Health inspection·July 24, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one of five residents (Resident # 38) reviewed for quality of life. Residents Affected - Few The facility failed to ensure Resident #38 received nail care. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: A review of Resident #38's face sheet dated 07/24/2024 indicated Resident #38 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with left-sided weakness, dysphagia (difficulty swallowing, gastrostomy tube placement (tube placed into stomach for provision of liquid nutrition), right below the knee amputee, osteoarthritis of the hip, major depressive disorder, COPD (chronic obstructive pulmonary disease - a group of lung diseases that block airflow and make it difficult to breathe), and diabetes. A review of an MDS dated [DATE], noted Resident #38 had a BIMS score of 0 (zero) which indicated he had severely impaired cognition. He was totally dependent on staff for activities of daily living (ADLs) which included showering and personal hygiene care. Record review of the comprehensive care plan dated 06/12/2024 indicated Resident #38 had an activities of daily living (ADL) self-care performance deficit. The care plan indicated interventions which included instructions for Resident #38 to have his nails cleaned on bath days and as necessary. Record review of a Task List Report dated 07/24/2024 indicated the task of bathing Resident #38 was assigned to the certified nurse aides and he was to receive a bath on Tuesdays, Thursdays, and Saturdays on the 2-10 shift. Record review of the plan of care flowsheet schedule for July 2024 indicated Resident #38 received a shower on the 2-10 shift on 07/23/2024. During observations on 07/22/2024 at 11:42 AM, Resident #38 was noted to be lying in bed and covered to the mid torso with a sheet and blanket. His arms were lying across his stomach with his hands exposed. Resident #38 was noted to have a dark brown substance under 4 of his fingernails on the left hand. His right hand was noted to have a dark brown substance under 3 of his fingernails. Resident Page 1 of 4 675152 675152 07/24/2024 Dogwood Trails Manor 647 US Hwy 190 W Woodville, TX 75979

F 0677 Level of Harm - Minimal harm or potential for actual harm #38 was observed again at 04:09 PM and was noted to still have a dark brown substance under the same fingernails. During an observation on 07/23/2024 at 10:10 AM, Resident #38 was again noted to have a dark brown substance under the same fingernails of both hands. Residents Affected - Few During an observation on 07/23/24 at 04:00 PM of Resident #38 while LVN A was preparing to administer medications to him, LVN A was asked to show the surveyor Resident #38's fingers and hands. LVN A said Resident #38's fingernails had something dirty under the nails and needed to be cleaned. LVN A said she would put that on her list of things to do. During an observation on 07/24/2024 at 09:40 AM, Resident #38 was noted to have a dark brown substance under the fingernails of both hands. During a observation and interview on 07/24/2024 at 11:10 AM, the DON removed a brown, dried substance from underneath the middle fingernail of Resident #38's left hand using a cuticle stick. She said she would clean his nails. During an interview on 07/24/2024 at 11:22 AM, the DON said Resident #38 was supposed to have his nails cleaned when he got a shower on Tuesdays, Thursdays, and Saturdays and as needed. She said the charge nurses were supposed to supervise the aides to ensure residents received nail care. During an interview on 07/24/2024 at 03:24 PM, CNA B said the residents' fingernails were supposed to be cleaned when they received a shower and as needed. During an interview on 07/24/2024 at 03:42 PM, LVN C said the residents were supposed to have their fingernails cleaned when they got a shower. She said the female residents received showers on Mondays, Wednesdays, and Fridays and male residents received showers on Tuesdays, Thursdays, and Saturdays. LVN C said the charge nurses were supposed to monitor to ensure residents received grooming and personal hygiene care. A review of the facility's policy dated 2003 and titled Nail Care indicated the following: 'Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath . 675152 Page 2 of 4 675152 07/24/2024 Dogwood Trails Manor 647 US Hwy 190 W Woodville, TX 75979

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview, observation, and record review, the facility failed to use the services of a registered nurse for 8 consecutive hours 7 days a week for 1 of 4 quarters of 2024 (Fiscal Year Quarter 2 January 1-March 1) PBJ reports reviewed for RN coverage. The facility did not have RN coverage for 8 consecutive hours on 01/25/2024, 01/26/2024, 01/27/2024, and 01/28/2024. This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of the CMS PBJ reports indicated Quarter 2 2024 (January 1-March 1) there were no consecutive 8 hours of RN coverage on 01/25/2024 (Thursday), 01/26/2024 (Friday), 01/27/2024 (Saturday), and 01/28/2024 (Sunday). During an interview and observation on 07/23/24 at 3:15 PM the Human Resources Manager, said she had been at the facility about a month. She pulled up the records on her computer to indicate where staff had clocked in and out for January 2024. She said RN D had been hired to fill the DON position and started in that capacity on 01/29/24 (Monday). She said the previous DON's last day had been 01/24/24 (Wednesday). She indicated time sheet documentation viewed on the computer indicating the following for RN coverage: 1/25/24 (Thursday) RN D scheduled as charge nurse on 10:00 PM-6:00 AM shift (Friday AM); indicating 2 hours of coverage on Thursday PM and 6 hours of coverage on Friday AM were not consecutive 8 hours. 1/26/24 (Friday) RN D scheduled as charge nurse on 10:00 PM-6:00 AM shift (Saturday AM); indicating 2 hours of coverage on Friday PM and 6 hours of coverage Saturday AM were not consecutive 8 hours. 1/27/24 (Saturday) Corporate Compliance RN E 9:00 AM-11:00 AM (2 hours); Corporate Compliance RN F 3:00 PM-10:00 PM (7 hours) were not consecutive 8 hours 1/28/24 (Sunday) Corporate Compliance RN E 12:00 AM-7:00 AM (7 hours); Corporate Compliance RN F 9:00 AM-4:00 PM (7 hours) were not consecutive 8 hours. During an interview and observation on 07/23/24 at 3:30 PM the Area Director of Operations said the Corporate Compliance RNs had been in the facility and indicated on his computer the days and hours they were in the facility on 01/27/24 and 01/28/24. Those hours were viewed on the computer. During an interview on 07/23/24 at 3:20 PM the administrator said the facility did not have RN coverage for 8 consecutive hours on 01/25/24 (Thursday), 01/26/24 (Friday), 01/27/24 (Saturday), and 01/28/24 (Sunday). She said she has had RN coverage 8 hours a day 7 days a week since 01/29/24 when the new DON started. During an interview on 07/24/24 at 9:15 AM the administrator provided the physical documentation indicating the lack of RN coverage for January 2024. 675152 Page 3 of 4 675152 07/24/2024 Dogwood Trails Manor 647 US Hwy 190 W Woodville, TX 75979

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of RN D charge nurse coverage indicated the following: 01/25/24 1.3 hours worked, 01/26/24 7.5 hours worked, 01/27/24 6.2 hours worked and no hours on 01/28/24. There was no DON coverage on 01/25/24 and 01/26/24 and not having 8 consecutive hours of RN coverage the facility had no supervisor present to oversee resident care. During an interview on 07/24/2024 at 4:05 PM the administrator said the company did not have a policy on staffing. 675152 Page 4 of 4