Honey Grove Nursing Center
Inspection Findings
F-Tag F0689
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.
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HONEY GROVE NURSING CENTER in HONEY GROVE, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HONEY GROVE, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HONEY GROVE NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.