Inspection·September 30, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few fracture with Resident #1's RP and it was determined there would not be surgical intervention at that time.On 9/29/25 at 11:26 AM and 12:07 PM, CNA A was called but there was no answer, the voicemail was full and was unable to leave voicemail. On 9/29/25 at 3:06 PM, CNA A was texted a detailed message and requested a return call. On 9/30/25 at 12:10 PM, CNA A was called but there was no answer and was unable to leave a voicemail. CNA A did not return the calls or text message prior to the surveyor exiting the facility.During an interview on 9/29/2025 at 1:45 PM, LVN B said she had worked at the facility for three years on the 6 AM-6 PM shift. LVN B said she was the nurse on duty on the day Resident #1 fell. LVN B said the fall with Resident #1 was horrible. LVN B said CNA A came and told her Resident #1 had fallen from the bed. LVN B said Resident #1 was face down on the floor and was unable to use her arms to catch herself and took a blow to her face. LVN B said the bed was elevated due to CNA A was performing incontinent care. LVN B said CNA A said she had looked for someone to help her perform incontinent care, but CNA A said she thought she could do it alone, even though Resident #1 was a two person assist. LVN B said when CNA A rolled Resident #1 onto her side to put the incontinent brief on, Resident #1 was too close to the edge and Resident #1 rolled off the bed. LVN B said Resident #1 was saying she was hurting. LVN B said she assessed Resident #1 and sent her to the hospital. LVN B said CNA A was a sweet aide and would have never done anything intentionally to hurt Resident #1. LVN B said staff should look at the Kardex to see how much care/assistant a resident needed or required. LVN B said she had received the in-services on bed positioning and ADL assistance, and abuse and neglect.During an interview on 9/30/25 at 11:27 AM, the ADON said she had worked at the facility since 2011. The ADON said she had already left for the day when she was called and was told Resident #1 had fallen out of bed. The ADON said she was told Resident #1 had rolled off the bed while CNA A was performing incontinent care by herself. The ADON said she called CNA A on the phone, and CNA A said she had done Resident #1's care by herself. The ADON said she had just had an in-service with the staff on using the Kardex and ensuring using the appropriate amount of staff when performing care and had discussed what residents required two-person assistance during ADL care. The ADON said CNA A said she got between Resident #1's bed and the wall and rolled Resident #1 away from her and Resident #1 fell out of the bed. The ADON said CNA A told her she always did Resident #1 that way. The ADON said CNA A knew she had to have two persons during bed position and incontinent care of Resident #1 and knew about the Kardex. The ADON said CNA A told her she did not attempt to find anyone to ask for assistance because everyone was busy. The ADON said CNA A knew she was wrong for trying to perform bed positioning and incontinent care on Resident #1 alone. The ADON said CNA A was very upset and remorseful for the incident. The ADON said the nurse assessed Resident #1 and sent her to the hospital. The ADON said Resident #1 was determined to have a fractured hip and they opted not to do surgery. The ADON said CNA A was suspended and they started in-servicing and quizzing staff on how to find the Kardex and the assistance needed to provide ADLs safely. The ADON said they ended up terminating CNA A because she did not follow Policy and Procedures or ask for help and CNA A knew she should have. During an interview on 9/30/25 at 9/30/25 at 1:47 PM, the ADON said she knew she had in-serviced the nursing staff approximately a month prior to the incident with Resident #1 because she had to show the DON and ADM that the staff had been previously in-serviced on looking in the Kardex to know what amount of assistance residents needed with ADL tasks approximately a month prior to the incident. The ADON said she was unable to locate the in-services. The ADON said she had given the in-services to the DON and the ADM during the investigation of Resident #1's fall and the ADON said that was how they were able to prove CNA A knew she should have used two people during Resident #1's incontinent care/bed positioning. The ADON said the DON and the ADM were no longer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675066 If continuation sheet Page 2 of 4 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 675066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Honey Grove Nursing Center 1303 E Main St Honey Grove, TX 75446 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 working at the facility and she did not know where to locate the in-service related to using the Kardex to determine the amount of assistance a resident needed or required during ADLs.During an interview on 9/30/25 at 2:07 PM, DON O said CNA A told her and others, she went into Resident #1's room to perform incontinent care and reposition her and did not want to bother anyone. DON O said CNA A said she went between Resident #1's bed and the wall and rolled Resident #1 over to place the brief and Resident #1 rolled off the bed. DON O said CNA A was very much aware and knew she had done wrong and was sorry for it. DON O said they terminated CNA A for not following policy and procedures which caused injury to Resident #1. DON O said they did in-service all the nursing staff to always refer to the Kardex to see what amount of assistance the resident required and if a resident was a two-person assist then staff were not to perform the task if there were not two persons. DON O said Resident #1 was a two person assist at the time of the incident and CNA A was aware prior to attempting to perform bed position/incontinent care with just herself. DON O said they had in-serviced nursing staff on using the Kardex to see what amount of assistance a resident required upon hire, quarterly, and with their annual competencies. DON O said she did not remember exactly when the in-service had been completed prior to the incident, but it had not been long. DON O said CNA A had never had any other issues to her knowledge.During an interview on 9/30/25 at 2:50 PM, ADM Q said she had been the Interim ADM for four weeks. ADM Q said she did not have any knowledge of the incident with Resident #1 other than she knew they were continuing to in-service staff on using the Kardex to ensure they were using the appropriate amount of staff to perform ADLs for safe.During an interview on 10/01/25 at 5:37 PM, ADM P returned a phone call and said she had been the ADM at the facility from February 2025 until July 7, 2025. ADM P said the incident with Resident #1 was a fall from the bed while CNA A was providing incontinent care by herself and had rolled the resident over and Resident #1 rolled off the bed onto the floor. ADM P said CNA A was interviewed and CNA A knew Resident #1 was a two person assist during incontinent care/bed positioning and did not do so. ADM P said Resident #1 was assessed by the nurse and sent to the emergency room. ADM P said they started in-servicing the staff on two-person assist during ADLs and began ongoing monitoring for compliance. ADM P said they suspended CNA A immediately, but after investigating the incident CNA A was terminated for not following policy and procedures. Record review of a CNA Proficiency Audit dated 3/12/25, indicated CNA A had a S in the column beside CNA care plans/worksheets and Turns/Repositions residents timely and correctly, which indicated CNA A performed those areas of care satisfactorily.Record review of CNA A's handwritten signed statement dated 4/15/25, indicated she was changing Resident #1. CNA A said she was holding Resident #1 and putting a brief under her, she rolled and fell off the bed.Record review of ADM P's Witness Statement dated 4/15/25, indicated CNA A stated she was lifting Resident #1 and placing a brief underneath the resident and Resident #1 slid off the bed.Record review of the ADON's Witness Statement dated 4/17/25, indicated CNA A stated she was aware resident was a two person assist and also stated she did not ask for help because LVN B and CNA F were busy doing something else.Record review of the facility's Employee Disciplinary Report dated 4/18/25 indicated CNA A failed to meet job duty/responsibility expectations and it was found that CNA A failed to follow policies and procedures when handling a resident on 4/15/25. CNA A attempted to move a resident without assistance knowing the resident was a two person assist. CNA A was not able to lift the resident alone and the resident ended up sliding off the bed. CNA A raised concerns for resident safety and security due to not following resident orders. CNA A was aware of their job duties/responsibilities and code of conduct expectations by their signature on the employee handbook acknowledgement and job description.Record review of the facility's undated policy titled Fall Policy indicated . Preventing falls requires an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675066 If continuation sheet Page 3 of 4 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 675066 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Honey Grove Nursing Center 1303 E Main St Honey Grove, TX 75446 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 interdisciplinary program that focused on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family . appropriate interventions will be addressed on the interdisciplinary plan of care . Interventions would be resident centered . staff must be trained in safe transfer technique .ADM Q was notified of PNC IJ on 9/30/25 at 9:25 AM due to the above failures. ADM Q was provided with the IJ template on 9/30/25 at 9:29 AM. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy and the facility had corrected the noncompliance on 04/16/25 by the following: The facility performed a skin assessment of Resident #1 after fall on 4/15/25. The facility initiated neurological assessments on Resident #1 after fall on 4/15/25. The facility sent Resident #1 to the emergency room on 4/15/25. CNA A was placed on suspension on 4/15/25 during the investigation. CNA A was terminated on 4/18/25 due to resident mistreatment, failed to follow policies and procedures when she attempted to move a resident without assistance, knowing the resident was a two person assist. Staff surveys were performed asking if staff had witnessed a staff member performing ADLs with the wrong amount of staff - all answered no. All nursing staff (nurses & CNAs) were in-serviced on 4/15/25 on Do Not Perform a Task (ADL) without Proper Amount of staff, finding amount of assist needed in the Kardex, and fall policy. All staff in-serviced 4/15/25 on Abuse, Neglect, and Exploitation. All nursing staff (nurses & CNAs) were in-serviced on 4/16/25 on Bed positioning. The facility performed weekly monitoring of at least 10 to ensure the proper number of staff was providing assistance with bathing, bed mobility, transferring, walking, and incontinent care. The facility conducted staff surveys of 10 staff members per week about how to locate, how much assistance was needed for a resident task and what they would do if the proper number of staff was not present.All staff interviewed (LVN B, LVN G, LVN H, LVN L, LVN N, RN C, CNA D, CNA E, CNA F, CNA J, CNA K, & CNA M) on 9/29/25 from the 6 AM-6 PM shifts and 6 PM-6 AM shifts which included: 1 of 3 RNs, 5 of 7 LVNs, and 6 of 12 CNAs, which also included newly hired staff, were able to answer appropriately where they would find the amount of assistance a resident needed for ADL care, proper bed positioning while performing ADLs, and Abuse/Neglect.During an observation on 9/29/2025 beginning at 2:40 PM, CNA F and RN C performed incontinent care on Resident #1. CNA F and RN C positioned themselves on each side of Resident #1's bed and performed safe bed positioning while performing incontinent care. Record review of undated staff surveys indicated 15 staff members said they had not witnessed a staff member performing ADL with the wrong amount of staff.Record review of an In-service Training Attendance Roster with training topic titled Do Not Perform a Task (ADL) Without Proper Amount of Staff, Finding Amount of Assist Needed in Kardex, and Fall policy and dated 4/15/25 indicated all nursing staff had signed the in-service.Record review of an In-service Training Attendance Roster with training topic titled Abuse, Neglect, and Exploitation Inservice and dated 4/15/25 indicated all staff had signed the in-service.Record review of an In-service Training Attendance Roster with training topic titled Bed Positioning and dated 4/16/25 indicated all nursing staff had signed the in-service.Record review of the facility's weekly monitoring of a least 10 to ensure the proper number of staff was providing assistance with bathing, bed mobility, transferring, walking, and incontinent care indicated it was initiated 4/15/25 and continued weekly to present.Record review of the facility's weekly monitoring of asking at least 10 staff members how to locate how much assistance was needed for a resident task and what they would do if the proper amount of staff was not present, indicated it was initiated on 4/15/25 and had continued weekly to present.The noncompliance was identified as PNC. The noncompliance began on 4/15/24 and ended on 4/16/24. The facility had corrected the noncompliance before the survey began. Event ID: Facility ID: 675066 If continuation sheet Page 4 of 4