents and accidents and were also in serviced after the incident. The DON was asked how she monitored and supervised residents to prevent accidents and to ensure their environment was free of hazards, the DON stated by having department heads check rooms in the morning and report back any issues. When the DON was asked what negative impact not appropriately monitoring and supervising residents to ensure they are from hazards could have on the residents, she stated, if they were not monitoring and ensuring things are safe in the building, accidents can happen. The facility did not have any specific policy that contained verbiage regarding the screening and handling of donated items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676087 If continuation sheet Page 4 of 4