Inspection·May 14, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to update Resident #1's care plan with the DNR code status after the OOH DNR order was signed by all appropriate parties on [DATE]. This failure could place residents at risk of receiving care out of line with their wishes. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female with an initial admission date of [DATE] and a current admission date of [DATE]. Pertinent diagnosis included Unspecified Dementia (dementia without a specific diagnosis or a diagnosis that is not yet known). Resident #1 was discharged on [DATE] due to death. Record review of Resident #1's PPS MDS assessment dated [DATE] revealed a BIMS score of 0 (severe impairment). Record review of Resident #1's comprehensive care plan dated [DATE] revealed the focus [Resident #1] wishes to have CPR performed should the need arise initiated on [DATE] and cancelled on [DATE]. The goal listed for this focus included Resident, family, surrogate will have wishes respected initiated on [DATE] and cancelled on [DATE]. Interventions listed for the focus included: -Ensure chart is properly identified initiated on [DATE] and cancelled on [DATE]. -If resident has no pulse or respirations, initiate CPR initiated on [DATE] and cancelled on [DATE]. Record review of Resident #1's order summary revealed a discontinued order for DNR initiated on [DATE] and ended on [DATE]. Record review of Resident #1's OOH DNR order revealed the document was signed by Resident #1's RP and two non-staff witnesses on [DATE]. The document was signed by the physician on [DATE]. In an interview with LVN A on [DATE] at 9:27 AM, LVN A stated if she did not know a resident's code (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676087 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 05/14/2025 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)