Inspection·May 3, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of an annual MDS assessment, dated [DATE], indicated Resident #56 had a BIMS score of 8 which indicated moderately impaired cognition, had physical behavioral symptoms directed towards others 1 to 3 days, and needed extensive assistance with bed mobility, transfer, dressing, toileting, and bathing. Record review of a care plan initiated on [DATE], indicated Resident #56 had a behavior problem related to inappropriate physical touch directed at other residents with interventions that included administer medication as ordered, anticipate resident's needs, intervene as necessary to protect the rights and safety of other residents and remove from the situation as needed. Record review of the Provider Investigation Report dated [DATE] indicated Resident #56 was observed with his hand under Resident #23's shirt. Resident #56 was asked to remove his hand by staff. He removed his hand and straightened Resident #23's shirt. The incident occurred on [DATE] at 5:30 p.m. and was reported to the state agency on [DATE]. The investigation findings were confirmed, Resident #56 denied the allegations, but a staff member witnessed the incident. Record review of the Provider Investigation Report dated [DATE] indicated Resident #56 was observed sitting beside Resident #23 at the nurse's station by CNA A. CNA A redirected Resident #56 and continued to pick up meal trays. When she looked back Resident #56 moved back near Resident #23. As CNA A approached the residents, she observed Resident #56 placed his hand between the legs of Resident #23. CNA A separated the residents and reported immediately to the charge nurse. The incident occurred on [DATE] at 8:45 a.m. and was reported to the state agency on [DATE]. The investigation findings were confirmed by the facility, Resident #56 was monitored 1 on 1 until transferred to another facility on [DATE]. During an interview on [DATE] at 1:25 p.m., CNA A said she was wheeling residents out of the dining room. She said observed Resident #56 wheel himself toward Resident #23 and she redirected him to keep going forward. CNA A said on the way back down the hall, Resident #56 was beside Resident #23 with his arm between her legs rubbing his hand up her legs toward her privates. She said his hands were not inside her pants. CNA A said she removed Resident #56 and reported to LVN B immediately. CNA A said she was made aware of Resident #56's inappropriate touching of Resident #23 after the first incident and educated to redirect Resident #56 if he approached Resident #23. CNA A said was educated on abuse/ neglect including reporting immediately to the nurse. During an interview on [DATE] at 1:45 p.m., LVN B said on [DATE] CNA A informed her Resident #56 was found with his hand between Resident #23's legs. She said she informed Resident#56 that was not an appropriate touch, separated the residents and notified the administrator, DON, and responsible party. She said Resident #56 was observed 1on 1. LVN B said Resident #23 was in later stages of dementia and would remover her clothes in public and had to be redirected. LVN B said Resident #56 was transferred to another facility. LVN B said she had been in-service on abuse/ neglect including reporting immediately to the administrator and DON. LVN B said she was informed about Resident #56's previous inappropriate touching of Resident #23. During an interview on [DATE] at 3:15 p.m. the social worker said with any suspected abuse/ neglect, the resident would be protected from abuse, and the incident reported to the administrator. She said the staff monitored Resident #56 constantly until he left the building. The social worker said after the first incident the staff separated Resident #56 and #23 and monitored him around her. She said she did not remember what was care planned but staff were aware to monitor Resident #56 around Resident #23. She said the two incidents would be considered a sexual matter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 2 of 3 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 675152 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dogwood Trails Manor 647 US Hwy 190 W Woodville, TX 75979 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 0600 Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 2:45 p.m., CNA C said she was in-serviced on abuse/ neglect including protecting the resident and report suspected abuse/ neglect immediately to the administrator and DON. CNA C said she was informed of the first incident and to keep a close eye on Resident #56 and make sure he kept his hands to himself. CNA C said not long after the incident (in January) he moved to another facility. She said the incidents were considered a sexual matter and to keep an eye on him. Residents Affected - Few During an interview on [DATE] at 2:55 p.m., CNA D said she was informed of the first incident involving Resident #56 and Resident #23 and to be mindful of Resident #56's where abouts and keep an eye on him. She said she was to make sure he did not go to near Resident #23's room. CNA D said Resident #56 and Resident #23's rooms were on different halls. She said the incidents were considered a sexual matter. During an interview on [DATE] at 3:36 p.m., the ADON said after the first incident staff were informed to keep Resident #23 and #56 separated to the best of their ability. She said their rooms were moved to separate ends of the building after the first incident. The ADON said the facility had a care plan meeting [DATE], the next day after the incident with Resident #56 putting his hand in between Resident #23's inner thighs. She said it was discussed for Resident #56 to move to another facility. She said both incidents from [DATE] and [DATE] were considered a sexual matter. The ADON said Resident #56 showed a lot of remorse and said he was sorry after the first incident. The ADON said Resident #56 was more aware than Resident #23. She said he could follow commands. The ADON said the staff had been in-serviced on Abuse/ neglect including sexual abuse after both incidents. During an interview on [DATE] at 3:49 p.m., the DON said she had been at the facility 4 weeks. She said her expectation related to potential abuse was ensure the resident was safe first and report immediately to herself and the administrator. She said the staff were in-serviced on abuse/ neglect including the reporting time frame for sexual abuse of within 2 hours. During an interview on [DATE] at 3:55 p.m. the administrator said he had been at the facility for three weeks. He said the staff have his phone number and can reach out to him at any time. The administrator said his expectations related to potential abuse/ neglect was to be notified of any incidents immediately, including injury of unknow origin including bruises all fractures, potential abuse/neglect, or potential sexual abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 3 of 3