Runningwater Draw Care Center, Inc.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen (Kitchen #1) reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer and pantry food items were properly stored, labeled, and dated. The facility failed to ensure refrigerator and freezer temperatures were monitored and logged per their policy. These failures place residents at risk for food borne illness.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 2 (Resident #35 and #43) of 17 residents reviewed for advanced directives. Resident #35 had a DNR in her record that had no date of when the notary witnessed Resident #35 sign the document. Resident #43 had a DNR in her record that had no information for the physician. This failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an assessment accurately reflected a resident's status for 1 (Resident #2) of 17 residents reviewed for accuracy of assessments. The facility failed to accurately assess Resident #2 for the use of a restraint. This failure could place residents at risk not receiving appropriate care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #30 and #42) of 17 residents reviewed for comprehensive care plans. -The facility failed to address the use of halo bedrails in Resident #30 and Resident #42's care plans. This failure could result in residents not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #16) of 4 residents observed for infection control. -Resident #16 had her catheter bag on the floor for 3 hours. This failure could place residents at risk for the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #45) of 15 residents reviewed for resident rights. The facility failed to prevent LVN B from referring to Resident #45's table in the dining room as the feeder table. The facility failed to prevent labelling 10-12 residents at the center table in the dining room as Feed/Assist on a large whiteboard diagram on the wall of the dining room. These failures could negatively impact the self-esteem, self-worth, and identity of residents who need assistance with eating. Findings Included: [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect. The facility failed to ensure Resident #1 was free from neglect. On 5/15/24 after lunch, CNA B performed a 1-person transfer of Resident #1, who was a 2-person transfer. The transfer resulted in CNA B and Resident #1 falling to the floor, causing the fracture of Resident #1's right femur. CNA B did not report the fall. CNA C, who was in the room with CNA B at the time of the incident, did not report the fall until approximately 7 hours after the inappropriate transfer and fall occurred. This failure could place residents at risk of major injury due to neglect in their care. The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all allegations involving neglect are reported immediately, but no later than 2 hours after the event, if the resident sustains serious bodily injury, to the Administrator of the facility and the State Survey Agency for 1 of 6 residents (Resident #1) reviewed for neglect. The facility failed to report an allegation of neglect for Resident #1 within 2 hours of the event. CNA C did not report a fall with potential injury until approximately 7 hours after the inappropriate transfer and fall occured. CNA B did not report the fall. This failure could place residents at risk of not having incidents of neglect reported and investigated in a timely manner and delay in proper treatment of injury. The non-compliance was identified as Past Non-Compliance (PNC). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that the resident environment remains free of accidents and hazards, as possible, and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for adequate supervision to prevent accidents and hazards. The facility failed to ensure that Resident #1 was assisted x 2 staff for all transfers and movement between surfaces. CNA B transferred Resident #1 independently which resulted in CNA B and Resident #1 falling to the floor. As a result of the fall, Resident #1 suffered a fractured right leg. This failure could place residents at risk for falls with serious injuries. The non-compliance was identified as Past Non-Compliance (PNC). The IJ began on 5/15/24 at approximately 1:30PM and ended on 5/16/24 at 9:53AM. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for one (Resident #54) of 18 residents reviewed for significant change. The facility failed to update Resident #54's MDS assessment within 14 days of Resident #54 being admitted to hospice. This failure could result in residents not receiving the care and coordination of services necessary to meet their needs and/or desires. Findings Included: [...]

Inspectors wroteBased 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. 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: [...]

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 10 of 10 residents (#1,#2,#3, #4,#5,#6,#7,#8,#9,#10) residents reviewed for infection control. 1. The facility failed to ensure staff (HK A, Unit Clerk, HK B, CNA C, CNA D, CNA E, HK F) utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination between residents' positive with COVID-19 and residents who were not positive for the virus. 2. The facility failed to ensure staff (CNA D and CNA E) practiced hand hygiene by using hand sanitizer or washing their hands after exiting positive COVID-19 resident rooms or touching COVID negative resident food trays. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 3 residents (Resident #2 and Resident #3) who were positive for COVID 19. Facility staff failed to follow the facility's COVID-19 policy regarding patient isolation protocols by failing to close doors to COVID positive patient rooms or precautions placed on door prior to entering for Resident #2 and Resident #3. This failure can place residents at risk of COVID- 19 or any airborne transmitted diseases in the facility. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 of 7 (Resident #1) residents reviewed for medical records. The facility failed to accurately document elopement information in Resident #1's records. This could place all residents at risk for elopement for inaccurate assessments in medical records.