Health inspection·January 18, 2024

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 01/16/24 at 10:40 AM Resident #54 was being pushed in her wheelchair down the hallway of the locked unit. She was neatly dressed, and her hair was neatly combed. Resident #54 was able to say hello and shake hands. When asked what her name was, Resident #54 was unable or unwilling to answer and looked down and to the left. During an observation on 01/16/24 at 12:06 PM Resident #54 was seated in her wheelchair at a table in the dining room. She had her eyes closed and staff were attempting to feed her bites from a plate of pureed food. Staff called her name repeatedly until she would open her eyes and take a bite. This pattern was repeated for each bite. During an interview on 01/16/24 at 06:51 PM Resident #54's family member stated he was pleased with the care she was receiving in the facility. He stated he chose to place Resident #54 in hospice care due to her condition and conversations he had with facility staff. During an interview on 01/18/24 at 11:09 AM when asked what policy she used for determining MDS assessment timing, MDS LVN stated, I follow the RAI manual. She said when a resident had a significant change the MDS assessment was to be completed within 14 days. When asked why this timing was not followed for Resident #54's significant change due to being admitted to hospice, MDS LVN stated, She was an interesting case. We had a care plan meeting with [Resident #54's family member] and we discussed steady decline. We discussed palliative care etcetera. A few days later he [Resident #54's family member] contacted hospice himself and I put it in the care plan and everywhere else but did do the dadgum MDS. I missed it. She said a possible negative outcome of not following the assessment timing as laid out in the RAI was, You know, state was not notified when they needed to be. During an interview on 01/18/24 at 11:20 AM DON stated a possible negative outcome of not having a significant change MDS in the allotted 14 days was, What is the payer source? Because I can see that being an issue. Record review of Long-Term Care Facility RAI Manual version 1.18.11 revealed the following: .For the other comprehensive MDS assessments, Significant Change in Status Assessment the . Completion Date must be no later than . 14 days from the determination date of the significant change in status . An SCSA [Significant Change in Status Assessment] is required to be performed when a terminally ill resident enrolls in a hospice program . The ARD must be within 14 days from the effective date of the hospice election . Record review of facility policy titled, Hospice Program and dated 08/09/23 revealed the following: Palliative/End-of-Life Care-Clinical Protocol Assessment and Recognition . 5. The comprehensive assessment will recur on a regular basis and in response to significant changes of condition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 2 of 11 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 01/18/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (Resident #26) of 18 residents reviewed for accuracy of assessments. Residents Affected - Few Resident #26 had an order for continuous oxygen dated 08/29/23 and her MDS with a completion date of 11/10/23 did not indicate she received oxygen while a resident. This failure could place residents at risk of not having their needs identified and therefore not receiving necessary care. Findings Included: Record review of Resident #26's admission record dated 01/17/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), shortness of breath, high blood pressure, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #26's quarterly MDS completed on 11/10/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS revealed Resident #26 was not receiving oxygen On Admission or While a Resident. Record review of Resident #26's care plan with a completion date of 11/27/23 revealed a focus area of The resident has oxygen therapy r/t SHORTNESS OF BREATH. This focus area was initiated on 06/22/23 and revised on 09/18/23. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @2-4L Continuous to maintain O2 sats>90%. This intervention was initiated on 06/22/23 and revised on 09/18/23. Record review of Resident #26's active order report dated 01/16/24 revealed the following order: Continuous Oxygen at 2-4L/min via NC to maintain 02 sat>90% every shift related to SHORTNESS OF BREATH. This order had a start date of 08/29/23 and no end date. Record review of Resident #26's O2 Sats Summary revealed 25 entries for the 14 days prior to completion of Resident #26's most recent MDS. Of those 25 entries, Resident #26 was receiving O2 17 times and was on room air 8 times. During an interview on 01/18/24 at 11:09 AM MDS LVN stated she followed the RAI as her policy for completing MDS Assessments. Record review of Long-Term Care Facility RAI Manual version 1.18.11 revealed the following: . Section O: Special Treatments, Procedures, and Programs . The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 3 of 11 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 01/18/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm programs. Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period defined for each column. Coding instructions for Column b. While a Resident Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and with the last 14 days. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 4 of 11 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 01/18/2024 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 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 18 residents (Resident #41) reviewed for PASRR requirements. Residents Affected - Few The facility failed to ensure Resident #41 had an initial PASRR Level 1 before admission on [DATE]. This failure could place residents with an MI (Mental Illness), ID (Intellectual Disability) or DD (Developmental Disability) at risk for not receiving PASRR related services, if qualified. The findings include: Record review of Resident #41's face sheet, dated 01/16/2024, revealed a [AGE] year-old male admitted to the facility initially on 08/08/2023 with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease with (acute) lower respiratory infection, major depressive disorder, recurrent, unspecified, atherosclerosis (plaque build up) of native coronary artery of transplanted heart without angina pectoris (chest pain), muscle weakness, epitaxis (bleeding from the nose), essential primary hypertension. Record review of Resident #41's quarterly MDS assessment, dated 11/24/2023, revealed a BIMS score of 11 out 15 which indicated his cognition was moderately impaired. He functional ability with eating, oral hygiene, toileting, and personal hygiene is classified as independent, with supervision or touching assistance with showering/bathing. Resident #41 is partial/moderate assistance with upper and lower body dressing and putting on/taking off footwear. Record review of Resident #41's care plan, revised 11/27/2023, revealed no documentation regarding PASRR status. Record review of Resident #41's PASRR Level 1 Screening, dated 01/22/2021, revealed, that in Section C, subsection C0100, C0200, and C0300 all sections are marked no. There was no new updated PASRR in Resident #41's chart. Resident #41 had no new PASRR performed with new admission on [DATE]. During an observation and interview on 01/16/2024 at 09:34 AM, Resident #41 was in his room, Resident #41 was standing next to his dresser putting his laundry away. Resident #41 had a NC hooked to portable oxygen; he had a rolling walker close by to assist him to ambulate. Resident stated that everyone treated him fine and did not voice any concerns with his care. During an interview on 01/18/2024 at 09:01 AM MDS LVN was asked about Resident #41's most recent PASRR. MDS LVN stated Yes, we saw that. I just didn't understand that a new one needed to be done. The new PASRR has been completed, but I can't submit it due to the admit date being more than 90 days out. MDS LVN was asked what a negative outcome would be for a resident not having and updated PASRR. MDS LVN stated since he is a resident that does not receive services there would be no negative outcome. MDS LVN stated that she had the email from the PASRR office and the email that she submitted to the PASRR office. Copies of this documentation was requested. During an interview on 01/18/2024 at 09:13 AM with DON revealed that a negative outcome for not having an updated PASRR upon admission could lead to the resident would have no help from services if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 5 of 11 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 01/18/2024 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 needed. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 01/18/2024 at 09:29 AM revealed paperwork provided by the MDS LVN that showed emails dated 01/17/2024 at 2:48pm, that she sent to PASRR support, it stated the following, Hi, I have missed completing a PASRR for a resident that was admitted on 08.08.2023. I have attempted to complete it for today's date and when it comes to adding in the NF admission date it says that it is an error. How can I correct this issue. The response email from PASRR support stated, Thank you for contacting the PASRR mailbox. Depending on the volume of emails received, it may take up to 3 business days to receive a response. We appreciate your patience. Residents Affected - Few Record review of facility policy, titled Admission-From Other Healthcare Facilities dated revised March 2017 states the following: 2. The following information will be provided to the facility prior to or upon the resident's admission: .I. PASARR (as appropriate); FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 6 of 11 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 01/18/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. The facility failed to store food at least 6 inches above the floor. This failure could place Residents at risk for foodborne illness. Findings Included: Observation of shelved/refrigerated foods on 1/16/2024 beginning at 10:03 am revealed the following: Observation of pantry on 1/16/24 at 10:06 am revealed 1 container of Jif peanut butter individual packs with no label or date. Observation of pantry on 1/16/ 24 at 10:11 am revealed 1 container of individual jelly packets with no label or date. Observation of pantry room on 1/16/24 at 10:26 am revealed 1 container of croutons with no label or date. Observation of refrigerator 1 on 1/16/24 at 10:43 am revealed 1 box of cabbage with no date. Observation of refrigerator 1 on 1/16 at 10:43 am revealed 1 box of tomatoes on shelf with no date. Observation of serving cart on 1/16/2 at 10:43 am revealed jelly packets in a bin with no label or date. Observation of serving cart on 1/16/24 at 1043 am revealed butter packets with no label or date. Observation of refrigerator 2 on 1/16/24 at 10:48 am revealed I tray of honey mustard in individual cups with no date. Observation of refrigerator 2 on 1/16/24 at 10: 48 am revealed unidentified I tray of salsa in fridge with no label or date. Observation of refrigerator 2 on 1/16/24 at 10:48 am revealed 1 bottle of ketchup with no date. Observation of freezer 1 on 1/16/24 at 11:02 am revealed 6 boxes of frozen meat on the floor not 6 inches off the floor. During an interview on 1/16/2024 at 11:20 pm, the cook stated that all kitchen staff are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 7 of 11 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 01/18/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many responsible for safe food storage per their policy. The cook said that she would go to the policy to see what the policy stated concerning food storage. The cook stated that the negative outcome for not practicing food storage would be contamination. During an interview on 1/16/24 at 1:27 pm, Dietary Manager stated that she is responsible for training kitchen staff. The Dietary Manager said kitchen staff are to follow facility policy for proper food storage. The Dietary Manager said that a negative outcome for Residents would be contamination. She said that a former DM told her that they could store items in the freezer on the floor. During an interview with the FSA on 1/17/24 at 10:33 am, FSA said she would go to the DM with any questions concerning food storage. She said a negative outcome would be a resident could get sick from bad food. FSA has not had any training on labeling and food storage. Record review of Food Receiving and Storage Policy dated /11/22 at 2:30 PM revealed the following: Dry foods that are stored in bins are removed from the original packaging, label and dated (use by date). Such foods are rated using a fist in-first out system. Food in designated dry storage areas is kept at least six inches off the floor. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Record review of Dietary Services Policy & Procedure Manual dated 11- 2022, for storage area stated all stored items must be 6 inches above the floor. Record review of Food and Drug Administration on, dated 1/18/23, stated in section 5-305.11 food storage should be at least 15cm (6 inches) above the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 8 of 11 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 01/18/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices for each resident that are complete, accurately documented, readily accessible, and systemically organized for one (Resident #26) of 18 residents reviewed for medical records. The facility failed to ensure Resident #26 had the most current physician's order in her chart for oxygen. The order in Resident #26's chart was for continuous oxygen but the most recent verbal order from the physician was to begin weaning Resident #26 off continuous oxygen. This failure could place residents at risk of having records that do not reflect their current status or needs. Findings Included: Record review of Resident #26's admission record dated 01/17/24 revealed a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), shortness of breath, high blood pressure, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #26's quarterly MDS completed on 11/10/23 revealed a BIMS of 00 which indicated severely impaired cognition. Section O of the MDS revealed Resident #26 was not receiving oxygen On Admission or While a Resident. Record review of Resident #26's care plan with a completion date of 11/27/23 revealed a focus area of The resident has oxygen therapy r/t SHORTNESS OF BREATH. This focus area was initiated on 06/22/23 and revised on 09/18/23. One of the interventions listed for this focus area was OXYGEN SETTINGS: O2 via nasal prongs @2-4L Continuous to maintain O2 sats>90%. This intervention was initiated on 06/22/23 and revised on 09/18/23. Record review of Resident #26's active order report dated 01/16/24 revealed the following order: Continuous Oxygen at 2-4L/min via NC to maintain 02 sat>90% every shift related to SHORTNESS OF BREATH. This order had a start date of 08/29/23 and no end date. Record review of Resident #26's progress notes revealed a note by LVN A dated 01/07/24 at 02:34 PM. This note stated, This nurse monitoring resident without O2. O2 reading of 92% RA [Room Air]. No s/s of distress noted. During an observation on 01/16/24 at 10:23 AM Resident #26 was lying in her bed on her right side in the fetal position under a blanket. She was not receiving O2. Her O2 concentrator machine was next to the bed with the tubing gathered together into a zipped plastic bag taped to the top of the machine. During an observation on 01/16/24 at 12:05 PM Resident #26 was sitting in her w/c with her eyes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 9 of 11 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 01/18/2024 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 0842 closed at a dining room table. She was not receiving O2. Level of Harm - Minimal harm or potential for actual harm During an observation on 01/17/24 at 07:36 AM Resident #26 was sitting in her w/c at the dining room table eating her breakfast. She was not receiving O2. She did not respond when spoken to. Residents Affected - Few During an observation on 01/17/24 at 08:19 AM Resident #26 was sitting in her w/c in the common room with several other residents. She was not receiving O2. During an observation on 01/17/24 at 11:25 AM Resident #26 was sitting in the common room in her w/c. She was not receiving O2. During an observation on 01/18/24 at 08:44 AM Resident #26 was sitting in her w/c in the common area having her hair curled by a staff member. She was not receiving O2. During an observation and interview on 01/18/24 beginning at 10:41 AM LVN A stated she had worked for the facility for 5 years. She said if a resident had orders for continuous O2 to keep O2 saturation above 90% the resident was supposed to have it [O2] on all the time. She stated nurses checked the residents' O2 sats in the morning. She stated nurses, Special Care staff, and CNAs were responsible for to make sure O2 orders were followed. She clarified that the nurse was responsible for setting levels and ensuring the order was followed and CNAs and Special Staff could adjust or apply the nasal cannulas. When asked why Resident #26 had an active order for continuous O2 and was not receiving O2, LVN A stated, We were gonna try to wean her and I think I have a note in there. At this point LVN A began to search her computer screen and printed off a note dated 01/07/24 at 02:34 PM. When asked if the physician said to wean Resident #26 off oxygen, LVN A looked at her computer screen and stated, Yes, but I didn't write it down. It is not in there. She stated a possible negative outcome of having the wrong orders in the chart was a resident could become disoriented, agitated, combative or restless. During an interview on 01/18/24 at 10:47 AM ADON stated if a resident had orders for continuous oxygen that resident should always be receiving oxygen. She stated she, the DON, and the nurses were responsible to ensure orders were followed. When asked about Resident #26 having orders for continuous oxygen and LVN A saying Resident #26 was being weaned from oxygen, ADON stated, Nurse would be responsible for noting that in the chart and would contact the doctor and get doctor orders and the nurse would be responsible to put those orders in the chart too. She stated a possible negative outcome of having the wrong orders in the chart was, Shortness of breath, they [residents] can't breathe. During an interview on 01/18/24 at 10:55 AM SC B said she knew which residents to put oxygen on because the nurse tells us. When asked how she knew which residents needed oxygen sometimes or all the time she stated, I ask the nurse. Has to be passed down through communication. They tell us who needs it all day. When asked why Resident #26 was not receiving oxygen she said, They [nurses] told us awhile back that she did not need it anymore. So, they leave her on it for a little bit and they take it off of her. During an interview on 01/18/24 at 11:20 AM DON stated a possible negative outcome of not following the orders in the EHR was, You could have someone go hypoxic (low levels of O2 in the blood). When asked about Resident #26 having orders in her EHR for continuous oxygen and LVN A stating they were weaning her off oxygen, DON stated, Nurse should have changed the order from continuous to PRN on the day that she spoke to the doctor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 10 of 11 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 01/18/2024 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 0842 Record review of facility policy titled Oxygen Administration and dated 08/09/23 revealed the following: Level of Harm - Minimal harm or potential for actual harm . 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Residents Affected - Few Record review of facility policy titled Medication and Treatment Orders and dated July 2016 revealed the following: . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. Record review of facility policy titled Telephone Orders and dated February 2014 revealed the following: . 1. Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc.). Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Record review of facility policy titled Verbal Orders and dated February 2014 revealed the following: . Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order. 1. Only authorized, licensed practitioners or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 2. Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. A telephone order is a verbal order given over the telephone. 4. The individual receiving the verbal order must write it on the physician's order sheet as 'v.o.' (verbal order) or 't.o.' (telephone order). 5. The individual receiving the verbal order will: . b. record the ordering practitioner's last name and his or her credentials (MD, NP, PA, etc.); and c. record the date and time of the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 11 of 11