Health inspection·December 10, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few complained 10/10 of leg and back pain. Resident #1 had a skin tea to left hand and discoloration to bilateral knees. Neglect and Abuse were ruled out. The physician, DON, and family were notified. Actions included being changed to 2-person assist. Record review of Resident #1's hospital records dated 12/06/25 indicated she sustained a comminuted distal left femur fracture with apex posterior angulation and mild impaction. Record review of Resident #1's hospital records dated 12/07/25 indicated a non-displaced fractur of the right distal femoral shaft. Record review of CNA W's personnel record indicated she was oriented to resident care on 01/21/25 and incontinent care and fall prevention on 02/13/25. During an interview on 12/09/25 at 9:55 a.m., the DON said she was made aware on 12/06/25 Resident #1 fell, had pain and was sent to the hospital. The hospital never called the facility to give report of their findings. On 12/08/25, the facility found out she had sustained a left leg fracture and during surgery the surgeon noticed Resident #1 had right foot and leg swelling and determined she also had a right leg fracture. Resident #1's family member came to the family on 12/08/25 and questioned how he sustained her injuries. The DON said she showed the family member the bed height was set up in the highest position and how she rolled out of the bed onto the floor. Resident #1 had no history of falls in the facility. Resident #1 was on an air mattress that was set based on her weight. She said she was not in a bariatric mattress because she did not meet the criteria of a BMI over 50. She said staff are trained on bed mobility. She said Resident #1 was a 1-person assist for bed mobility. Staff are aware of resident care requirements through the care plan and care record. She said the facility determined the air mattress probably factored into Resident #1's fall during care and the facility had already begun the process of obtaining bolsters to prevent falls and a bariatric mattress. She said Resident #1's care plan would be reviewed and revised based on needs upon her return to the facility. She said Resident #2 would be a two-person assist for bed mobility upon her return to the facility. During an interview on 12/09/25 at 10:42 am., CNA W said Resident #1 was a 1-person assist for bed mobility and ADL care. She said she was going to change Resident #1. She said she rolled Resident #1 on to her weak right side and lifted her left leg to begin care. She said Resident #1 continued to roll off the bed. She said she held onto Resident #1's left knee and left arm as she fell to the floor. She said she was still hanging on to Resident #1's left leg and left arm when she was on the floor and she was hanging over the bed mattress. She said she left Resident #1 to get LVN N. She said LVN N was walking in the hall and came into the room immediately. She said Resident #1 was complaining of pain to her leg and back. She said Resident #1 was lying flat in the middle to her bed prior to the start of care. She said she did not pull Resident #1 closer toward her prior to turning her from her back onto her weak side. She said she felt there was not enough room and it would not have made any difference. She said she was trained on bed mobility and incontinence care. She said Resident #1 was a 1 person assist for ADL care. The surveyor attempted to call LVN N on 12/09/25 at 11:38 a.m. There was no answer. The surveyor left a voicemail message with contact information. LVN N did not respond as of the investigation exit. During an interview on 12/09/25 at 12:12 p.m., the DON said staff were supposed to pull residents toward them before they are rolled away. She said the risks of not completing bed mobility tasks as required could lead to falls with possible injuries. She said it was her expectations for staff to complete all care tasks as required to maintain resident safety. During an observation and interview on 12/09/25 at 1:22 p.m., Resident #1 in hospital and lying in bed. Resident #1 said she fell from her bed and hurt her leg. She said she rolled out of the bed. She could not recall how or why she fell from the bed. During an interview on 12/09/25 at 1:30 p.m., Family Member B, he said he did not feel the facility was neglectful. He said the surgeon was completing the surgery on Resident #1's left leg and noticed the right foot and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675230 If continuation sheet Page 2 of 3 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 675230 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Grove Nursing Center 246 Haley Dr Center, TX 75935 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete right leg were swollen. He said a CT indicated there was a right leg fracture. He said Resident #1 was scheduled to have the second surgery for her right leg on 12/09/25. During an interview on 12/10/25 at 7:20 a.m., LVN T said Resident #1's level of care was listed in in her care plan. She said the care plan indicated 1 person for bed mobility. During an interview on 12/10/25 at 7:25 a.m., CNA P said Resident #1 was 1 person assist for bed mobility and care in bed. She said she had no difficulty performing care without additional staff assistance. During an interview on 12/10/25 at 7:35 a.m., CNA H said Resident #1 was 1 person assist for bed mobility and care in bed. She said she had no difficulty performing care without additional staff assistance. During an interview on 12/10/25 at 7:40 a.m., the DON said she found out on 12/09/25 (after surveyor entrance) from CNA W that there was not enough room to pull Resident #1 toward her before she began turning her for care. She said she had already ordered enabler bars and bolsters and was going to obtain a bariatric mattress. She said the care plan and care record would be updated to reflect Resident #1 was a 2-person assist upon her return to the facility. She said she started training staff on making sure there was adequate room for turning residents and the training would continue until all staff were trained. Record review of the facility's Fall Management policy dated 01/12/28 indicated Purpose: 1. The community will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. The community will manage falls by providing an environment that is free from potential hazards.3. A resident fall management program will be implemented that educates staff in creative, functional strategies while recognizing resident's rights and their need to maintain the highest practical level of function.Procedures: . 4. If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason and determines the intervention to prevent future falls - complete the Incident/Accident Report in the EHR. Event ID: Facility ID: 675230 If continuation sheet Page 3 of 3