Inspection·July 11, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete form on 06/12/25. There was no documentation the allegation of verbal abuse was reported. During an interview on 07/08/25 at 1:40 p.m., the Administrator said she was the abuse preventionist. She said she was not aware of Resident #8's Grievance/Complaint report dated 06/09/25. She said the previous SW must have placed the grievance in the binder after the DON completed the form. She said the allegation of verbal abuse was reportable. She said residents were at risk of further abuse if allegations were not reported as required. During an interview on 07/08/25 at 2:01 p.m., MA C said she did not hate Resident #8 and did not yell at her. She said on 06/09/25 Resident #8 was walking through the dining area with her breast almost hanging out of her robe. She said she directed her to put on proper clothes. She said verbal abuse should be reported to the Administrator and/or the DON/designee immediately. She said residents were at risk of further abuse if allegations were not reported as required. During an interview on 07/09/25 at 9:40 a.m., the DON said when she received Resident #8's Grievance/Complaint report dated 06/09/25, she did not take the allegations as verbal abuse. She said she could not recall the time she received the complaint. She said the allegations should have been reported within two hours to the sState. She said residents were at risk of further abuse if allegations were not reported as required. During an interview on 07/09/25 at 11:38 a.m., AD AA said Resident #8 came into his office on 06/09/25 and alleged MA C said she hated her and yelled at her. He could not recall the time. He said he completed the grievance form and immediately took it to the DON. He said he did not witness the alleged event. He said residents were at risk of further abuse if allegations were not reported as required. During an observation and interview on 07/09/25 at 1:00 p.m., Resident #8 appeared appropriately dressed in a dress and leggings. Her hair was clean and brushed. She said she had no complaints of her care or staff. She said she did not recall any staff yelling at her. Record review of the facility's Abuse/Neglect policy dated 09/09/24 indicated . E. Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. 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 Letter 2024-14 dated 8/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation . Event ID: Facility ID: 675152 If continuation sheet Page 2 of 12 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 07/11/2025 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 0610 Respond appropriately to all alleged violations. 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 investigate and report the findings of the investigation to the State Survey Agency within 5 working days of the incident for 1 of 8 residents (Residents #8) reviewed for abuse. The facility failed to investigate and submit the results of their investigation within 5 days after Resident #8 alleged MA C yelled at her on 06/09/25. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Findings included: Record review of Resident #8's face sheet dated 07/09/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's (brain condition that progressively damages memory, thinking, and learning skills), depression (mood disorder), moderate dementia (decline in cognitive function) with anxiety (feelings of dread and inner turmoil), dementia with mood disturbance, dementia with behavioral disturbance, and unspecified psychosis (presence of psychotic symptoms such as hallucinations). Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated she was usually understood and usually understood others and had moderate cognitive impairment (BIMS-10). There were no behavioral symptoms noted. Record review of Resident #8's care plan dated 01/31/23 indicated Resident #8 had a history of making false allegations. Interventions included notify family and the MD of and changes in condition, attempt to locate items PRN, and encourage resident to search for items. Record review of Resident #8's care plan dated 02/21/23 indicated she hallucinated and had delusions. Interventions included intervene as necessary to protect the rights and safety of others in a calm manner, divert attention, remove from the situation and take to another location as needed. Record review Resident #8's care plan dated 03/05/25 indicated Resident #1 was sexually active and would undress in front of open windows and others (roommates) and would not close her curtains or privacy curtain. Interventions included evaluate the ability to understand behavior and consequence of that behavior. Record review of Resident #8's Grievance/Complaint report dated 06/09/25 and completed by AD AA, indicated she alleged MA C hated her and yelled at her. She said MA C yelled at her about taking a shower. The DON was assigned the grievance on 06/09/25. The DON documented she spoke with MA C. MA C stated she did not hate Resident #8. She tried to redirect her because she dressed inappropriately with little robe on and her breast was almost hanging out. MA C asked her to get some clothes on and Resident #8 got upset with MA C. MA C educated on better customer service. The prevalence was resolved with one-to-one discussion on 06/12/25. The DON completed the grievance form on 06/12/25. There was no documentation the allegation of verbal abuse was reported. During an interview on 07/08/25 at 1:40 p.m., the Administrator said she was the abuse preventionist. She said she was not aware of Resident #8's Grievance/Complaint report dated 06/09/25. She said the previous SW must placed the grievance in the binder after the DON completed the form. She said the allegation of verbal abuse was reportable. She said she did not conduct an investigation and submit a report within 5 days to HHSC. She said residents were at risk of further abuse if allegations were not reported as required and investigations were not completed. During an interview on 07/08/25 at 2:01 p.m., MA C said she did not hate Resident #8 and did not yell at her. She said on 06/09/25 Resident #8 was walking through the dining area with her breast almost hanging out of her robe. She said she directed her to put on proper clothes. She said verbal abuse should be reported to the Administrator and/or the DON/designee immediately. She said residents were at risk of further abuse if allegations were not reported as required. During an interview on 07/09/25 at 9:40 a.m., the DON said when she received Resident #8's Grievance/Complaint report dated 06/09/25, she did not take the allegations as verbal abuse. She said she could not recall the time she received the complaint. She said the allegations should Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 3 of 12 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 07/11/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete have been reported within two hours to the sState. She said residents were at risk of further abuse if allegations were not reported as required. During an interview on 07/09/25 at 11:38 a.m., AD AA said Resident #8 came into his office on 06/09/25 and alleged MA C said she hated her and yelled at her. He could not recall the time. He said he completed the grievance form and immediately took it to the DON. He said he did not witness the alleged event. He said residents were at risk of further abuse if allegations were not reported as required. During an observations and interview on 07/09/25 at 1:00 p.m., Resident #8 appeared appropriately dressed in a dress and leggings. Her hair was clean and brushed. She said she had no complaints of her care or staff. She said she did not recall any staff yelling at her. Record review of the facility's Abuse/Neglect policy dated 09/09/24 indicated . E. Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. 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 Letter 2024-14 dated 8/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. F. InvestigationComprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated.1.The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC.2. Determination will be made for required reporting to HHSC per reporting guidelines found in Provider letter 19-17.3. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form.6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s).7. The facility will report and cooperate with any and all investigations concerning reports of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source by the company's employees as set forth in state law (including to the state survey and certification agency. Event ID: Facility ID: 675152 If continuation sheet Page 4 of 12 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 07/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 8 residents (Resident #1 and Resident #2) reviewed for supervision to prevent accidents. The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 hit Resident #2 on 06/08/25 on the secure unit. The facility failed to provided training regarding 1-1 or notify management of 1-1 status. CNA A was the only staff assigned to the unit. After the altercation, CNA A was also assigned to provide 1-1 for 1.5 hours for Resident #1 but took Resident #2 with her as she cared for other residents and did not provide 1-1 for Resident #1. The facility failed to ensure Resident #1 and Resident #2 did not hit each other on 06/17/25 on the secure unit. CNA A did not request assistance when she was providing care to another resident. CNA A was assigned to the unit and assigned to provide 1:1 for Resident #1 from 9:30 a.m. to 12:45 p.m. She had to take Resident #1 with her while providing care for other residents. MA C was assigned 1:1 for Resident #2 from 9:30 a.m. - 1:00 p.m. There was no additional staff assigned to provide care and supervision for the remaining residents on the unit. The facility did not review, update, or implement interventions to include adequate supervision and continued to leave Resident #1 alone and unsupervised with Resident #2 and with other residents. There was no documentation of who discontinued the 1:1 monitoring of Resident #1 or Resident #2. A De-escalation Techniques training was provided following the second incident. It did not address staff 1:1, notifying management of escalation behaviors, or identifying escalating behaviors. The behavior management policy did not address 1:1 monitoring when residents had escalated/aggressive behaviors or if management would be notified. The facility did not have a system in place to ensure residents were supervised in the secured unit while the assigned staff was providing care for other residents. An Immediate Jeopardy (IJ) was identified on 07/10/25 at 2:25 p.m. The IJ template was provided to the facility on [DATE] at 2:48 p.m. While the IJ was removed on 07/11/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk for emotional distress, fear, decreased quality of life, and further abuse. Findings included: Record review of Resident #1's face sheet dated 07/08/25 indicated she was a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included Alzheimer's (brain condition that progressively damages memory, thinking, and learning skills), severe dementia (loss of cognitive function) with agitation, and anxiety (feelings of dread and inner turmoil). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was usually able to make herself understood and usually understood others, had severe cognitive impairment (BIMS-4), and had behavioral symptoms not directed at others. Record review of Resident #1's care plan dated 06/09/25 indicated Resident #1 had potential to exhibit physical behaviors. Interventions included give resident as many choices as possible about care and activities, if Resident #1 had physical behavior towards another resident, immediately intervene to protect the residents involved and call for assistance, if intervening would be unsafe, call out for staff assistance immediately, notify the charge nurse of any physically abusive behaviors, restarted Buspirone, Resident #1 was separated from other resident, and one-to-one monitoring until determined safe, and secure care consult referral, and when Resident #1 becomes agitated: intervene before agitation escalates. Record review of Resident #1's late entry progress note dated 06/08/25 at 10:15 p.m., completed by RN D, indicated she was notified by CNA A Resident #1 hit Resident #2 with an open hand. The physician and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 5 of 12 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 07/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few RP were notified. Resident #1 was restarted on Buspar (Buspirone) (anti-anxiety medication). Record review of Resident #1's progress note dated 06/17/25 at 9:35 a.m., completed by LVN E indicated MA B reported she was outside the secure unit and Resident #1 and Resident #2 being physically combative with each other. There were no injuries noted. Residents were separated with no further events. The MD and the RP were notified. Record review of Resident #2's face sheet dated 07/08/25 indicated she was an [AGE] year old female, admitted on [DATE] and her diagnoses included Alzheimer's and severe dementia with anxiety. Record review of Resident #2's quarterly MDS dated [DATE] indicated she was rarely able to make herself understood, sometimes understood others, had severe cognitive impairment (BIMS-3), and had physical and verbal behaviors directed at others (behavior of this type occurred 1-3 days). Record review of Resident #2's care plan dated 06/18/25 indicated Resident #2 had potential to demonstrate physical behaviors due to dementia and poor impulse control. Interventions included give Resident #2 as many choices as possible about care and activities, if Resident #2 has physical behaviors toward another resident immediately intervene to protect the residents involved and call for assistance, if intervening is unsafe call out for staff assistance immediately, notify the charge nurse of any physically abusive behaviors, and when Resident #2 becomes agitated: intervene before agitation escalates guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk away calmly away and approach later. Record review of Resident #2's progress note dated 06/17/25 at 9:34 a.m., completed by LVN E indicated MA B reported she was outside the secure unit and Resident #1 and Resident #2 being physically combative with each other. There were no injuries noted. Residents were separated with no further events. The MD and the RP were notified. Record review of facility investigation dated 06/13/25, completed and signed by the Administrator, indicated the allegation of abuse was confirmed. Resident #1 level of supervision was within eyesight. Resident #2's level of supervision was within eyesight. Resident #2 had a history of physical aggression. CNA A was getting a resident up for the day when she heard yelling. She went to investigate and noticed Resident #1 and Resident #2 yelling at each other with their fingers in each other's faces. CNA A stepped in between Resident #1 and Resident #2 to separate them and Resident #1 grabbed CNA A's wrist and twisted her arm behind her back. CNA A got loose and was able to separate them, then went back to finish with the other resident. CNA A tried to keep Resident #2 out of the dining area and redirect; however Resident #2 managed to get into the dining room. When Resident #2 tried to come out of the dining hall, Resident #1 would not let her pass, and then hit Resident #2 with an open hand on the left arm/shoulder area. There were no injuries. Residents were immediately separated, Medical Director, RP, ADON, Administrator, Corporate Compliance Nurse, and Area Director of Operations, were all notified. The facility conducted staff training on Abuse/Neglect and Resident Rights. Staff were not in-serviced on deescalating behaviors with residents. There was no documentation of who implemented or discontinued the 1:1 monitoring of Resident #1. CNA A's statement dated 06/08/25 indicated I was getting a resident up for the day. I started to transfer that resident to her wheelchair when I heard yelling. When I got the resident in the wheelchair I went to see about the yelling I saw Resident #1 and Resident #2 yelling at each other and their fingers pointing in each other's faces. I got in between them so they will not make contact with each other. In the process of separating them, Resident #1 pushed me and grabbed my wrist and twisting it and then twisted my arm behind my back. I finally got loose and got them separated. Then I went back to finish attend to the other resident. Resident #1 was sitting at the dining room table. I tried to keep Resident #2 out of the dining room but she still managed to get in the dining room. As I was getting Resident #2 out of the dining room she went the other way. Resident #1 would not let her past. That's when Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 6 of 12 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 07/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #1 hit Resident #2 open handed on the left arm shoulder area. I got Resident #2 out of the dining room I saw MA B coming to break me out for lunch. I let her know what happened and to keep them separated. Then I let my nurse know what happened. Before this incident I had to let my nurse know that Resident #1 might need a PRN because shortly after Resident #1 got up she started with her normal behavior of we are stealing her stuff and Resident #1 was rummaging way above her normal behavior the nurse did get come and give her something.[sic] Record review of the facility investigation dated 06/19/25, completed by the Administrator indicated the allegation of abuse was confirmed. Resident #1 level of supervision was within arms length. She had a history of similar allegations. Resident #2's level of supervision was within eyesight. Resident #2 had a history of physical aggression. MA B was passing medications just outside the secure unit. She looked up and saw both residents passing licks to one another. MA B hollered out for help and rushed into the secure unit to separate the residents due to CNA A was providing care to another resident. There were no injuries. Provide action taken Post-Investigation included staff training on abuse and neglect and resident rights. One-to-One provided for Resident #1 and Resident #2. Staff were not in-serviced on deescalating behaviors with residents. There was no documentation of who implemented or discontinued the 1:1 monitoring of Resident #1. Record review of MA B's statement dated 06/17/25 indicated I was passing pills on the outside of the unit. When gathering pills, I looked up and saw both residents passing licks to one another. I hollered out and rushed into the doors to separate due to the staff member was with another resident. Record review of Resident #1's monitoring sheet dated 06/17/25 and signed by CNA A indicated CNA A documented in 15 minute intervals from 9:30 a.m. through 12:45 p.m. There was no documentation of one-to-one assignment or what Resident #1 was doing at the time of the 15 minute monitoring. Record review of Resident #2's monitoring sheet dated 06/17/25 and signed by MA C indicated MA C documented in 15 minute intervals from 9:30 a.m. through 1:00 p.m. There was no documentation of one-to-one assignment or what Resident #2 was doing at the time of the 15 minute monitoring. During an interview on 07/08/25 at 9:15 a.m., the Administrator said the secure unit had 8 beds. She said the current census indicated there were 7 residents on the unit. She said the CNAs worked 12 hour shifts from 6:00 a.m. through 6:00 p.m. and 6:00 p.m. through 6:00 a.m. She said a nurse was not physically on the unit for any shift but would come on the unit, as necessary. During observation and interview on 07/08/25 at 9:25 a.m., CNA A said she was the only staff assigned to work in the secure unit from 6:00 a.m. through 6:00 p.m. She said she was in the process of cleaning the dining room after Resident #2 had an incontinent episode. She said she did not ask for staff assistance to clean the area or while she provided incontinent care for Resident #2. Resident #1 was off the secure unit and in therapy. Resident #2 smiled and said hello. During an interview on 07/08/25 at 11:10 a.m., the Administrator said one-to-one meant watching a resident all the time. She said CNA A was monitoring and 1-1 on 06/08/25. She said she was not aware another staff was assigned. She said resident supervision that required within eyesight was not possible with only one staff. During an interview on 07/08/25 at 11:15 a.m., the ADON said she spoke with the psych NP on 06/08/25 and Resident #1's Buspar was restarted that was previously discontinued on 06/06/25. She said she was not aware of who started or discontinued Resident #1's one-to-one staff on 06/08/25. During an interview on 07/08/25 at 11:53 a.m., the Administrator said the facility did not have a policy or a procedure/protocol for one-to-one staff. She said she was not aware of staff training related to one-to-one staff or expectations. During an interview on 07/09/25 at 9:25 a.m., CNA A said she was the only staff assigned to work on the unit for the shift 6:00 a.m. to 6:00 p.m. She said secure unit/memory care unit only had one staff assigned for each shift and each shift was 12 hours. She said another staff would supervise the unit if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 7 of 12 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 07/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she was on her break or had to leave the unit. She said on 06/08/25 she was getting another resident ready for the day and was transferring the resident to a wheelchair when she heard a commotion. She said she opened the door of the resident's room and observed Resident #1 and Resident #2 in an argument with their fingers in each other's face. She said she separated the residents and Resident #1 was in the dining room and Resident #2 was in the TV room. She said she returned to the other resident's room to finish getting her dressed. She said she came back out of the room and observed Resident #2 walk into the dining room. She said Resident #2 refused to leave the dining room and when she walked to the other side of the dining room Resident #1 hit Resident #2. She said she was assigned to one-to-one supervision of Resident #1 but took Resident #2 around with her as she took care of other residents. She said Resident #2 was more compliant and would wait in another resident's room while she assisted other residents in the washroom with the door closed. She said she did not ask for assistance when she had to care for other residents while providing one-to one. She said she did not recall who assigned or discontinued Resident #1's one-to-one on 06/08/25. She said the second incident on 06/17/25 occurred when she was taking care of another resident. She said MA B intervened. She said she was assigned one-to-one for Resident #1 and MA B was assigned one-to-one for Resident #2. She said there was no other staff to assist the other 5 residents on the unit. She said she did not recall who assigned or discontinued the one-to-one for Resident #1 or Resident #2. She said one-to-one meant staying with the resident all the time. During an interview on 07/09/25 at 9:40 a.m., the DON said MA B stayed on the unit until the one-to-one was discontinued. She said if CNA A needed help she would call out to the nurses' station for assistance. During an interview on 07/09/25 at 11:53 a.m., the Administrator said the facility did not have a policy for resident supervision or one-to-one resident supervision. During an interview on 07/09/25 at 1:57 p.m., the ADON said Resident #1's Buspar was restarted due to her increased behaviors after the GDR on 06/06/25. She said RN D completed an incident report and notified me because the DON was on PTO. She said one-to-one was stopped because we had de-escalated her behaviors. During an interview on 07/10/25 at 9:43 a.m. the DON said on 06/08/25 the corporate secure care nurse was notified of the incident and scheduled a TEAMS meeting to review the incident on 06/17/25. She said the second incident occurred right before the meeting started. The secure care nurse suggested the residents be evaluated for pain and routine pain medications be administered if appropriate. It was also suggested the staff receive training on de-escalation. She said the incident on 06/17/25 was discussed with the Administrator and the ADON. Resident #1 and Resident #2's behaviors had calmed and the one-to-one was discontinued. She said staff were trained on de-escalation on 06/23/25. She said the other resident that received care during the incident on 06/08/25 and 06/17/25 was moved off the unit. She said staff was directed to call for assistance if they need help. She said there was no additional issues identified with the one-to-one during both incidents. During an interview on 07/09/25 at 4:30 p.m., the Administrator said one-to-one was someone to sit with a resident, so another altercation did not happen. She said she would not want other residents endangered. She said a TEAMS call with a secure care nurse was completed after the incident on 06/08/25. She said the facility did not talk to the secure care nurse until the following week after the second incident on 06/17/25. She said one-to-one was not really one-to-one because we did not assign an additional staff to watch the other residents. She said the RN weekend supervisor was responsible for ensuring adequate staff on the weekend. She said the RN weekend supervisor should have separated residents 06/08/25 and gotten another staff to sit with the resident until the behaviors were under control and until we got direction from the doctor on how to proceed. She said residents were at risk of injury for accidents without adequate supervision. During an interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 8 of 12 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 07/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 07/10/25 at 12:51 p.m., RN B said she did not recall the incident on 06/08/25. She said she did not remember assigning one-to-one to any staff. She said residents were at risk of accidents and injuries without adequate supervision. During an interview on 07/10/25 at 1:10 p.m., weekend supervisor RN BB said she recalled the incident on 06/08/25 but she was not involved. She said she did not know who assigned one-to-one or who discontinued one-to-one for Resident #1. She said RN B was involved with the incident. She said residents were at risk of accidents and injuries without adequate supervision. During an interview on 07/10/25 at 2:04 p.m., MA B said she was passing medications outside of the secure unit on 06/17/25. She said she observed Resident #1 and Resident #2 hitting each other. She said she immediately went on the unit and separated the residents. She said she was not aware of any one-to-one assignment. She said residents were at risk of accidents and injuries without adequate supervision. During an interview on 07/10/25 at 2:21 p.m., MA C said she was assigned one-to-one with Resident #2 on 06/17/25. She said CNA A was assigned one-to-one with Resident #1. She said there were no additional staff assigned to the unit while the one-to-one was in place. She said we managed to keep up with everything. She said CNA A took Resident #1 with her while she assisted other residents or she was in her (MA C's) eyesight. She said the DON directed her to stop on-to-one. She said residents were at risk of accidents and injuries without adequate supervision. An Immediate Jeopardy/Immediate Threat was identified on 07/10/25 at 2:25 p.m. The ADO and the DON were notified of the Immediate Jeopardy and provided the IJ template on 07/10/25 at 2:48 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 07/10/25 at 8:26 p.m. and reflected the following: Plan of Removal: The facility failed to adequately supervise residents to implement interventions to prevent accidents and protect residents from potential injuries from resident to resident altercations.Interventions: All residents in template or put at risk for harm were assessed by charge nurse. No findings identified. All Residents are assessed weekly for behaviors on the weekly nursing summary. To include Wandering, verbal and physical behavior symptoms directed towards others. Last assessment completed on 7/10/25Resident were separated, placed on 1:1, social service consult, safe surveys, trauma informed PRN assessment completed, interviewed staff, skin assessments, secure care consult scheduled, Inservice regarding abuse/neglect to include resident to resident abuse and resident rights, medical director was notified, ADHOC initiated for incident date 6/8/25 & 6/17/25Monitored on the following for incident date 6/8/25 & 6/17/25Ask 10 staff members per week, if they have noticed any inappropriate behavior among residents, if so, verify what the staff member did and if it was reported properly. Document any corrective action as needed. If they have not observed any inappropriate behavior, ask what they would do if they did and who they would report it to. Document date/time, if they answered correctly, the staff member's name, and any corrective action if needed.Document 5 resident quality of life rounds every week, asking how things are going for them, etc. Document date/time, the resident's name, if there was any negative response, and any corrective action if needed.During incident/event review in standup, the DON and Admin will monitor for potential inappropriate resident behaviors in the event reports.During facility rounds, are there any signs of potential resident to resident inappropriate behavior.medication adjustments for Resident #1 on 6/8/25.The DON and ADON were in-serviced 1:1 by the ADO on following in-services on 7/10/25 at 4:30 pm.1:1 monitoring: Consistent observation involving assigning a dedicated staff member to continuously observe a single resident. Process of determining when 1:1 is initiated and concluded: one on one will be determined by the DON or designee and concluded by consulting with psych services/secure care team/or IDT team. De escalating behaviors Abuse and neglect to include increased supervision for residents with aggressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 9 of 12 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 07/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few behaviors.1:1 in service with the aides who completed the one on one on 6/8 & 6/17/25- the staff member doing one on one will have consistent observation involving assigning a dedicated staff member to continuously observe a single resident. All other staff we're also in-serviced over 1:1 monitoring. Starting 7/11/25 review all new incident and accidents and self-reports during clinical meeting & stand down to ensure the correct process was followed regarding one on one and reporting to be reviewed by IDT team. Review of staffing in memory care unit- In the event an incident occurs between residents additional staff will be pulled to assist with monitoring and resident care. The aide will notify the charge nurse immediately via phone located in memory care unit. When the aid is providing care to residents they will call additional staff to supervise residents in the memory care unit during that time. The Medical Director was notified of the Immediate Jeopardy on 7/10/25 by the [NAME] ADHOC QAPI meeting was completed by the interdisciplinary team to include the Medical Director 7/10/25.In-services: The following services were initiated on 7/10/25 for all staff members by the DON, ADON, and/or Regional Compliance Nurse. All staff not present for in-servicing will not be permitted to work their assignment until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior working their floor assignment. Abuse and Neglect: Failure to properly monitor residents with aggression towards others can lead to negative outcomes and not having proper 1:1 may result in additional behaviors and additional aggressive behaviors.Deescalating behaviors with resident- how staff can manage and deescalate residents when having altercations. In the event the resident becomes aggressive with staff or other residents, the staff or aide need to keep residents separated and notify the charge nurse immediately. Prevention of resident-to-resident abuse- staff to engage residents with activities, snack, redirection, and monitor for any new changes of condition.1:1 monitoring: Consistent observation involving assigning a dedicated staff member to continuously observe a single resident (not providing care to any other residents during this time). One on one will be determined by the DON or designee and concluded by consulting with psych services/secure care team/or IDT team. Documentation of one on one monitoring will be reflected on the monitoring sheets and show discontinuation. Any staff member can provide one on one monitoring. Monitoring: Monitor 5 days a week x 6 weeks any events that required 1:1, was there proper 1:1 completed.Monitor 5 days a week x 6 week any changes of condition or possible resident to residents.Monitoring of the facility's Plan of Removal included the following: Record review of Resident #1 and Resident #2 assessments dated 07/10/25 indicated no negative findings . Record review of Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, and Resident #8's weekly nursing summaries dated 07/10/25 included wandering, verbal and physical behavior symptoms directed towards others. There were no concerns noted.Record review of staff training dated 07/10/25 at 4:40 p.m. indicated the DON and ADON were in-serviced 1:1 by the ADO on 1:1 monitoring: Consistent observation involving assigning a dedicated staff member to continuously observe a single resident. Process of determining when 1:1 is initiated and concluded: one on one will be determined by the DON or designee and concluded by consulting with psych services/secure care team/or IDT team, de-escalating behaviors, abuse and neglect to include increased supervision for residents with aggressive behaviors.Record review of 1:1 in service dated 07/10/25 with CNA A and MA C who completed the one on one on 6/8/25 & 6/17/25 indicated the staff member doing one on one will have consistent observation involving assigning a dedicated staff member to continuously observe a single resident. All other staff we're also in-serviced over 1:1 monitoring. Record review of incident and accident reports and self reports from 07/08/25 though 07/11/25 indicated there was no concerns noted during clinical meeting & stand down on 07/11/25 regarding one on one and reporting to be reviewed by IDT team. Record review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 10 of 12 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 07/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few staffing in memory care unit- In the event an incident occurs between residents additional staff will be pulled to assist with monitoring and resident care. The aide will notify the charge nurse immediately via phone located in memory care unit. When the aid is providing care to residents they will call additional staff to supervise residents in the memory care unit during that time. Record review of staff training dated 07/10/25 and 07/11/25 conducted by the DON, ADON, and/or Regional Compliance Nurse indicated Abuse and Neglect: Failure to properly monitor residents with aggression towards others could lead to negative outcomes and not having proper 1:1 may result in additional behaviors and additional aggressive behaviors. De-escalating behaviors with resident- how staff can manage and deescalate residents when having altercations. In the event the resident becomes aggressive with staff or other residents, the staff or aide need to keep residents separated and notify the charge nurse immediately. Prevention of resident-to-resident abuse- staff to engage residents with activities, snack, redirection, and monitor for any new changes of condition. 1:1 monitoring: Consistent observation involving assigning a dedicated staff member to continuously observe a single resident (not providing care to any other residents during this time). One on one would be determined by the DON or designee and concluded by consulting with psych services/secure care team/or IDT team. Documentation of one on one monitoring would be reflected on the monitoring sheets and show discontinuation. Any staff member can provide one on one monitoring. Observation and interview on the secure unit on 07/11/25 at 10:46 a.m. Resident #1 and Resident #2 were sitting in the TV room. They were calm and there were no signs of agitation. Resident #1 and Resident #2's 1-1 was previously discontinued. MA C was assigned to watch the 7 residents of the secure unit while CNA F was on her lunch break. MA C indicated she received training related abuse/neglect/reporting, behaviors and de-escalating behaviors, and one-to-one resident supervision. She indicated for one-to-one she would remain within close proximity, engage the resident and monitor for any changes. She would notify the nurse in charge, DON, and Administrator of any changes. During an interview on the secure unit on 07/11/25 at 10:50 a.m., MA B indicated she received training related abuse/neglect/reporting, behaviors and de-escalating behaviors, and one-to-one resident supervision. She indicated for one-to-one she would remain within close proximity, engage the resident and monitor for any changes. She would notify the nurse in charge, DON, and Administrator of any changes. There was no resident assigned one-to-one monitoring as of 07/11/25. Interviews conducted on 07/11/25 from 10:46 a.m. through 2:00 p.m. representing staff from all shifts and departments (6a.m.-6p.m., 6p.m.-6a.m., 6a.m.-2p.m., 2p.m.-10p.m., and 10p.m.-6a.m.) included the DON, CNA A, MA B, MA C, LVN G, CNA H, HR/CNA I, CNA J, BOM K, CNA L, LVN M, CNA N, PT/DOR O, Medical Records P, MDS LVN Q, Dietary [NAME] R, LVN S, ADON/LVN T, Dietary [NAME] U, Dietary [NAME] V, HSK W, SW X, Dietary Manager Y, and HSK Z. All staff were able to identify the different types of abuse, what to do if they witnessed resident to resident abuse, what signs to watch for in residents to prevent resident to resident abuse, who to report any incidents of abuse. Staff were able to identify ways to prevent residents with high-risk behaviors such as wandering and agitation from abuse and neglect (remove from reach of others, increase supervision of wandering by monitoring while they are wandering, and/or engaging in activity). Staff indicated they were to be aware of resident behaviors, monitor for behaviors, and how to de-escalate behaviors. Staff knew they were to separate residents immediately and ensure residents were safe. All staff were able to identify the responsibilities of assigned 1:1 supervision. All staff were able to identify the responsibilities of caring for a resident with aggressive behaviors. All staff were able to identify the responsibilities for supervision and monitoring residents. All staff were able to identify 1:1 monitoring/supervision meant always staying with resident -keep eyes on the residents and they had to be relieved by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675152 If continuation sheet Page 11 of 12 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 07/11/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete another trained staff before going on break/meal. All staff aware of supervising and monitoring was a preventive or proactive intervention. The process of determining when 1:1 was initiated and discontinued would be determined by the DON or designee. Nursing staff indicated they would be notified of CNA/MAs breaks and were responsible for monitoring residents until the aide returned. All staff indicated resident behaviors and triggers including resident specific triggers to provide optimal monitoring and prevention on falls/injuries. All staff identified redirection techniques of walking with residents and/or engage in diversional activities if a resident was agitated or wandering. CNA staff identified responsibilities of checking Kardex for resident specific care plan and triggers. During an interview on 07/11/25 at 10:46 a.m., MA C indicated1:1 monitoring included consistent observation involving a dedicated staff member to continuously observe a single resident. The process of determining when 1:1 is initiated and concluded would determined by the DON or designee and, was able to give examples of de-escalating behaviors, and prevention of abuse and neglect included increased supervision for residents with aggressive behaviors. During an interview on 07/11/25 at 11:00 a.m., CNA A said indicated1:1 monitoring included consistent observation involved a dedicated staff member to continuously observe a single resident. The process of determining when 1:1 was initiated and concluded would be determined by the DON or designee and was able to give examples of de-escalating behaviors, and prevention of abuse and neglect included increased supervision for residents with aggressive behaviors. During an interview on 07/10/25 at 1:15 p.m., the DON said. Monday through Friday she and the ADON would review all incidents and the 24-hour report and make needed changes to care plans with any change of condition including behaviors or resident-to-resident altercations. She indicated 1:1 monitoring included [TRUNCATED] Event ID: Facility ID: 675152 If continuation sheet Page 12 of 12