Inspection·June 19, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's care plan revision dated 6/14/2024 indicated Resident #1 had potential to demonstrate physical behaviors. Interventions included to analyze of key times, places, circumstances, triggers and what de-escalated the behavior and document, give the resident as many choices as possible about care and activities, if the resident had physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance, if intervening would be unsafe, call out for staff assistance immediately, monitor/document/report to MD of danger to self and others, notify the charge nurse of any physically abusive behaviors, when the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #1's progress note indicated that on 5/16/2024 at 6:00 pm resident was transferred to another inpatient facility related to resident was physically aggressive with another resident striking her with closed fist to left upper arm. Record review of Resident #1's event nurses' note - behavior authored by LVN A indicated that on 5/16/2024 at 4:00 p.m., the nurse was preparing for residents to go smoke when she turned to make sure all residents were ready, she witnessed Resident #1 strike Resident #2 with closed fist to left upper arm, no verbal altercation was heard between the two. Record review of a face sheet dated 1/9/2024 indicated Resident #2 was a 66-years-old female, initially admitted to the facility on [DATE] with readmission date of 01/05/2024. Her diagnoses included Alcohol Dependence with Alcohol-induced persisting dementia (type of alcohol-related brain damage), Type 2 Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of a MDS assessment dated [DATE] indicated Resident #2 was able to make himself understood and understand others. She had a BIMS of 15 (cognitively intact). No behavioral symptoms had occurred during the 7 day look back period. She required supervision for most ADLs. She was continent of bowel and occasionally incontinent of bladder. Record review of Resident #2's care plan revision dated 2/24/2023 indicated Resident #1 had potential to demonstrate physical and verbal behaviors anger, poor impulse control. Interventions included to analyze of key times, places, circumstances, triggers and what de-escalates behavior and document, COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, give the resident as many choices as possible about care and activities, if the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance, if intervening would be unsafe, call out for staff assistance immediately, monitor/document/report to MD of danger to self and others, notify the charge nurse of any physically abusive behaviors, when the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #2's event nurses' note - behavior authored by LVN A indicated that on 5/16/2024 at 4:00 p.m., that the nurse was preparing for residents to go smoke when she turned to make sure all residents were ready, she witnessed Resident #2 being struck closed fist to left upper arm by Resident #1 causing resident to shift to right in her wheelchair after the blow. No bruising (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 2 of 4 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 06/19/2024 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 0609 noted at this time. Resident states It just hurts a little. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/18/2024 at 11:09 a.m., Resident #1 said she recalled the incident involving her and Resident #2 that happened on 5/16/2024. Resident #1 said Resident #2 ran over her foot with her wheelchair, so she hit her, she said Resident #2 always trying to be the first one out to smoke and get her cigarettes first, now they go out to smoke at different times, so she did not see her much. She said that she was sent to another facility for hitting another resident and was aware that she was not supposed to hit other residents. Residents Affected - Few During an interview on 6/18/2024 at 1:09 p.m., Resident #2 said she does not recall the incident involving her and Resident #2 that happened on 5/16/2024. Resident #2 said that she does go out before or after the other residents now for smoke times but that is so I can get in or out with my wheelchair, takes me longer than others sometimes. During an interview on 6/19/2024 at 1:30 p.m., LVN A said she recalled the incident between Resident #1 and Resident #2. She said the weather was bad, so she was having to relocate the location for smoke time, said she was preparing the residents to go smoke, and when turned around to inform the residents that they would be going to the front porch area to smoke, she witnessed Resident #1 struck with closed fist by Resident #2 on left upper arm. LVN A said she intervened and separated the two residents, she said she did not see Resident #2 move her wheelchair or run over Resident #1's foot/toes as she claimed. She said she does not recall seeing any marks or abrasions on the residents when she intervened and separated them. She said she has been trained on abuse and neglect and was aware to report any allegations of abuse to the administrator/AC immediately which she did. Record review of TULIP intake for Resident #1 and Resident #2 indicated information date received on 5/20/2024 at 11:27 a.m., read that the allegation of abuse occurred on 5/16/2024 at 4:00 p.m. Caller information indicated the reporter of the allegation was the Administrator. During an interview on 6/19/2024 at 2:45 p.m., the Administrator said she became aware of the allegation of abuse between Resident #1 and Resident #2, immediately after it happened on 5/16/2024, she had left the facility and was in route home in inclement weather, she intended to report the allegation of abuse when she arrived home but was unable to due to the inclement weather caused power and internet outage at her personal residence, when she returned to the facility the next day, power was out and facility on backup generator power, she became involved with the inclement weather and power outage at facility and personal residence and forgot to report the allegation of abuse. She said when she realized on 5/20/2024 that she had forgotten to report the allegation of abuse from 5/16/2024 that she reported to HHSC at that time. She said she takes full responsibility for the delayed reporting of abuse allegation from 5/16/2024. She said that she was aware that the timeframe for reporting allegations of abuse to the HHSC/state agency was to report within 2 hours of the allegation. The administrator said the expectations was for the facility staff to report all suspicions or allegations of abuse immediately to her, as the abuse coordinator. She said the timeframe for reporting allegations of abuse to the state agency was to report within 2 hours of the allegation. The administrator said she should have reported allegation of abuse to the state agency within 2 hours of the allegation. Record review of the facility's Abuse and Neglect policy dated 3/29/18 indicated . Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 3 of 4 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 06/19/2024 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 0609 Letter 19-17 dated 7/10/19. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2hours of the allegation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 4 of 4