Inspection·August 20, 2025

F 0641 Ensure each resident receives an accurate assessment. 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 an accurate MDS was completed for 2 of 12 residents (Residents #6 and #11) reviewed for MDS assessment accuracy. The facility did not accurately code Resident #6 for dialysis care on 3 quarterly, 1 annual/Medicare 5 day and 1 Medicare 5 day MDS assessments.The facility did not accurately code Resident #11's quarterly MDS assessment for hospice care.These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included:1.A review of Resident #6's face sheet and physician orders for August 2025 indicated Resident #6 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included ESRD (end stage renal disease), dependence on renal dialysis, and Alzheimer's dementia. A review of hospital records dated 06/05/2024 indicated Resident #6 had a medical history of ESRD and was receiving hemodialysis (a medical procedure used to remove waste products and excess fluid from the blood when a person's kidneys are not functioning properly). A review of Resident #6's physician orders dated August 2025 indicated she had an order dated 07/16/2025 for dialysis 2 (two) times a week beginning on 07/08/2025.A review of a care plan initiated on 01/09/25 and revised on 03/24/25 indicated Resident #6 was scheduled for dialysis three times a week.Record review of progress notes dated 12/26/2024, 03/14/2025, 05/09/2025, 06/22/2025, 06/27/2025, and 07/25/2025 indicated Resident #6 was receiving dialysis while a resident during the MDS assessment periods. Record review of dialysis communication forms dated 05/09/2025 and 07/16/2025 indicated Resident #6 received dialysis treatments on those dates. A review of Resident #6's Medicare 5-day assessment dated [DATE] Section O j1: Dialysis care was not marked as being received while a patient. The same MDS noted Resident #6 had a BIMS score of 12 indicating her cognition was moderately impaired. Further review of Resident #6's MDS assessments indicated the following:-Quarterly MDS assessment dated [DATE]: Section O j1: Dialysis care was not marked as being received while a patient. -Quarterly MDS assessment dated [DATE]: Section O1: Dialysis care was not marked as being received while a patient. -Annual/Medicare 5-day assessment dated [DATE]: Section O j1: Dialysis care was not marked as being received while a patient. -Quarterly MDS assessment dated [DATE]: Section O j1: Dialysis care was not marked as being received while a patient. During an interview on 08/19/2025 at 03:30 PM, the MDS Coordinator said she did not mark Resident #6's MDS assessments for dialysis because she did not have documentation from the dialysis center stating Resident #6 had received dialysis during the assessment periods. During an interview on 08/19/2025 at 09:50 AM, the MDS Coordinator said she had requested and received documentation of the 3 (three) times a week dialysis treatment since 07/29/2025 from the dialysis center. 2.A review of Resident #11's face sheet and physician's orders for August 2025 indicated Resident #11 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including traumatic brain injury, stroke, vascular dementia with agitation and Alzheimer's disease. A review of Resident #11's physician's orders dated August 2025 indicated she had an order dated 11/11/2024 Residents Affected - Few (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 5 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 08/20/2025 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)