Inspection·November 24, 2025

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Norco tablets were delivered to the facility on [DATE].Record review of the packing slip for Resident #1 dated 08/08/25 revealed a card of 60 10mg Norco tablets and a card of 18 10mg Norco tablets were delivered to the facility on [DATE]. Record review of Resident #1's individual narcotic count sheet dated 08/09/25 revealed her discharge home with 60 tablets of hydrocodone 10-325 mg. There were no other narcotic count sheets for the Month of August 2025. Record review of the label on Resident #1's individual patient's narcotic record (count sheet) dated 08/09/25 lists 2 of 2, filled 08/07/25. Written on the sheet was Resident #1 discharged home 08/09/25 60 (tablets). Record review of Police Case Report #2508110071 revealed Officer #13841 contacted the ADM at the time by phone on 08/11/25 at 3:05 pm. The ADM stated on 08/07/25 a resident requested a pain pill and they were unable to locate the medication or the count sheet. He stated he was notified on 08/08/25 at 4:30 pm and after an internal investigation, he reported it to the state on 08/09/25. He stated both nurses working that night underwent a drug test, and both nurses tested positive however, only one was taking medication that could account for the positive result. He stated LVN A admitted to stealing the narcotics and LVN B admitted to purchasing the narcotics from LVN A for $200.00. He stated both nurses have been suspended. No other information. Record review of Resident #1's EHR (electronic health record) indicated she was no longer in the facility, having been discharged home on [DATE]. On 09/30/25 at 10:00 am, 10/01/25 at 3:10 pm, and 10/02/25 at 11:10 am, neither Resident #1 nor her RP responded to multiple attempts for interview via phone messages and email throughout the investigation. Record review of intake # 1029167 had a note that indicated tulip history identified a potential pattern regarding one of the AP's (alleged perpetrator). The reference was to LVN A at another facility. In an interview with RN K on 09/30/2025 at 3:09 pm, he said he identified the drug diversion involving Resident #1. He said Resident #1 had requested her Norco for pain, and when he went to get it, he did not find the card or the sheet in the binder or the medical records. He said he medicated Resident #1 with Norco he could get from the facility's emergency box. He said that was when he reported it to ADON F, ADON/LVN D, and DON J (at the time). He said over the next few days, several in-services were conducted regarding narcotics, counting, and reporting suspicion. He said DON H implemented a new way of documenting that followed best practices for documentation that included signing out narcotics on the computer and in the binder at the same time, and verifying the morning counts with the rest of the days. He said the verification sheets were for the whole week. In an interview with ADON F on 09/30/2025 at 2:00 pm, she said when RN K came in to work on 08/08/25, he discovered the missing narcotic and the missing count-down sheet for Resident #1. ADON F said she immediately called DON J (at the time), and the nurses were drug tested. ADON F said LVN B told her in the testing room that LVN A did it (stole the narcotic). She said LVN A and LVN B were suspended immediately after their drug tests were collected. She said RN K tested negative, but LVN A tested positive. She said LVN B's drug test was negative. ADON F said the amount was exactly what was missing (23). In an interview with ADON/LVN D on 09/30/2025 at 3:56 pm, she said RN K told her and ADON F Resident #1 was asking for her pain medication (Norco) and she did not have a blister pack or sign-out page. She said she called the pharmacy, and that was when they discovered Resident #1 should have had plenty of Norco left and they had been re-ordered that night by LVN A. She said she and DON J interviewed LVN A and said she told them she did not know where the sheet was and thought RN K had pulled it (indicating there were no more pills in the package). She said LVN B was taken to the office in front of DON J, herself, and ADON F, and LVN B told them she bought the Norco from LVN A, who said they belonged to her relative #3. LVN B told them LVN A popped them from a blister pack into a specimen cup at the facility, and that was how she received them. ADON/LVN D said LVN B told her she bought 23 pills for $200.00. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676087 If continuation sheet Page 2 of 5 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 11/24/2025 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)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She said LVN B was told to go home and get the pills and bring them back, then she never returned. ADON/LVN D said LVN B called the facility and told them she was not returning. ADON/LVN D said both were suspended and neither of them had come back. She said in-services and full audits were done on all six med carts. She said there were 3 nurse carts and 3 CMA carts. She said the new DON H implemented counting all the blister packs to the med sheets. She said before, they only looked at the number on the blister packs, and not how many blister packs there were. Now they match each blister pack with its own count sheet and its contents to each med sheet. In a phone interview with LVN A on 10/02/2025 at 9:50 am, she said on 08/08/25, someone told her Resident #1 wanted pain medicine. She said when she went to get it (Norco), there was no sheet or card, so she re-ordered it. She said DON J said everyone had to test because the card and count sheet were gone. She said she was called to the office because her drug test was positive. She said she did not think the medication was missing, it just wasn't there. She said the nurses were responsible for the narcotic sheets. She said the narcotic sheets were not in the bins. She said the last medication given should have been with the (empty) blister pack in the bin, but there was nothing there for Resident #1. She said she assumed Resident #1 had run out of the medication, so she called in the refill on 08/08/25. She said she worked Monday through Friday on the 2p-10p shift, and medicated Resident #1 the day before, but could not remember how many pills were in the blister pack. She said DON J told her there were over 50 Norco's not clicked out by her. She said DON J kept asking her about the narcotic sheet, but it was not there, it was not in the binder. She said they narrowed the missing Norco down to her and LVN B. She said ADON F told her LVN B showed them a screenshot from herself (LVN A) about her getting medication for LVN B, but the message was from Relative #3. She said the text message was about Norco. She said Relative #3 had a prescription for Norco but did not take them anymore. She said Relative #3 was using her as a middle person to get the Norco to LVN B. She said she did not know if LVN B ever got the drugs, then said Relative #3 told her LVN B never got the drugs. She said the screenshot she sent to LVN B was from Relative #3 and she gave LVN B Relative #3's phone number so they could do whatever they were going to do. She said there was no talk of money exchanged with her. In a phone interview with DON J on 10/02/2025 at 10:40 am, she said her last day of work at the facility was Friday, 08/08/25. She said on Friday, 08/08/25, near the end of shift, RN K went to ADON F to inform her that he could not find Resident #1's Norco, and it was not in the med cart. She said she asked RN K if it was possible Resident #1's blister pack had been exhausted. She said RN K said no, because he gave it yesterday to Resident #1, and she got it nearly the same time daily. DON J said she and RN K looked through all the carts & binders but found no blister pack or count sheet for Resident #1. She said at that time, she called the interim ADM and was told to begin drug testing. She said she and ADON F split up staff and LVN B went with ADON F. She said ADON F told her that LVN B said it was LVN A. DON J said she called LVN B to her office and was told it was LVN A, because LVN A offered to sell her 22-25 Norcos, and LVN A had been texting her about the deal. DON J said LVN B went on to say, she bought them (the pills) and they were at her house. DON J said they (ADON F and herself) sent LVN B home to get them. She said around 20 minutes later, LVN B called ADON F and told her she was not returning. DON J said at that time, we brought LVN A into her office and had to suspend her. DON J said LVN A refused to sign the counseling form. DON J said LVN A refused to write a statement at that time and told her she would do it at home and email it, but that never happened. She said she did not know how or when LVN A was terminated or quit. Attempts to contact LVN B for an interview were made on 10/01/25 at 5:30 pm, 10/01/25 at 6:30 pm, and 10/02/25 at 11:30 am. None of the calls were answered, and voice messages with a callback number were left on all attempts. In an interview with CMA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676087 If continuation sheet Page 3 of 5 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 11/24/2025 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)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few G on 09/30/25 at 12:28 pm, she said there was an in-service around the time of the incident, including counting medications and new sheets to ensure all drugs were reconciled, as well as the narcotics. She said the narcotics were counted, and there was a sheet for every blister pack that also got counted. She said, Now they count the sheets and the blister packs. She said the nurses were the only ones allowed to give any PRN medications. In an interview with LVN E on 09/30/2025 at 3:25 pm, she said in-services, and a new narcotic sign-out process was introduced to ensure there was a sign-out sheet for each bubble pack. She said they were now counting the pills, the number of blister packs, and the number of sheets at the beginning and end of every shift. In an interview with DON H on 09/30/2025 at 12:58 pm, she said she formulated a spreadsheet to audit narcotics regularly. She said she implemented a new controlled substance/MAR change of shift audit on 09/23/25 that combined everything except the individual resident's narcotic record because that was kept on file. In an interview with CMA L on 09/30/2025 at 1:30 pm, she said DON H implemented a new spreadsheet for auditing the drugs in the carts a couple of weeks ago. She said there was an in-service around the time of the incident. She said the in-service was about counting medications and how to use the new sheets to ensure all drugs were reconciled. She said now they count the sheets and the blister packs. In an interview with the ADM on 10/02/2025 at 8:34 am, she said she was not at the facility at the time of the incident, and there was an interim ADM (unavailable). She said the facility was implementing increased pharmacist audits if concerns arose, as well as regular quarterly and monthly visits. She said department heads were now checking the narcotic counts at the carts with the nurses instead of just looking at the binder, which only contained the signatures. She said she received a phone call from regional that 2 nurses, LVNs A and B were suspended for drug diversion during the investigation and then were terminated. She said a sergeant from the Office of the Attorney General had already been to the facility, but she did not know what his findings were and provided a contact number. Record review of an email between the ADM and pharmacy dated 10/02/25 revealed, I listened to the call, and the nurse did not state her name when she was requesting a refill for Resident #1's Norco. However, we have identified her name from her phone number. The call is attached above. The nurse's name is [LVN A]. In an interview with DON H on 10/02/2025 at 10:30 am, she said she completed full audits of all narcotics on 08/09/25. She said on 10/01/25, she audited LVN A's MARs for July 2025 and August 2025, which revealed 27 instances of undocumented 10mg Norco for Resident #1 in July and 11 instances of 10mg Norco in August. She said she audited all medication carts daily for 4 weeks (08/09/25-09/06/25), then weekly. Record review of all staff in-services:-08/08/25-counting narcotics, documenting the count, verifying the morning counts with the rest of the days, signing out the computer & binder at the same time, resident rights, reporting suspected abuse, neglect, and misappropriation.- 08/19/25-MARS and TARS (treatment administration record), documentation, weekly skin checks, charting on antibiotics and incidents, change of conditions, point of care CNA documentation.- 09/23/25-new controlled substance and MAR change of shift audit sheets, verify the morning counts with the rest of the days. Record review of DON H's daily and weekly drug audits dated 08/09/25-10/01/25 revealed consistent auditing with no identified concerns. In an interview with the ADM on 10/02/25 at 3:00 pm, she said she had tried to call the interim ADM and the sergeant at the OAG as well, yesterday and today, but was unable to reach either of them. Record review of the Facility policy dated December 2012, titled Controlled Substances, revealed 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Record review of the facility policy dated October 2014, titled Discarding and destroying Medications, revealed 11. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676087 If continuation sheet Page 4 of 5 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 11/24/2025 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)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Completed medication disposition records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records. 13. Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for a medication. Record review of the facility policy dated December 2009, titled Reporting Abuse to Facility Management. Policy statement: It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Under policy interpretation: 1. Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2h. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Event ID: Facility ID: 676087 If continuation sheet Page 5 of 5