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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 675152 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 07/24/2024 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)