Honey Grove Nursing Center

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.

Facility ID: