Inspection·December 1, 2023

F 0880 Resident #4, COVID positive on 11/22/23; sore throat, congestion, fatigue Level of Harm - Minimal harm or potential for actual harm Resident #5, COVID positive on 11/23/23; congestion, nasal drainage, watery eyes, hoarse, sore throat, body aches, restlessness, anxiety Residents Affected - Some Resident #6, COVID positive on 11/25/23; headache, sore throat, loss of appetite, shortness of breath, decrease O2, congestion, hoarse. Resident #7, COVID positive on 11/26/23; decrease O2, cough, chills, headache, vomiting, muscle aches, sore throat, loss of appetite, congestion, signs/symptoms of cold. Resident #8, COVID positive on 11/27/23; afebrile, decrease O2, cough, fatigue, sore throat, weakness, signs/symptoms common cold. Resident #9, COVID positive on 11/28/23; cough Resident #10, COVID positive on 11/29/23; fatigue, signs/symptoms cold, afebrile, hoarseness. Record Review of an undated face sheet for Resident #1 revealed: admitted to the facility on [DATE] with the following diagnoses : Multiple Sclerosis- (potentially disabling disease of the brain and spinal cord (central nervous system) Anemia(Low healthy red blood cells), Weakness, Reduced Mobility, Postural Kyphosis-Thoracolumbar Region(spinal disorder resulting in rounding of upper back), Primary Hypertension. Record Review of an undated face sheet for Resident #2 revealed: admitted to the facility on [DATE], discharge (deceased ) on 11/29/23 at 3:00 am with the following diagnoses : unspecified protein-calorie malnutrition, acute respiratory distress syndrome, pressure ulcer/skin tears, hypothyroidism(low thyroid hormone), major depressive disorder, acute cystitis with hematuria(blood in urine), dysphagia(difficulty in swallowing), weakness. Record Review of an undated face sheet for Resident #3 revealed: admitted to the facility on [DATE] with the following diagnoses : major depressive disorder(Persistent depressed mood), unspecified dementia, acute pain. Record Review of an undated face sheet for Resident #4 revealed: admitted to the facility on [DATE] with the following diagnoses : Dementia, COVID-19, Hypothyroidism (low thyroid hormone), Type 2 Diabetes, Shortness of Breath. Record Review of an undated face sheet for Resident #5 revealed: admitted to the facility on [DATE] with the following diagnoses : Dementia, Anxiety Disorder, Hypertension, Anorexia, COVID -19, Urinary Tract Infection. Record Review of an undated face sheet for Resident #6 revealed: admitted to the facility on [DATE] with the following diagnoses : Dementia, COVID-19, Essential hypertension; Anxiety. Record Review of an updated Resident #7's face sheet for Resident #7 revealed: admitted to the facility on [DATE] with the following diagnoses : Anemia, Shortness of Breath, COVID-19, Repeated Falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 2 of 7 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 12/01/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of an undated face sheet for Resident #8 revealed: admitted to the facility on [DATE] with the following diagnoses : Transient Cerebral Ischemic Attack(stroke), COVID-19, Cough, Dementia, Hypertension. Record Review of an undated face sheet for Resident #9 revealed: admitted to the facility on [DATE] with the following diagnoses : Fracture of First Lumbar Vertebra(compression fracture of the spine), COVID-19, Nausea, Hyperlipemia(high fat/lipids in blood), Depression, Hypertension, Chronic Obstructive Pulmonary Disease (COPD). Record Review of an undated face sheet for Resident #10 revealed: admitted to the facility on [DATE] with the following diagnoses : Metabolic Encephalopathy(brain disease/alteration in consciousness), Squamous Cell Carcinoma of Skin of nose(cancer of skin), Dehydration, Hypertension, Osteoarthritis(degeneration of joint cartilage), Repeated falls. During an observation on 11/28/23 at 10:40 a.m. upon entrance to facility, posting on door instructed masks required, list of COVID symptoms. A desk was observed inside the door with N-95 and surgical masks and a hand sanitizer station. During observations on 11/28/23 between 12:00 p.m. and 1:00 p.m. of the 4 resident hallways revealed no hand sanitizer on PPE carts outside of COVID positive resident rooms or within reach to DON or DOFF (putting on and taking off) PPE. During an interview and observation on 11/28/23 at 12:06 p.m., HK A was observed in the hallway with her mask pulled down below her nose. HK A was observed pinching her nose and wiping her nose with her bare hands and then touching the housekeeping cart. HK A stated she only spoke Spanish and a Therapy staff member translated the interview. HK A stated that she was sweaty from wearing the mask and wiped her nose several times to wipe the sweat away. HK A stated she was aware of the COVID outbreak and was trained to disinfect her hands with hand sanitizer or soap and water. HK A stated she planned on washing her hands after she took the trash outside. During an interview and observation on 11/28/23 at 12:19 p.m., Unit Clerk was observed behind the nurses station wearing a N95 mask over a surgical mask. The Unit Clerk stated she believed that wearing a N95 over a surgical mask would offer more protection against N-95. The Unit Clerk stated she had been trained on Infection Control, COVID and how to properly wear a N-95 mask and had not been trained to wear a N95 over a surgical mask. During an observation and attempted interview on 11/28/23 at 12:22 p.m. of HK B revealed Resident #5's room door was left open to the hallway, HK B exited Resident #5's room with a N95 mask on and carried a trash bag out of the resident room. HK B grabbed disinfectant off the PPE cart outside the door and sprayed aerosol disinfectant on her body and walked off. HK B stated she did not speak English and left the hallway. During an interview on 11/28/23 at 12:26 p.m. the ADM, stated that staff should remove the N95 after they exit a positive COVID room. The ADM stated that staff should disinfect their hands after they exit the positive COVID room at one of the dispensers. The ADM stated that Spanish speaking staff are in-serviced and trained on COVID precautions by their supervisor who understands English but barely speaks it. The ADM stated that the HKS is provided the written infection control policies in English and the HKS then verbally provides the in-service or trainings in Spanish. The ADM stated that the DON is in charge of Infection Control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 3 of 7 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 12/01/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 11/28/23 at 12:39 p.m. CNA C exited Resident #2's room with a N95 mask on, opened the PPE cart outside the door, grabbed a trash bag and placed trash bag on top of the PPE cart. The PPE cart had no hand sanitizer. CNA C removed her contaminated N95 mask with her bare hands, opened a closed PPE cart drawer and reached into a box and pulled out a new N95 mask. CNA C then donned the new N95 mask, grabbed the trash bag and walked down the hall. CNA C walked down the hall, opened, and closed a utility room door and then opened and entered the next utility room door. CNA C tossed the trash bag, washed her hands with soap and water and exited the utility room wearing the N95 mask. CNA C stated that she could not disinfect her hands before removing her contaminated N95 mask or before she donned a new N95 mask because there was no hand sanitizer outside of the room. CNA C stated she should have disinfected her hands after she removed her N95 mask. CNA C stated that she should not have grabbed a new N95 mask or put it on because she did not disinfect her hands. CNA C stated that COVID is spread by droplets and droplets could be on her N95 mask from Resident #2. CNA C stated when she touched the contaminated N95 mask and then touched the PPE cart and door handles, she spread COVID because her hands were not disinfected. During an observation of meal service on 11/28/23 at 12:52 p.m., CNA E exited Resident # 5's room wearing a N95 mask. CNA E did not remove the N95 mask and did not disinfect her hands before or after CNA E touched her N95 mask several times with her bare hands. CNA E then touched the meal tray cart and moved the cart forward. CNA E then touched a resident meal tray with her bare hands. The DON approached and was made aware of the situation and informed CNA E to disinfect her hands, remove the N95 mask, wash her hands and to put on a new mask. During an interview and observation of meal service on 11/28/23 at 12:55 p.m., CNA D was outside Resident #2's room and was observed placing a surgical mask on and then placing a N95 mask over it. CNA D then reached and touched an unknown resident meal tray that CNA D previously touched. The DON was in the hallway and stated that CNA D should not wear a surgical mask under the N95 mask. The DON was made aware that CNA D touched the meal tray, and the DON stated the tray was contaminated and removed the tray from meal service. During an observation and interview on 11/28/23 at 12:58 p.m. with CNA E and DON, CNA E was observed entering Resident #5's room wearing full PPE. CNA E exited the room with no N95 mask on. The DON stated that the sign on the door printed from the CDC provided instructions on how to DOF PPE and the DON confirmed that CNA E should have waited to remove the N95 mask until she exited the room. During an interview on 11/28/23 at 3:02 p.m. CNA E stated that prior to today, she had been taking off the N95 mask in the COVID positive resident rooms. CNA E stated that the DON had instructed them in the past to remove the N95 mask before they would exit the resident room but today, she was instructed to remove the N95 after exiting the positive resident room. CNA E stated that although she would disinfect her hands before she exited the resident room, she would still pull the door handle to shut the resident room and would not disinfect her hands again. CNA E stated that there is not hand sanitizer on the PPE carts and they would have to use a hand sanitizer station on the wall down the hall. CNA E stated that the posting on the resident room door instructed staff to remove the N95 after they exit the resident room. CNA E stated that COVID is airborne and is spread via droplets. CNA E stated COVID had spread in the facility with residents and staff, and she believed there were several factors contributing to the rise in facility cases. CNA E stated that staff had not followed the CDC postings on proper hand washing or wearing or taking off PPE and residents also roam the building. During an interview on 11/28/23 at 3:16 p.m. CNA E stated that prior to this outbreak the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 4 of 7 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 12/01/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had a special unit for COVID positive residents but now residents were in several hallways. CNA E stated that she believed she wore the N-95 mask over the surgical mask so she would not have to change out the surgical mask after she exited the resident room. CNA E stated that prior to today, she would remove her mask inside of the positive covid resident room because she had been instructed to by the DON. CNA E stated that after she exited the resident room, she would have to walk down the hall to get to a hand sanitizer pump on the wall. CNA E stated that she had COVID during this outbreak. Stated that Resident #1 tested positive before she did, but she had not worked in her hall prior to when Resident #1 tested positive. CNA E stated she had been trained several times on how to correctly use PPE, DON/DOFF PPE, hand sanitizing and COVID/Infection Control. CNA E stated the risk of staff not following COVID precautions is that it could spread to other residents or other staff in the facility. During an interview on 11/28/23 at 4:35 p.m. the DON stated that the previous administrative staff instructed staff to spray themselves with and she stated she would personally not do it or instruct staff to do it. The DON stated that a nurse who was working the floor today tested positive for COVID and was sent home. The DON stated that the RN had worked with approximately half of the residents today. The DON stated that she never instructed staff to remove the N95 in the positive resident room and that I literally told them this morning not to not be taking them off in the room. The DON stated today there was an in-service that went over Don/doffing, handwashing, infection control. The DON stated that the HKS received the in-service in English. The DON stated I'm not saying she understands everything. She can read English. She gives the in-services to her staff in Spanish. No one is with her when she gives the in-services unless she has questions. No one oversees her giving the in-services but if you think it's something we should do then let us know. The DON stated that there is a risk of staff spreading COVID by not wearing masks properly or not sanitizing their hands. The DON stated that the infection control policies and procedures instruct staff to wear full PPE into the COVID resident room, to remove all PPE except the N95 mask before exiting the room and to disinfect hands before and after exiting the resident room and before and after replacing the N-95 mask once outside the resident room. The DON stated that by wearing and removing PPE properly and disinfecting hands it would prevent the spread of COVID-19. During an interview on 11/29/23 at approximately 9:40 a.m. the ADM stated that there were additional residents who tested positive since 11/28/23 and she would have to get the list from the DON. During an interview on 11/29/23 at 9:47 a.m., conducted in person and on speaker phone with an interpreter with HK B, who stated that the housekeeping supervisor (HKS) trains her on Don/Dof PPE, COVID and Infection control. HK B stated that the in-services and trainings are written in English and the HKS gives them the in-services orally in Spanish. HK B stated that on 11/28/23 when she exited Resident #5's room, she forgot to remove her N95 mask, and she did not remove it until after she took the trash outside. HK B stated that she did not disinfect her hands until after she came back inside from taking the trash out and removing the N95. HK B stated that she has never signed an in-service. HK B stated that she speaks, reads, and writes Spanish and cannot read English. HK B stated that if she received trainings and in-services in Spanish, it would be beneficial so she could fully understand the material. During an interview on 11/29/23 at 10:14 a.m. conducted in person and by speaker phone with an interpreter with HKS, who stated that the in-services are presented to her in English, and she presents them to the housekeeping staff in Spanish. HKS stated that she can read English and when there are parts of the training or in-services she does not understand, she will either ask the DON or use the computer to look up the words she does not understand. HKS stated that today the facility posted the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 5 of 7 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 12/01/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CDC postings on DON/Doffing in both English and Spanish on the resident doors. HKS stated that it would be helpful to have in-services and trainings written in Spanish because her staff all speak Spanish and cannot read English. HKS stated that HK A should not have pulled her mask down and wiped her nose without disinfecting her hands after. HKS stated that she spoke with HK A about it and instructed her to disinfect or wash her hands. HKS stated that housekeeping has meetings every 2 weeks and staff sign the trainings during those meetings. HKS stated that if the facility puts out an in-service on a day that does not fall on her staff meeting days, she does not have staff sign the roster. HKS stated that HK B should not have left the N95 mask on when she exited Resident #5's room and she had been trained to disinfect her hands, remove the N95 mask, disinfect her hands and then put on a new clean mask. Record Review of Resident #2's nurse's note revealed Resident #2's tested positive for COVID on 11/21/2023, and on 11/29/2023 Resident #2 was found unresponsive with no pulse in her bed. The facility performed CPR and emergency services contacted, resident was transferred to the hospital and declared deceased . During an interview on 11/29/23 at 11:40 a.m. the DON stated that Resident #2 passed away at the hospital this morning. The DON stated that staff went into Resident #2's room at approximately 1:45 a.m. to complete the second round of checks for the night. The DON stated that the staff found Resident #2 unresponsive, warm and no pulse. The DON stated that staff immediately began CPR and continued until the ambulance arrived. The DON stated that Resident #2 passed away at the hospital. The DON stated that the resident had COVID and the previous weekend her oxygen levels had dropped, and she was ordered oxygen. The DON stated that the resident had been restless the previous day. The DON stated that there is another resident who is positive, Resident #10. The DON stated that there are currently 9 positive residents and 1 deceased resident. During an observation on 11/29/23 at 11:46 a.m. of HK F in Resident #10's room revealed HK F entered room wearing N95 mask, gown and face shield and left the resident door fully opened to the hallway. HK F was observed wiping down a table and moving items around the room with bare hands. HK F reached into her pocket and pulled out a pair of surgical gloves. HK F put on the surgical gloves and continued to clean the room with the door opened. During an interview on 12/01/2023 at 11:00 a.m. with HK B, translated by facility staff member LVN G. LVN G stated she is fluent in English and Spanish is able to translate the interview and HK B consented to the translation by LVN G. HK B stated she was in-serviced and received hands on training on DON/DOF PPE, hand sanitizing, face masks and to keep resident doors closed. HK B stated that she is more cautious about the methods of infection control, and she stated she felt the training was beneficial because it was presented in Spanish. HK B stated that the staff had also been provided written training in Spanish. During an interview and observation on 12/01/2023 at 11:30 a.m. with Resident #10; stated that she had been in isolation in her room for the last 3 days. Stated that her throat is raspy and sore. During an interview and observation on 12/01/2023 at 12:14 p.m. of Resident #1 in the dining room, Resident stated that she had COVID and was on isolation for approximately 10-15 days. Resident #1 stated that she did not know where or how she contracted COVID. Record review of the facility provided policies for infection control: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 6 of 7 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 12/01/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Handwashing/Hand Hygiene dated 2001 Medpass/Revised August 2019: Hand hygiene is the final step after removing and disposing of PPE. Centers for Disease Control (CDC) Respirator On/Respirator Off: Remove by pulling the bottom strap over back of head, followed by the top of strap without touching the respirator. Discard in waste container. Clean your hands with alcohol-based hand sanitizer or soap and water. Centers for Disease Control (CDC) Airborne precautions: everyone must: Clean hands before entering and leaving the room. Remove respirator after exiting the room and closing the door. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 7 of 7