Dogwood Creek Retirement Center

What the state also noted

• — June 2026: cited for incomplete controlled medication counts on all 4 of 4 medication carts, with dozens of missing on-coming and off-going nurse signatures over roughly two weeks. The health and wellness director said weekend aides and night shift 'are bad about not signing the log sheets.' The plan of correction was accepted July 1, 2026.
• — The June 2026 reports state that narcotic sheets were compared to remaining counts, but the surveyor never documented that the counts reconciled. The statement that 'all medications were accounted for' appears only in the facility's own plan of correction, not in any OSDH finding.
• — The June 2026 heat complaints coincided with the facility's air conditioning being out of service. Residents were on window units with fans and portable coolers in common areas, and staff were interviewed about the timeline to have the air conditioning replaced. Ask the facility whether the system has since been replaced.
• — Ten separate complaints were filed and investigated in June 2026 alone; fourteen complaint investigations appear across the two-year window. High complaint volume is itself worth asking the facility about, even where most did not result in citations.
• — October 2025 licensure survey: cited for having no documentation the quality assurance committee met quarterly over a full year, and for an expired bag of medication (dated 04/12/24) found in the medication refrigerator.
• — June 2025: the state cited an Immediate Jeopardy deficiency (the most serious level) for failure to protect residents from sexual abuse, cited for 2 of 3 sampled residents. Records showed an earlier December 2024 incident involving the same resident, and a 05/27/25 DHS note describing sexual contact with a 'less cognitive resident.' The Director of Nursing acknowledged that after a 05/29/25 incident the two residents were separated but not placed on supervised watch, and there was no documentation of safety rounds. Another resident told the surveyor they did not feel safe around that resident. The state verified the immediacy was removed 06/16/25 and cleared all deficiencies on 08/25/25.
• — The October 2024 investigation of a sexual-abuse allegation closed with no deficiencies cited. That outcome should be read alongside the documented 12/01/24 incident and the June 2025 Immediate Jeopardy finding at the same facility — 'no deficiencies cited' is not a finding that nothing occurred.
• — Three of the four surveys reviewed resulted in citations. This is not a clean record.
• — The mold complaint was closed without a citation, but the surveyor noted being 'unable to see concrete under carpet' — the area under the carpet was not inspected.
• — OSDH investigative reports do not formally label complaints 'substantiated' or 'unsubstantiated.' The substantiated count here reflects complaints where a related deficiency was cited on the attached State Form, and is an interpretation.
• — The document filed under the 11-21-2025 exit date is an offsite paper revisit of the 10-21-2025 licensure survey; the citations described for that period come from the October survey, and the compliance confirmation was a paper review rather than an on-site inspection.
• — Administrator names change across the letters in this period (Dani Woodland, Charlisa Stroman, and Briana Libey are addressed at different points), and the facility's own plan of correction states the Director of Nursing involved in the 2025 abuse incident is no longer employed there. That statement is the facility's, not the surveyor's.
• — The scanned text is OCR'd and noisy in places — complaint #91171's summary contains a merged sentence ('Facility was observed for bugs. temp and followed the menu.') and several plan-of-correction passages are partly illegible. The citation text and complaint numbers are legible; the narrative summaries are fragmentary.