F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to perform a preadmission screening for
individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 of 11
residents (Resident #51) reviewed for PASRR requirements.
Residents Affected - Few
The facility failed to ensure Resident #51 had a PE after having a positive PL1 on 02/16/22.
This failure could place residents with an MI, ID or DD at risk for not receiving PASRR related services, if
qualified.
The findings include:
Record review of Resident #51's face sheet, dated 11/28/22, revealed an [AGE] year-old male admitted to
the facility initially on 08/09/21 with diagnoses that included, but were not limited to, unspecified dementia,
unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety,
painful micturition (urination) and dysphagia (difficulty swallowing food or liquid).
Record review of Resident #51's annual MDS assessment, dated 07/30/22, revealed, Preadmission
Screening and Resident Review (PASRR) . Is the resident currently considered by the state level II PASRR
process to have serious mental illness and/or intellectual disability or a related condition? .No.
Record review of Resident #51's quarterly MDS assessment, dated 09/12/22, revealed a BIMS score of 6
out 15 which indicated his cognition was severely impaired. He required extensive two-person assistance
with bed mobility, total two-person dependence with transferring, total one-person dependence with
dressing, toilet use and personal hygiene and extensive one-person assistance with eating.
Record review of Resident #51's care plan, revised 11/16/22, revealed no documentation regarding PASRR
status or services received.
Record review of Resident #51's PASRR Level 1 Screening, dated 02/16/22, revealed, in part, .Mental
Illness .Is there evidence or an indicator this is an individual that has a Mental Illness? with a 1 typed in the
box which indicated, Yes. The screening revealed it was completed by a behavioral health facility. The
screening also revealed .NF Date of Entry 2/16/22.
Record review of Resident #51's electronic chart did not reveal documentation a PE was completed after
the PASRR Level 1 Screening on 02/16/22.
(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 8
Event ID:
675117
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
675117
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Runningwater Draw Care Center Inc
800 W 13th St
Olton, TX 79064
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 0645
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an observation and attempted interview on 11/28/22 at 3:11 PM, Resident #51 was in his room, in a
wheelchair. He was well-groomed and dressed for the day. Resident #51 was observed talking to staff in his
room and had told them he was fine. When this surveyor entered his room after the staff members left,
Resident #51 did not open his eyes or otherwise respond to any interview questions.
During an interview on 11/29/22 at 11:05 AM, the DON stated she was responsible for submitting PASRR
information. She stated she started as the DON in June 2022 and took over PASRR duties from then, it was
previously the responsibility of the prior DON. She stated Resident #51 was sent to a behavioral health
facility in February 2022, and they completed the PASRR Level 1 Screening. She stated Resident #51 did
not have a PE, she did not see that one was submitted in the program she used to submit PASRR
information. The DON stated Resident #51 should have had a PE. She stated she thought a PE might not
have been submitted due to Resident #51 having a negative PL1 already when he was initially admitted ,
but she saw where he had a diagnosis of recurrent depressive disorder from the behavioral health facility.
She stated she did receive PASRR training regarding submitting PL1's only. The DON stated by not
submitting a PE after a resident had a positive PL1, the resident could have not received services from
PASRR that could have been offered to him.
Record review of a facility policy titled, Nursing Facility PASRR Responsibility Checklist, dated May 23,
2017, revealed, in part, Referring Entities and PL1s .Communicate with the LIDDA/LMHA to make sure that
all active positive PL1s have a completed PE and that a copy of the PE is in the individual's file.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675117
If continuation sheet
Page 2 of 8
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
675117
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Runningwater Draw Care Center Inc
800 W 13th St
Olton, TX 79064
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 0656
Level of Harm - Potential for
minimal harm
Residents Affected - Some
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
interview and record review, the facility failed to develop and implement a comprehensive person-centered
care plan for each resident that included the resident's preference and potential for future discharge,
whether the resident's desire to return to the community was assessed, any referrals to local contact
agencies and/or other appropriate entities or discharge plans, as appropriate for 11 of 11 residents
(Resident #4, Resident #5, Resident #11, Resident #18, Resident #35, Resident #39, Resident #50,
Resident #51, Resident #55, Resident #57, Resident #116) reviewed for comprehensive care plans.
The facility failed to ensure Resident #4, Resident #5, Resident #11, Resident #18, Resident #35, Resident
#39, Resident #50, Resident #51, Resident #55, Resident #57, and Resident #116's care plans contained
the resident's preference and potential for future discharge, whether the resident's desire to return to the
community was assessed, any referrals to local contact agencies and/or other appropriate entities or
discharge plans.
This failure could place all residents at risk for not having their discharge preferences known.
The findings include:
Record review of Resident #4's face sheet, dated 11/29/22, revealed an [AGE] year-old female admitted to
the facility on [DATE], readmitted on [DATE], with diagnoses that included, but were not limited to,
unspecified dementia with behavioral disturbance, dermatitis (skin conditions characterized by red, itchy
rashes), and edema (swelling).
Record review of Resident #4's most recent comprehensive MDS assessment, an admission MDS
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .Yes .Resident's Overall Expectation .
Select one for resident's overall goal established during assessment process . Unknown or uncertain .
Indicate information source . Resident . Discharge Plan . Is active discharge planning already occurring for
the resident to return to the community? .No . Return to Community . Ask the resident .Do you want to talk
to someone about the possibility of leaving this facility and returning to live and receive services in the
community? .No . Has a referral been made to the Local Contact Agency .No.
Record review of Resident #4's care plan, revised 11/09/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #5's face sheet, dated 11/29/22, revealed a [AGE] year-old female admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia,
unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety,
chronic periodontitis (gum infection that damages the soft tissue), abnormalities of gait (manner of walking)
and mobility, edema, weakness, reduced mobility, hypertensive chronic kidney disease with stage 1 through
stage 4 chronic kidney disease (damage to the kidney due to chronic high blood pressure), heart failure,
peripheral vascular disease (disease affecting the blood vessels), obstructive sleep apnea (hoarse or harsh
sound from nose or mouth that occurs when breathing is partially obstructed), type 2 diabetes, major
depressive disorder, recurrent, hypertension and atrial
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675117
If continuation sheet
Page 3 of 8
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
675117
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Runningwater Draw Care Center Inc
800 W 13th St
Olton, TX 79064
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 0656
fibrillation (irregular heart rhythm).
Level of Harm - Potential for
minimal harm
Record review of Resident #5's most recent comprehensive MDS assessment, an annual MDS assessment
dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting, Participation in
Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge planning
already occurring for the resident to return to the community? .No . Return to Community . Ask the resident
.Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive
services in the community? .No . Has a referral been made to the Local Contact Agency .No.
Residents Affected - Some
Record review of Resident #5's care plan, revised 09/20/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #11's face sheet, dated 11/29/22, revealed a [AGE] year-old male admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, hyperlipidemia (is abnormally
elevated levels of any or all lipids or lipoproteins in the blood), anemia (lack enough healthy red blood cells
to carry adequate oxygen to the body's tissues), abnormalities of gait and mobility, weakness, hemiplegia,
unspecified affecting left nondominant side (paralysis of one side of the body), legal blindness, and edema.
Record review of Resident #11's most recent comprehensive MDS assessment, an annual MDS
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge
planning already occurring for the resident to return to the community? .No . Return to Community . Ask the
resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live
and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.
Record review of Resident #11's care plan, revised 10/21/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #18's face sheet, dated 11/29/22, revealed an [AGE] year-old male admitted to
the facility on [DATE], readmitted on [DATE], with diagnoses that included, but were not limited to, chronic
cholecystitis (inflammation of gallbladder), fracture of right shoulder girdle, part unspecified, initial
encounter for closed fracture (broken right shoulder), paroxysmal atrial fibrillation (intermittent irregular
heart rhythm), cellulitis of left lower limb (bacterial skin infection), weakness, difficulty in walking, insomnia,
chronic kidney disease state 3, presence of right artificial hip joint, hepatic failure unspecified without coma
(liver failure), diabetes mellitus due to underlying condition with diabetic nephropathy (damage to your
kidneys caused by diabetes), atherosclerotic heart disease of native coronary artery without angina
pectoris (thickening or stiffening of the arteries of the heart), and heart failure.
Record review of Resident #18's most recent comprehensive MDS assessment, an annual MDS
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675117
If continuation sheet
Page 4 of 8
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
675117
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Runningwater Draw Care Center Inc
800 W 13th St
Olton, TX 79064
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 0656
Level of Harm - Potential for
minimal harm
Residents Affected - Some
planning already occurring for the resident to return to the community? .No . Return to Community . Ask the
resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live
and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.
Record review of Resident #18's care plan, revised 11/09/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #35's face sheet, dated 11/29/22, revealed an [AGE] year-old female admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, chronic
kidney disease stage 3, hereditary lymphedema (swelling of the leg or arm that occurs due to blockage in
the lymphatic system which is part of the immune system), type 2 diabetes mellitus, hypertensive chronic
kidney disease with stage 1 through stage 4 kidney disease, chronic atrial fibrillation, anxiety disorder due
to known physiological condition, unspecified dementia with behavioral disturbance, hypertension, and
chronic diastolic (congestive) heart failure (chamber of the heart loses it's ability to relax normally (because
the muscle has become stiff) so the heart cannot properly fill with blood during rest).
Record review of Resident #35's most recent comprehensive MDS assessment, an annual MDS
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge
planning already occurring for the resident to return to the community? .No . Return to Community . Ask the
resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live
and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.
Record review of Resident #35's care plan, revised 10/26/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #39's face sheet, dated 11/29/22, revealed an [AGE] year-old male admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, dysphagia
(difficulty swallowing food or liquid), anorexia (eating disorder characterized by an abnormally low body
weight), major depressive disorder recurrent, difficulty in walking, unsteadiness on feet, weakness,
complete traumatic amputation at level between elbow and wrist, unspecified dementia with behavioral
disturbance, and legal blindness.
Record review of Resident #39's most recent comprehensive MDS assessment, an annual MDS
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .No . Family or significant other
participated in assessment .No . Guardian or legally authorized representative participated in assessment
.No .Discharge Plan . Is active discharge planning already occurring for the resident to return to the
community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the
possibility of leaving this facility and returning to live and receive services in the community? .No . Has a
referral been made to the Local Contact Agency .No.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675117
If continuation sheet
Page 5 of 8
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
675117
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Runningwater Draw Care Center Inc
800 W 13th St
Olton, TX 79064
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 0656
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Record review of Resident #39's care plan, revised 10/26/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #50's face sheet, dated 11/29/22, revealed a [AGE] year-old female admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, pressure ulcer of right buttock,
unstageable (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), cellulitis
of right lower limb, anxiety disorder due to known physiological condition, Alzheimer's disease,
hypertension, and rheumatoid arthritis (chronic inflammatory disease that affects the joints).
Record review of Resident #50's most recent comprehensive MDS assessment, an annual MDS
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge
planning already occurring for the resident to return to the community? .No . Return to Community . Ask the
resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live
and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.
Record review of Resident #50's care plan, revised 11/28/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #51's face sheet, dated 11/28/22, revealed an [AGE] year-old male admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia,
unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety,
painful micturition (urination) and dysphagia.
Record review of Resident #51's most recent comprehensive MDS assessment, an annual MDS
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .Yes .Discharge Plan . Is active discharge
planning already occurring for the resident to return to the community? .No . Return to Community . Ask the
resident .Do you want to talk to someone about the possibility of leaving this facility and returning to live
and receive services in the community? .No . Has a referral been made to the Local Contact Agency .No.
Record review of Resident #51's care plan, revised 11/16/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #55's face sheet, dated 11/29/22, revealed a [AGE] year-old male admitted to
the facility on [DATE], readmitted on [DATE], with diagnoses that included, but were not limited to,
unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood
disturbance, and anxiety, secondary pulmonary arterial hypertension (increased pressure of the blood
vessels of the lungs as a result of other medical conditions), nonrheumatic mitral valve insufficiency (heart
valve disorder), abdominal aortic aneurysm without rupture (enlarged area in the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675117
If continuation sheet
Page 6 of 8
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
675117
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Runningwater Draw Care Center Inc
800 W 13th St
Olton, TX 79064
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 0656
Level of Harm - Potential for
minimal harm
lower part of the major vessel that supplies blood to the body), insomnia, hypertension, unspecified atrial
fibrillation, unspecified diastolic (congestive) heart failure, muscle weakness, neuromuscular dysfunction of
bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral
nerves involved in the control of urination), personal history of transient ischemic attack (TIA) and cerebral
infarction without residual side effects (stroke) and presence of a cardiac pacemaker.
Residents Affected - Some
Record review of Resident #55's most recent comprehensive MDS assessment, an admission MDS
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .Yes . Resident's Overall Expectation .
Select one for resident's overall goal established during assessment process . Expects to remain in this
facility .Discharge Plan . Is active discharge planning already occurring for the resident to return to the
community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the
possibility of leaving this facility and returning to live and receive services in the community? .No . Has a
referral been made to the Local Contact Agency .No.
Record review of Resident #55's care plan, revised 11/16/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #57's face sheet, dated 11/29/22, revealed a [AGE] year-old female admitted to
he facility on 04/28/22 with diagnoses that included, but were not limited to, extraarticular fracture of lower
end of left radius (a fracture of the left arm occurring outside a joint), displaced fracture of left ulna styloid
process (a fracture of the left arm), displaced fracture of left phalanx of left thumb (fracture of left thumb)
and hypertension.
Record review of Resident #57's most recent comprehensive MDS assessment, an admission MDS
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .Yes . Resident's Overall Expectation .
Select one for resident's overall goal established during assessment process . Expects to remain in this
facility .Discharge Plan . Is active discharge planning already occurring for the resident to return to the
community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the
possibility of leaving this facility and returning to live and receive services in the community? .No . Has a
referral been made to the Local Contact Agency .No.
Record review of Resident #57's care plan, revised 11/28/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
Record review of Resident #116's face sheet, dated 11/29/22, revealed an [AGE] year-old male admitted to
the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia,
unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety,
unspecified injury of lower back, major depressive disorder, other idiopathic scoliosis (spinal deformity that
affects the curvature of the spine), and acute respiratory failure with hypoxia (below-normal level of oxygen
in your blood, specifically in the arteries).
Record review of Resident #116's most recent comprehensive MDS assessment, an admission MDS
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675117
If continuation sheet
Page 7 of 8
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
675117
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Runningwater Draw Care Center Inc
800 W 13th St
Olton, TX 79064
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 0656
Level of Harm - Potential for
minimal harm
Residents Affected - Some
assessment dated [DATE], revealed in Section Q titled, Participation in Assessment and Goal Setting,
Participation in Assessment .Resident participated in assessment .Yes . Resident's Overall Expectation .
Select one for resident's overall goal established during assessment process . Expects to remain in this
facility .Discharge Plan . Is active discharge planning already occurring for the resident to return to the
community? .No . Return to Community . Ask the resident .Do you want to talk to someone about the
possibility of leaving this facility and returning to live and receive services in the community? .No . Has a
referral been made to the Local Contact Agency .No.
Record review of Resident #116's care plan, revised 11/28/22, revealed no documentation of the resident's
preference and potential for future discharge, whether the resident's desire to return to the community was
assessed, any referrals to local contact agencies and/or other appropriate entities or discharge plans.
During an interview on 11/29/22 at 11:16 AM, the MDSC stated she was responsible for updating care
plans. She stated everything in the CAA (section of the MDS), medications and typically everything, needed
to be included in a comprehensive care plan. She stated she was not sure if it was required to document
discharge planning in the care plan unless there was an actual plan of discharge. She stated she did not
know if their preference for discharge had to be documented in the care plan. She stated she did not know
if not having a resident's discharge preference documented in the care plan would negatively affect the
resident, but she could see how it could negatively affect a resident if it was not assessed at all. She stated
resident's discharge preferences were assessed, they were just not documented in the care plan. She
stated the facility tried to provide her with care plan training, but her in-person training was stopped due to
COVID-19. She stated she had received more care plan training from when a consultant was in their facility
recently.
Record review of a facility policy titled, Care Plan Goals and Objectives, dated 03/14/18, revealed, in part,
.3. Care plan goals and objectives are derived from information contained in the resident's comprehensive
assessment and: a. Are resident oriented; b. Are behaviorally stated; c. Are measurable; and d. Contain
timetables to meet the resident's needs in accordance with the comprehensive assessment. 4. Goals and
objectives are entered on the resident's care plan so that all disciplines have access to such information
and are able to report whether or not the desired outcomes are being achieved.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675117
If continuation sheet
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