Dogwood Trails Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 7 residents reviewed for misappropriation of resident property. (Resident #1) The facility failed to keep Resident #1 free of misappropriation of property when HSK A took Resident #1's Android cell phone, changed her account password, ordered an iPhone 15, and was having it delivered to his address, and was trying to order an IPhone 17. This failure could place residents at risk for decreased quality of life, misappropriation of property, and compromised dignity.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan, or comprehensive care plan with necessary information within 48 hours of the resident's admission for 1 of 7 residents (Resident #101) reviewed for new admissions. The facility failed to develop a baseline care plan within 48 hours of admission for Resident #101 when the resident was admitted on [DATE]. This failure could lead to residents not receiving necessary care and decreased quality of life.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for 1 of 5 residents (Resident #6) reviewed for medical records accuracy. The facility failed to ensure Resident #6's order for dialysis treatments was accurately reflected in the facility's electronic health records. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #10) reviewed for infection control. The facility failed to implement enhanced barrier precautions for Resident #10. These failures could place residents at risk for cross contamination, spread of infection and sepsis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to include mandatory training as part of its infection prevention and control program for staff reviewed for infection control. The facility failed to implement EBP training to all staff members and an upon hire and refresher training annually thereafter. These failures could place residents at risk for cross contamination, spread of infection and sepsis.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #8) reviewed for reporting allegations of abuse. The DON failed to ensure allegations of verbal abuse were reported to the Abuse Coordinator immediately or to the sState within 2 hours. On 06/09/25 at an unknown time, Resident #8 alleged to the Activity Director that MA C hated her and yelled at her. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services that determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 2 nurses' medication carts (100/300/unit nurses' medication cart) reviewed for pharmacy services. The facility failed to ensure the 100/300/unit nurses' medication cart Controlled Drugs Audit Record was signed off before and after each shift for October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, and April 2025. The Audit Record had a total of 28 missing nurse signatures. These failures could place residents at risk for medication errors and loss of medications through drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 5 (Resident # 1) residents reviewed for misappropriation of resident property. The facility failed to prevent a drug diversion (misappropriation) of Resident #1's liquid morphine sulfate, a controlled medication. During the narcotic count audit, on 10/17/24, LVN D and LVN F discovered approximately 1 mL of Resident #1's liquid morphine sulfate was missing. The non-compliance was identified as past non-compliance. The noncompliance began on 10/17/24 and ended on 10/17/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, increased pain, and misappropriation of property or physician ordered medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 2 of 4 residents reviewed for comprehensive care plans related to behaviors. (Resident #2 and Resident #3) 1. The facility failed to ensure Resident #2's comprehensive care plan for physical aggression was personalized and person-centered. 2. The facility failed to develop a person-centered care plan for Resident #2's verbal and other (verbal/vocal symptoms like screaming, disruptive sounds) behaviors. 3. The facility failed to develop a person-centered care plan for Resident #3's verbal behaviors. These failures could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for 1 of 7 residents (Resident #4) on the secured unit reviewed for pests. The facility failed to ensure Resident #4's room was free of ants, which resulted in 10 ant bites to her left arm, 2 ant bites for her right arm, and 2 ant bites to her left clavicle. The bites were identified on 12/18/24. These findings could place residents at risk for an injury or infection related to ant bites, an unsanitary environment, and a decreased quality of life.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse of residents were reported to HHSC within the 2-hour period for 2 of 5 residents (Resident #1 and #2) reviewed for abuse. The facility failed to report an allegation of physical abuse within 2 hours to the State Agency when Resident #1 struck Resident #2 in left upper arm with a closed fist. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 did not sustain injuries of unknown origin. On 03/10/24 Resident #1 was diagnosed with a comminuted (broken in two places) intertrochanteric left femur (thigh bone) fracture with varus angulation, comminuted intertrochanteric right femur fracture with varus (inwards) angulation, and anteriorly displaced distal fracture fragment of the right femoral fracture, and an acute angulated displaced fracture of the left proximal humeral diaphysis (shaft). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 10 residents (Resident #1) reviewed for notification of changes. The facility failed to ensure Resident #1's physician was notified when the resident's oxygen was at 77% on room air on 03/09/24. The noncompliance was identified as PNC. The noncompliance began on 03/09/24 and ended on 03/10/24. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for delay in treatment and decreased quality of life.