Runningwater Draw Care Center, Inc.

In the surveyor’s words

From the most serious findings on record at Runningwater Draw Care Center, Inc., in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 31, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF609May 31, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689May 31, 2024

  Based 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). […]

• No harm, potential for more than minimal, widespreadF812May 7, 2026

  Based 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.Findings included:During an observation of the refrigerator on 05/05/2026 at 9:44 AM, revealed the following:Five small glasses with orange colored liquid, open to air and had no label.One plate with two pancakes, open to air; the tinfoil covering was off… […]

• No harm, potential for more than minimal, widespreadF812Feb 27, 2025

  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. […]