Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Runningwater Draw Care Center Inc during CMS and state inspections, most recent first.
Food Storage and Temperature Monitoring Deficiencies: Kitchen #1 had multiple food items left open to air or stored without labels or dates, including refrigerated liquids, pancakes, pantry items, freezer items, and tortilla chips. The temperature log also lacked refrigerator and freezer checks for the morning and lunch shifts, despite staff stating that labeling, dating, covering, and daily temperature monitoring were required by policy.
Two residents had incomplete DNR documentation in their records. One resident’s DNR lacked the notary date, and another resident’s DNR had no physician information, including no date, signature, printed name, or license number. Both residents were listed as DNR in the chart and care plan, and nursing leadership confirmed the forms were not valid because required sections were missing.
Inaccurate MDS Coding for Limb Restraint: A resident with severe cognitive impairment and a history of left shoulder dislocation was coded on the MDS as using a limb restraint less than daily, even though no restraint order was present in the chart, the care plan did not document restraint use, and staff observations found no restraint on the resident. The MDS LVN stated the limb restraint should not have been coded, and the DON, ADM, and ADON acknowledged that inaccurate MDS coding could affect care planning and reimbursement.
Care plans for two residents did not include halo bedrails even though both had Halo Positioning Bar consents and the rails were in use. One resident had dementia, COPD, and moderate cognitive impairment, and the other had dementia, severe cognitive impairment, and required substantial/maximal assistance with bed mobility. Staff and the DON confirmed the halo bedrails were not care planned.
Catheter Bag Left on Floor: A resident with an indwelling Foley catheter and ureteral stents was observed in bed with the catheter drainage bag resting on the floor and later still in direct contact with the floor, with no privacy bag or barrier in place. A CNA later moved the bag off the floor and secured it, and the DON and nursing staff stated the bag should be stored off the floor and in a privacy bag.
The facility failed to store and label food items properly in the kitchen, as observed during an inspection. Various food items in the refrigerator, pantry, and freezer were found without proper labels or dates, posing a risk of serving spoiled food to residents. Interviews with the Dietary Manager and Dietary Aide confirmed that all kitchen staff were responsible for ensuring proper labeling and storage, as per the facility's policy.
The facility failed to properly label and store medications, with two medication carts missing open dates on medications and a medication room refrigerator storing insulins below the recommended temperature for two days. LVNs acknowledged the risk of using expired medications, and the DON noted the night nurse's responsibility to monitor and report temperature discrepancies, which was not done.
A facility failed to uphold resident dignity by labeling a dining table as 'Feed/Assist' and referring to it as the 'feeder table.' A resident with Parkinsonism and other conditions was affected by this practice, which was against facility policies on dignity and resident rights. Staff interviews confirmed the inappropriate nature of these actions.
A facility failed to complete an Admission MDS for a resident within the required 14-day period after admission. The resident, admitted with acute respiratory failure and melena, had an incomplete MDS, which was still in progress. Interviews with staff revealed a lack of oversight and awareness regarding the timely completion of the MDS, which is crucial for comprehensive care planning.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect documentation of active diagnoses. A disagreement between the MDS LVN and the previous DON resulted in the inaccurate coding of wound infections, which could potentially lead to inappropriate care. Interviews with staff highlighted the importance of accurate assessments to ensure proper resident care.
A resident was admitted without a timely PASRR screening for mental disorders or intellectual disabilities, contrary to facility policy. The responsibility for completing PASRRs was unclear among staff, leading to a delay in assessment and potential risk of unmet service needs.
A resident with severe cognitive impairment and multiple diagnoses was injured due to an improper 1-person transfer by a CNA, despite requiring a 2-person transfer. The incident was not reported immediately, delaying medical assessment and intervention.
A facility failed to report a resident's fall and injury within the required 2-hour timeframe. A CNA attempted a one-person transfer of a resident who required a two-person assist, resulting in a fall and a fracture. The incident was reported approximately 7 hours later, delaying the resident's assessment and treatment.
A resident with severe cognitive impairment and multiple physical ailments fell and fractured her right leg after a CNA attempted an independent transfer, despite the requirement for assistance from two staff members. The incident was not immediately reported, delaying the resident's assessment and treatment.
Food Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in Kitchen #1. During observation, refrigerated items included five small glasses of orange-colored liquid left open to air with no label and one plate with two pancakes left open to air after the tinfoil covering was removed. In the pantry area, surveyors observed one opened bag of small marshmallows with hardened marshmallows, one opened bag of crisp cereal with no open date, one clear plastic bag of crackers not labeled or dated, two pitcher-type containers with white cream not labeled or dated, and one container of red sauce with no label or date. In the walk-in freezer, surveyors observed one clear plastic bag of pancakes removed from the original packaging and not labeled, and one clear plastic bag of crumbled meat not labeled. In the preparation area, one bag of tortilla chips was not labeled or dated. Review of the temperature log binder showed the May 2026 documentation sheet lacked refrigerator and freezer temperature checks for the morning and lunch shifts on 05/04/2026, with only the dinner check documented. Facility staff stated that it was everyone's responsibility to label, date, cover, and properly store food items, and that the DM was responsible for ensuring compliance and for monitoring and documenting refrigerator and freezer temperatures. The facility policy required dry foods removed from original packaging to be labeled and dated, all refrigerated and frozen foods to be covered, labeled, and dated, and refrigeration and food temperatures to be monitored daily and documented.
Incomplete DNR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had valid advance directive documentation for DNR status. Resident #35 had a DNR in the record, but the form did not include the date when the notary witnessed the signature. Resident #43 had a DNR in the record, but the physician section was blank and did not include a date, signature, printed name, or license number. Both residents were listed in the chart and care plan as DNR status, and both had orders reflecting DNR status in the electronic record. Resident #35 was a female resident with diagnoses including cerebral aneurysm, atrial fibrillation, congestive heart failure, osteoarthritis, osteoporosis, and history of malignant neoplasm. Her MDS showed a BIMS of 11, indicating moderate cognitive impairment, and she required partial/moderate assistance with most ADLs. Her care plan identified advanced directives with DNR status, and the DNR form in the record was signed by her adult child, but the notary section lacked the date of the notary’s witness signature. Resident #43 was a female resident with diagnoses including dementia, osteoarthritis, and Wegener's Granulomatosis without renal involvement. Her MDS showed a BIMS of 05, indicating severe cognitive impairment, and she was dependent on staff for most ADLs. Her care plan also identified DNR status, but the DNR form had no physician information completed. During interview and record review, nursing staff and the DON confirmed that both DNR forms were not valid because required information was missing, and the DON stated the residents were listed as DNRs despite the incomplete forms.
Inaccurate MDS Coding for Limb Restraint
Penalty
Summary
Resident #2’s quarterly MDS assessment, dated 02/13/26, coded Section P0100 to indicate the resident used a limb restraint less than daily. Record review showed the resident was a [AGE] year-old female admitted [DATE] with diagnoses including dislocation of the left shoulder joint, COPD, anxiety disorder, and edema. The resident’s most recent BIMS score was 06, indicating severe cognitive impairment. However, the Order Summary Report dated 05/06/26 showed no order for a limb restraint, and the care plan dated 05/19/25 addressed limited physical mobility related to falls and the left shoulder dislocation without documenting restraint use. During observation on 05/05/26 at 10:19 AM and again on 05/06/26 at 11:00 AM, no restraint was observed on the resident’s body. A family member stated the resident had been admitted with a sling for her arm because of the shoulder dislocation and said they were not aware of any limb restraints. The MDS LVN stated a limb restraint should not have been coded on the MDS and that it would be corrected. The DON, ADM, and ADON each stated the MDS LVN was responsible for completing accurate assessments and that inaccurate coding could affect care planning and reimbursement.
Care Plans Failed to Address Halo Bedrails for Two Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents by not including the use of halo bedrails in their care plans. Resident #30 was an older female with diagnoses including dementia, aortic aneurysm, pain, weakness, need for assistance, and COPD; her quarterly MDS showed a BIMS of 11 and partial/moderate assistance needed for lying to sitting on the side of the bed. Her record contained a Halo Positioning Bar Consent signed by the resident, but her active orders and care plan did not address halo rails. During observation, she was in her room sitting in a recliner, and her right halo bedrail was up and locked in place while she stated she used it to move around in bed and had been trained on its use. Resident #42 was an older male with diagnoses including dementia, pain, muscle weakness, MI, and acquired absence of the left leg below the knee; his annual MDS showed a BIMS of 03 and substantial/maximal assistance needed for lying to sitting on the side of the bed. His record also contained a Halo Positioning Bar Consent signed by his legal representative, but his active orders and care plan did not include halo rails. During observation, he was asleep in his recliner and did not wake to knocking or introduction, and his bilateral halo bedrails were up and locked in place. Staff and the DON confirmed that halo bedrails were supposed to be care planned and that neither resident's care plan addressed the halo bedrails.
Catheter Bag Left on Floor
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #16 when her urinary catheter drainage bag was left in contact with the floor for an extended period. Resident #16 was a female resident with diagnoses including Alzheimer's disease and calculus of kidney with calculus of ureter. Her record showed she was dependent on staff for all activities of daily living, and her care plan and active orders included an indwelling Foley catheter with enhanced barrier precautions due to the catheter and bilateral ureteral stents. During observation, Resident #16 was found in bed with the bed in the lowest position and the catheter bag resting on the floor because it was attached to the lower portion of the bed frame. The bag was observed approximately one quarter full of urine and had no privacy bag covering it. Later observations showed the catheter bag still hanging from the foot of the bed with the bottom half, including the drain mechanism, in direct contact with the floor and no barrier between the bag and the floor. A CNA later removed the bag from the floor, placed it in a privacy bag, and secured it to the bed. Staff interviewed stated the catheter bag should not touch the floor and should always have a barrier between the bag and any surface, and the DON stated the bag should be stored off the floor and in a privacy bag.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that various food items in the walk-in refrigerator, pantry, freezer, and another refrigerator were not properly labeled, dated, or stored. Specific items included a ziplock bag with an unlabeled yellow substance, an open bag of turkey breast lunch meat without dates, and a bag of small round meat with no label or date. Additionally, in the pantry, an opened bag of toasted oats cereal lacked an open or received date. In the freezer, a box of biscuits was left open to air without a date, and a basket of ice cream containers was undated. Furthermore, a refrigerator contained a container of coffee creamer and several Styrofoam cups and containers with liquids and substances that were not labeled or dated. Interviews with the Dietary Manager (DM) and Dietary Aide (DA) revealed that all kitchen staff were responsible for ensuring food items were labeled, dated, and stored correctly. The DM admitted to discarding the coffee creamer and other improperly stored items, acknowledging the oversight. The DA confirmed that improper labeling and storage could lead to residents receiving spoiled food. The facility's Food Receiving and Storage Policy, dated November 2022, mandates that all foods be received and stored following safe food handling practices, including proper labeling and dating of items in dry, refrigerated, and frozen storage.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed in two medication carts and one medication room. Specifically, a Breo Ellipta inhaler for a resident on Side B and a Novolin R insulin bottle for a resident on Side A were found without open dates, which is against the facility's policy. Interviews with LVNs revealed that not labeling the open date could lead to the use of expired medications, potentially resulting in ineffective treatment and waste. Additionally, the refrigerator in the medication room was found to be below the recommended temperature of 36 degrees Fahrenheit for two consecutive days, affecting the storage of various insulins for multiple residents. The Director of Nursing (DON) stated that it was the night nurse's responsibility to monitor and report any temperature discrepancies, but the DON was not informed of the issue. The facility's policy requires medications to be stored under proper temperature conditions to maintain their efficacy, which was not adhered to in this instance.
Dignity Violation in Dining Room Practices
Penalty
Summary
The facility failed to treat residents with respect and dignity, specifically in the dining room setting. An LVN referred to a table where residents who needed assistance with eating were seated as the 'feeder table.' This terminology was used in the presence of residents, potentially impacting their self-esteem and dignity. Additionally, a whiteboard in the dining room labeled the table as 'Feed/Assist,' which was visible to residents and staff, further contributing to the issue. Resident #45, a male with Parkinsonism, glaucoma, and weakness, was one of the residents affected by this practice. His care plan indicated that he required a puree textured diet and nectar thickened liquids, and he was dependent on staff for eating. Despite these needs, the labeling and terminology used by staff did not respect his dignity or individuality. Interviews with staff, including CNAs, LVNs, the ADON, and the DON, revealed a consensus that referring to residents as 'feeders' was inappropriate and could negatively affect their morale and self-esteem. The facility's policies on dignity and resident rights emphasized treating residents with respect and providing a dignified dining experience, which was not upheld in this instance.
Failure to Complete Admission MDS Timely
Penalty
Summary
The facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission. Specifically, the Admission Minimum Data Set (MDS) for a resident was not completed within the required timeframe. The resident, an elderly female, was admitted with acute respiratory failure with hypoxia and melena. The MDS was noted to be in progress but not completed, which is a requirement for ensuring that the resident's needs are fully assessed and met. Interviews with facility staff, including the MDS Licensed Vocational Nurse (LVN), Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator (ADM), revealed a lack of awareness and oversight in completing the MDS timely. The MDS LVN acknowledged the oversight and the potential negative outcomes, such as delayed care planning and financial implications. The ADON and DON emphasized the importance of timely MDS completion for comprehensive resident care, while the ADM highlighted the necessity of having complete information about a resident upon admission.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to incorrect documentation of active diagnoses on their Minimum Data Set (MDS) assessments. Resident #11, a female with a history of skin conditions, was inaccurately marked as having an active wound infection on her MDS, despite no evidence of a wound in her care plan or active treatment orders. Similarly, Resident #36, also a female with skin-related diagnoses, was incorrectly coded as having a wound infection on her MDS, with no corresponding care plan or treatment orders for such a condition. Interviews with facility staff revealed a disagreement between the MDS Licensed Vocational Nurse (LVN) and the previous Director of Nursing (DON) regarding the criteria for marking diagnoses as active on the MDS. The MDS LVN believed that only current and affecting diagnoses should be marked as active, while the previous DON maintained that all past diagnoses should remain active. This discrepancy led to the inaccurate coding of wound infections for both residents, which could potentially result in unnecessary or inappropriate care. The Assistant Director of Nursing (ADON) and the current DON acknowledged that inaccurate MDS assessments could lead to incorrect resident care.
Failure to Conduct Timely PASRR Screening
Penalty
Summary
The facility failed to perform a preadmission screening for a resident with potential mental disorders or intellectual disabilities prior to or at the time of admission. The resident, an elderly female, was admitted with diagnoses including acute respiratory failure with hypoxia and melena. Despite these conditions, there was no completed MDS assessment, and the care plan initiated did not address any mental health issues or intellectual disabilities. The PASRR Level 1 assessment was only completed after admission, which is contrary to the facility's policy requiring such screenings to be conducted for all new admissions. Interviews with facility staff revealed a lack of clarity and consistency in the responsibility for completing PASRRs. The MDS LVN and the previous DON shared this responsibility, but it had mostly fallen to the MDS LVN recently. The ADON and ADM acknowledged that not completing the PASRR could result in residents not receiving necessary services. The DON, however, did not believe there would be a negative outcome from the delay. The facility's policy mandates that all new admissions be screened for mental disorders, intellectual disabilities, or related disorders as part of the Medicaid PASRR process, which was not adhered to in this case.
Neglect Resulting in Resident Injury Due to Improper Transfer
Penalty
Summary
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 required a 2-person transfer. This inappropriate transfer resulted in both CNA B and Resident #1 falling to the floor, causing a fracture to Resident #1's right femur. CNA B did not report the fall, and CNA C, who was present in the room at the time, also failed to report the incident until approximately 7 hours later. Resident #1 was a [AGE] year-old female with severe cognitive impairment and multiple diagnoses, including a complete transverse atypical femoral fracture, osteoarthritis, and repeated falls. Her care plan required total assistance from two staff members for all transfers and movement between surfaces. Despite this, CNA B attempted a solo transfer, leading to the fall and subsequent injury. The incident was not reported immediately, delaying the necessary medical assessment and intervention. The facility had conducted in-service training on abuse, neglect, and proper transfer procedures the day before the incident, which both CNA B and CNA C attended. However, the training did not prevent the neglectful actions that led to Resident #1's injury. The failure to follow the care plan and the delay in reporting the fall resulted in significant harm to Resident #1, highlighting a serious deficiency in the facility's care practices.
Failure to Report Neglect and Injury Timely
Penalty
Summary
The facility failed to ensure that all allegations involving neglect were reported immediately, but no later than 2 hours after the event, if the resident sustained serious bodily injury. This failure was identified for one resident who experienced a fall and potential injury. Specifically, a CNA attempted a one-person transfer of a resident who required a two-person assist, resulting in both the CNA and the resident falling to the floor. The incident was not reported until approximately 7 hours later, delaying the resident's assessment and treatment for a fracture to the right femur. The resident involved was a female with severe cognitive impairment and multiple medical conditions, including a complete transverse atypical femoral fracture, osteoarthritis, repeated falls, and the presence of a right artificial knee joint. The resident required total assistance from two staff members for all transfers and movement between surfaces. Despite these requirements, the CNA attempted the transfer alone, leading to the fall and subsequent injury. Another CNA present in the room did not witness the incident and initially failed to report it. The facility had recently conducted in-service training on abuse, neglect, and proper transfer techniques, which both CNAs had attended. However, the CNAs did not adhere to the training, and the incident was not reported in a timely manner. The delay in reporting resulted in the resident not being assessed by nursing staff until hours later, when an x-ray confirmed a fracture. The failure to report the incident immediately placed the resident at risk of not receiving timely medical attention and proper treatment for the injury.
Failure to Provide Adequate Supervision and Assistance During Transfers
Penalty
Summary
The facility failed to ensure that the resident environment remained free of accidents and hazards, and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide the required assistance of two staff members for all transfers and movements between surfaces for a resident with severe cognitive impairment and multiple physical ailments. This failure resulted in a fall that caused a fracture to the resident's right leg. The resident, who had a history of repeated falls and severe cognitive impairment, required total assistance from two staff members for all transfers and movements. Despite this requirement, a CNA attempted to transfer the resident independently, leading to both the CNA and the resident falling to the floor. The fall resulted in a fractured right leg for the resident, who already had a history of fractures and severe osteoarthritis. The incident was not immediately reported to the facility staff, delaying the resident's assessment and treatment. The fall was only reported after the CNA's shift had ended, leading to a delay in medical intervention. The resident was eventually assessed, and an x-ray confirmed the fracture. The facility's failure to follow proper transfer procedures and the delay in reporting the incident contributed to the resident's injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Olton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmonee House | 19.8 mi | ★★★★★ | 1 | 0 |
| Arbor Grace Wellness Center | 21.8 mi | ★★★★★ | 15 | 0 |
| Prairie House Living Center | 22.3 mi | ★★★★★ | 0 | 0 |
| Plainview Healthcare Center | 23.5 mi | ★★★★★ | 3 | 0 |
| Country View Living | 27.3 mi | ★★★★★ | 4 | 0 |
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