Health inspection·February 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm diet and nectar thickened liquids. The care plan noted, Resident may sit at the Feeding/Assist table. The resident sits at feeding table and is dependent x1 staff for eating pureed diet on divided plate with nectar thick liquids. Record review of Resident #45's active orders report as of 02/25/25 revealed the following orders: Residents Affected - Few Regular diet Pureed texture, Nectar/Mildly Thick consistency . with a start date of 10/03/24. May have a divided plate and right handed [sic] curved spoon for ease of loading utensils and promoting independence. with meals with a start date of 10/27/24. During an observation and interview on 02/25/25 at 12:00 PM in the dining room LVN B was standing approximately 3 feet from residents seated at a large oval table made up of several skinny tables end to end with the middle left open for staff to sit and assist residents with eating. This table was located in the center of the dining room on the end closest to the kitchen. When LVN B was asked to point out Resident #45 she gestured to opposite side of the large oval table in the center of the dining room and stated, He's in the red sweater at the feeder table. During an observation on 02/25/25 at 12:02 PM in the dining room a dry erase white board approximately 2 feet by 3 feet was hanging on the wall. It had diagrams of each table in the dining room with round magnets with numbers placed around the tables. The large oval table in the center of the dining room was labelled Feed/Assist. Two small tables on the same wall as the white board were labelled Assist and the remaining tables in the dining room were labelled Table 1- Table 6. During an observation and interview on 02/25/25 at 12:14 PM in the dining room LVN B was again standing approximately 3 feet from residents seated the large oval table. When LVN B was asked to point out another resident she gestured to end of the large oval table and stated, He is at the feeder table in the green sweater. During an interview on 02/26/25 at 02:08 PM CNA C stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated, It is a dignity issue with them. Or if other residents hear that we are saying that to them. CNA C stated the whiteboard in the dining room was used by staff to know where residents sat in the dining room. She stated the magnets arranged around the diagrams of the tables had the room numbers of the residents. CNA C stated the white board might have a negative outcome for residents if they saw their room numbers on the table labelled Feed/Assist. She stated she had been trained at orientation and during in-services not to refer to residents who needed assistance eating as feeders. During an interview on 02/26/25 at 02:13 PM LVN A stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated doing so could negatively affect their morale and self-esteem. LVN A stated of the residents who needed assistance eating, A lot of them still understand and can't help not being able to feed themselves. LVN A stated she had not noticed the whiteboard in the dining room with the large oval table labelled Feed/Assist. She stated she could see how the whiteboard might have a negative impact on residents' dignity. LVN A stated she had been trained at orientation and during in-services not to refer to residents who needed assistance eating as feeders. During an interview on 02/26/25 at 02:28 PM ADON stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated, It is degrading. It is a dignity issue. It (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 2 of 13 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 02/27/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm doesn't present a homelike experience. She stated a possible negative outcome of the whiteboard in the dining room with the large oval table labelled as Feed/Assist was, Again, it is not a homelike experience which we try to create here, and it is embarrassing and does not maintain dignity and integrity of our residents as humans. ADON stated staff had been trained not to refer to residents who needed assistance eating as feeders. Residents Affected - Few During an interview on 02/26/25 at 02:34 PM DON stated referring to residents as feeders could be a dignity issue if outside people heard. She stated she did not think the whiteboard with the large oval table labelled as Feed/Assist was a dignity issue unless outside people saw it, but we don't really have outside people go into our dining room. I think it just depends on who sees it (the whiteboard). During an interview on 02/26/25 at 02:53 PM ADM stated it was not okay for staff to refer to residents who needed assistance eating as feeders. She stated, It is a dignity issue. Record review of facility policy titled Dignity and dated 2021 revealed the following: . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: . e. provided with a dignified dining experience. 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labelling' or referring to the resident by his or her room number, diagnosis, or care needs. Staff protect confidential clinical information. Examples include the following: . b. Signs indicating the resident's clinical status or care needs are not openly posted . 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity . Record review of facility policy titled Resident Rights and dated 2021 revealed the following: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 3 of 13 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 02/27/2025 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission for 1 (Resident #214) of 15 residents reviewed for comprehensive assessments. The facility failed to complete an admission MDS on Resident #214 within 14 calendar days after admission date of 02/11/25. This failure could place residents at risk of not having their needs met due to lack of information. Findings Included: Record review of Resident #214's admission record dated 02/25/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (a condition resulting from not enough oxygen in the tissues of the body) and melena (dark, tarry stool). Record review of Resident #214's EHR revealed an admission MDS with ARD of 02/19/25 which was not competed. It was noted to be in progress. Record review of Resident #214's care plan revealed it was initiated on 02/19/25. During an interview on 02/26/25 at 02:17 PM MDS LVN stated she was responsible for completing MDS assessments. She stated she used the RAI as her policy when completing MDS assessments. MDS LVN stated an admission MDS was to be completed within 14 days of a resident's admission to the facility. MDS LVN stated she thought she had completed Resident #214's admission MDS timely. She looked at her computer screen and said, Oh, it is still in progress, and I need to sign it. MDS LVN stated a possible negative outcome of not completing an admission MDS timely was, We might not get paid as well and it could lead to care plan not being updated as quickly. During an interview on 02/26/25 at 02:28 PM ADON stated an admission MDS not being completed timely could lead to we cannot completely take care of the residents due to not having a complete assessment of care areas. During an interview on 02/26/25 at 02:34 PM DON stated having an admission MDS completely timely was important to the care of a resident so everyone can be on the same page. During an interview on 02/26/25 at 02:53 PM ADM stated MDS LVN was responsible for completing MDS assessments. She stated an admission MDS not being completed timely could negatively impact resident care. ADM stated, You need to know everything you can about a resident as soon as they show up. Find out as much as you can as soon as you can. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed a chart on page 38 with the following: Assessment Type .admission .MDS Completion Date .no later than 14th calendar day of the resident's admission (admission date + 13 calendar days) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 4 of 13 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 02/27/2025 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 2 (Resident #11 and Resident #36) of 15 residents reviewed for accuracy of assessments. Residents Affected - Few The facility failed to remove diagnoses of Wound Infection (other than foot) from Resident #11 and Resident #36's MDS' when said diagnoses were inactive. This failure could lead to residents receiving unnecessary care or not receiving necessary care. Findings Included: 1. Record review of Resident #11's admission record dated 02/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, local infection of the skin and subcutaneous tissue (a bacterial or fungal infection confined to a specific are of the skin and the layer of tissue directly beneath it resulting in inflammation, redness, warmth, swelling, pain), psoriasis (chronic skin condition characterized by raised, red, scaly patches of skin called plaques), pruritus (an unpleasant sensation that triggers the urge to scratch), and seborrheic dermatitis (common chronic skin condition that causes flaky greasy scales and redness). The onset date of the local infection of the skin and subcutaneous tissue diagnosis was 05/17/17. The onset dates of the psoriasis and seborrheic dermatitis diagnoses were 02/25/15. The onset date of the pruritus diagnosis was 01/11/21. Record review of Resident #11's annual MDS completed on 11/22/24 by the previous DON revealed the following: Section I-Active Diagnoses: Active Diagnoses in the last 7 days - Check all that apply The box next to Question I2500 Wound Infection (other than foot) was marked indicating Resident #11 had a wound or infection of this kind. Question I8000 Additional active diagnoses listed pruritus and disorder of the skin and subcutaneous tissue. Record review of Resident #11's care plan completed on 01/24/25 revealed no mention of a wound. Record review of Resident #11's active orders report as of 02/26/25 revealed no order for the treatment of a wound. 2. Record review of Resident #36's admission record dated 02/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, local infection of the skin and subcutaneous tissue (a bacterial or fungal infection confined to a specific are of the skin and the layer of tissue directly beneath it resulting in inflammation, redness, warmth, swelling, pain), cellulitis of other sites (common bacterial skin infection that causes redness, swelling, and pain), and seborrheic dermatitis (common chronic skin condition that causes flaky greasy scales and redness). The onset date of the local infection of the skin and subcutaneous tissue diagnosis was 08/26/23. The onset date of the cellulitis of other sites diagnosis was 05/14/22. The onset date of the seborrheic dermatitis was 01/09/20. Record review of Resident #36's quarterly MDS completed on 01/20/25 by DON revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 5 of 13 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 02/27/2025 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 Section I-Active Diagnoses: Active Diagnoses in the last 7 days - Check all that apply The box next to Question I2500 Wound Infection (other than foot) was marked indicating Resident #36 had a wound or infection of this kind. Question I8000 Additional active diagnoses listed cellulitis and seborrheic dermatitis. Record review of Resident #36's care plan completed on 01/24/25 revealed no mention of a wound. Residents Affected - Few Record review of Resident #36's active orders report as of 02/26/25 revealed no order for treatment of a wound. During an interview on 02/26/25 at 02:17 PM MDS LVN stated she was responsible for completing MDS assessments. She stated she used the RAI as her policy when completing MDS assessments. MDS LVN stated she and the previous DON disagreed on which diagnoses should remain active on an MDS assessment. MDS LVN stated she believed if a diagnosis has been cleared and was no longer affecting the resident it should no longer be active on the MDS in Section I. She stated the previous DON thought all diagnoses should remain active on the MDS in Section I whether they had cleared up or not. She stated that was the reason Resident #11 and Resident #36 were coded as having wound infections. MDS LVN stated an inaccurate MDS would not affect residents' care. During an interview on 02/26/25 at 02:28 PM ADON stated an inaccurate MDS could lead to inaccurate care of a resident. She stated, And we want accurate care here from every level. During an interview on 02/26/25 at 02:34 PM DON stated having an inaccurate MDS could lead to the facility not providing the care they (residents) need. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: .: Active Diagnoses in the Last 7 Days . Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available. Examples of Inactive Diagnoses (do not code) 1. The admission history states that the resident had pneumonia 2 months prior to this admission. The resident has recovered completely, with no residual effects and no continued treatment during the 7-day look back period. Coding: Pneumonia item (I2000), would not be checked. Rationale: The pneumonia diagnosis would not be considered active because of the resident's complete recovery and the discontinuation of any treatment during the lookback period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 6 of 13 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 02/27/2025 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 interview and record review the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability for 1 (Resident #214) of 15 residents reviewed for preadmission screening. Residents Affected - Few The facility failed to perform a preadmission screening for Resident #214 prior to or at admission of 02/11/25. This failure could place residents at risk of not receiving needed services. Findings Included: Record review of Resident #214's admission record dated 02/25/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (a condition resulting from not enough oxygen in the tissues of the body) and melena (dark, tarry stool). Record review of Resident #214's EHR revealed no completed MDS assessment. Record review of Resident #214's care plan revealed it was initiated on 02/19/25 and did not address any mental health issues or intellectual disabilities. Record review of Resident #214's PASRR Level 1 revealed an assessment date of 02/19/25. During an interview on 02/26/25 at 02:17 PM MDS LVN stated she and the previous DON shared the responsibility of completing PASRRs. She stated, But it is mostly me lately. MDS LVN stated a possible negative outcome of not completing Resident #214's PASRR prior to or at admission was, If she (Resident #214) was positive (from mental disorder or intellectual disability), which she was not, she could have lacked or delayed services. During an interview on 02/26/25 at 02:28 PM ADON stated MDS LVN and DON have historically been responsible for completing PASRRs prior to or at admission. She stated a possible negative outcome of not completing the PASRR prior to or at admission was, Accuracy of care. Making sure we are offering them the services they need. During an interview on 02/26/25 at 02:34 PM DON stated MDS LVN was responsible for completing PASRRs. DON stated when she was employed in the facility previously (as DON) she was responsible for completing PASRRs. She stated she was not sure why the responsibility had shifted to MDS LVN. DON stated she did not believe there would be a negative outcome to the resident if a PASRR was not completed at or prior to admission. During an interview on 02/27/25 at 09:14 AM ADM stated a resident might not get the services they need if a PASRR was not completed at or prior to admission. Record review of facility policy titled admission Criteria and dated 2019 revealed the following: . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 7 of 13 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 02/27/2025 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 disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. a. The facility conducts a Level I PASARR [sic] screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID, or RD. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 8 of 13 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 02/27/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored under proper temperature, and the expiration date when applicable on 2 of 2 medication carts and 1 of 1 medication rooms reviewed for medication storage. - Medication cart for Side B revealed a Breo Ellipta inhaler for Resident #8 with no open date on inhaler. - Medication cart for Side A revealed a Novolin R insulin bottle for Resident #10 with no open date on bottle. - Refrigerator in medication room was below 36 degrees for 2 days. Refrigerator contained insulins for the following residents: *Resident #2 had 1 unopened box for Tesiba flex touch *Resident #2 had 2 bottles Novolin R *Resident #5 had 2 flex pen boxes Novolin 70/30 *Resident #5 had 1 bottle Novolin R *Resident #10 had 3 KwikPen boxes for Basaglar *Resident #10 had 2 bottles of Humulin R *Resident #10 had 4 bottles of Novolin R *Resident #15 had 3 bottles of Novolin R *Resident #15 had 2 bottles of Humulin 70/30 *Resident #27 had 1 KwikPen Basaglar *Resident #29 had 4 bottles of Lantus *Resident #29 had 1 bottle of Humulin R *Resident #35 had 2 bottles of Lantus *Resident #38 had 1 pen box for Lantus Solostar *Resident #48 had 1 bottle of Novolin R *Resident #48 had 1 bottle of Humulin R 70/30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 9 of 13 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 02/27/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility's failures could place residents receiving medication at risk for lack of drug efficacy, and adverse reactions. Findings included: During an observation on [DATE] at 10:30 AM of Medication cart for side B contained a Breo Ellipta inhaler for Resident #8 with an open date of [DATE], but on the actual inhaler there was no open dated noted. During an interview on [DATE] at 10:35 AM Interview with LVN A stated that a negative outcome for not writing an open date on the medication would be that the medication could be expired and not be effective. During an observation on [DATE] at 10:40 AM of Medication cart for side A revealed that Resident #10's Novolin R had no open date written on it. During an interview on [DATE] at 10:46 AM LVN B stated that a negative outcome for not writing the open date on a medication would lead to a waste of medication and could lead to harm if the medication is expired. During an observation on [DATE] at 10:48 AM of the medication room with LVN A revealed that the refrigerator temperature log for the medications was out of range on [DATE] at 35 degrees and [DATE] at 35 degrees. Temperature was observed in fridge at 39 degrees when visually checked. Medications for the following residents were revealed to have been below recommended temperatures for 2 days: *Resident #2 had 1 unopened box for Tesiba flex touch *Resident #2 had 2 bottles Novolin R *Resident #5 had 2 flex pen boxes Novolin 70/30 *Resident #5 had 1 bottle Novolin R *Resident #10 had 3 KwikPen boxes for Basaglar *Resident #10 had 2 bottles of Humulin R *Resident #10 had 4 bottles of Novolin R *Resident #15 had 3 bottles of Novolin R *Resident #15 had 2 bottles of Humulin 70/30 *Resident #27 had 1 KwikPen Basaglar *Resident #29 had 4 bottles of Lantus *Resident #29 had 1 bottle of Humulin R (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 10 of 13 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 02/27/2025 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 0761 *Resident #35 had 2 bottles of Lantus Level of Harm - Minimal harm or potential for actual harm *Resident #38 had 1 pen box for Lantus Solostar *Resident #48 had 1 bottle of Novolin R Residents Affected - Some *Resident #48 had 1 bottle of Humulin R 70/30 During an interview on [DATE] at 10:56 AM LVN A stated that the negative outcome for having medication at a temperature below the recommended level could lead to the medications losing their efficacy and not perform like they should for the resident. During an interview on [DATE] at 11:06 AM DON stated that it was the night nurse's responsibility to check the carts and the temperatures of the medication refrigerator. DON stated that the Nurse that performs the nightly duties is supposed to report abnormalities to the DON, however DON was not made aware of this discrepancy. DON stated that the negative outcome for the medications not having open dates on the medication could lead to the medication being expired and losing its effectiveness. DON stated that the negative outcome for having medications stored below their recommended storage temps could lead to the medications being compromised and losing their efficacy. Record review of the facility provided policy titled, Medication Labeling and Storage, undated, revealed the following: Policy Statement The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls . .Medication Storage . .3. If the facility has discontinued, outdated or deteriorated medications or biologicals .6.Refrigeration temperature settings should e maintained between 36-46 degrees Fahrenheit. .Medication Labeling . .2 .d .expiration date, when applicable; . .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 11 of 13 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 02/27/2025 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 foods were properly stored, labeled, and dated. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include: Observation of the walk-in refrigerator on 02/25/2025 at 9:50 AM revealed the following: 1. 1 ziplock bag with a square yellow substance no label, no date. 2. 1 open bag of turkey breast lunch meat in a ziplock bag, no open date, no received date. 3. 1 bag of turkey breast lunch meat no received date. 4. 1 ziplock bag of small round meat no label, no date. Observation of the walk-in pantry on 02/25/2025 at 10:00 AM revealed the following: 5. 2 lb. bag of opened toasted oats cereal in a white basket, no open date, no received date on packaging. Observation of walk-in freezer on 02/25/2025 at 10:13 AM revealed the following: 6. 1 box of biscuits, opened to air, no date. 7. 1 basket of individual containers of blue-ribbon ice cream, no date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 12 of 13 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 02/27/2025 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 Observation of refrigerator on 02/25/2025 at 10:32 AM revealed the following: Level of Harm - Minimal harm or potential for actual harm 8. 1 container of Southern Butter Pecan Coffee Creamer approximately 1/8 full no open date. Residents Affected - Many 9. 5 Styrofoam cups with liquid in the cups, no label, no date. 10. 9 individual containers of white creamy substance with no label, no date. In an observation and interview on 02/26/2025 at 8:54 AM, the DM threw the coffee creamer in the trash and stated the creamer was hers and it was her fault it was in the refrigerator. The DM was observed with the yellow substance in the ziplock bag and the opened turkey meat and stated she did not know how it got missed and threw the items in the trash. The DM said all kitchen employees were responsible for ensuring items in the kitchen were labeled, dated, and covered. The DM stated a possible negative outcome for not having items labeled, dated, or stored properly would be the food would go bad. In an interview on 02/26/2025 at 2:06 PM, the DA stated that all staff were responsible for ensuring items in the kitchen were covered, labeled, and dated and a possible negative outcome would be residents could receive bad food. Record review of Food Receiving and Storage Policy dated November 2022 revealed the following: Foods shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: Dry foods that are stored in bins are removed from original packaging, labeled, and dated. Refrigerator/Frozen Storage: All foods stored in the refrigerator or freezer are covered, labeled, and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675117 If continuation sheet Page 13 of 13