Health inspection·November 29, 2022

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. Page 1 of 8 675117 675117 11/29/2022 Runningwater Draw Care Center Inc 800 W 13th St Olton, TX 79064

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. 675117 Page 2 of 8 675117 11/29/2022 Runningwater Draw Care Center Inc 800 W 13th St Olton, TX 79064

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 675117 Page 3 of 8 675117 11/29/2022 Runningwater Draw Care Center Inc 800 W 13th St Olton, TX 79064

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 675117 Page 4 of 8 675117 11/29/2022 Runningwater Draw Care Center Inc 800 W 13th St Olton, TX 79064

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. 675117 Page 5 of 8 675117 11/29/2022 Runningwater Draw Care Center Inc 800 W 13th St Olton, TX 79064

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 675117 Page 6 of 8 675117 11/29/2022 Runningwater Draw Care Center Inc 800 W 13th St Olton, TX 79064

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 675117 Page 7 of 8 675117 11/29/2022 Runningwater Draw Care Center Inc 800 W 13th St Olton, TX 79064

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. 675117 Page 8 of 8