Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Honey Grove Nursing Center during CMS and state inspections, most recent first.
Failure to Coordinate Hospice Care Before Labs and IV Hydration: A resident receiving hospice services with severe cognitive impairment and multiple chronic conditions had lab work ordered by the attending physician, followed by IV hydration with 0.9% Sodium Chloride. The orders were entered and the IV fluids were started without notifying the hospice agency. The hospice nurse stated she was not informed before the orders were carried out, while the DON, ADON, LVN, and MDS Nurse each described a breakdown in communication and assumed someone else had contacted hospice.
Unclean and Damaged Resident Rooms: A survey found multiple resident rooms with dirty floors, stained bathrooms, stained toilets, and damaged flooring, including broken tiles, gaps, and peeling linoleum. The Administrator viewed the condition as mainly aesthetic, while housekeeping and maintenance staff stated the rooms required more thorough cleaning and some flooring and toilet areas needed special cleaning or repair.
Ice Machine Not Cleaned: The facility failed to keep the dining room ice machine clean, as surveyors observed a thick white substance on the inside walls and inside door of the machine. The ADM was unsure who was responsible for cleaning it, and the Dietary Mgr later stated she and the lead cook were responsible for weekly cleaning but it was not cleaned the prior week.
A resident with an indwelling urinary catheter and diagnoses including obstructive and reflux uropathy was observed in bed with his catheter bag hanging on the side of the bed facing the door and not placed in a privacy bag. The resident was cognitively intact, and his care plan included keeping the catheter bag and tubing below bladder level and in a privacy bag. RN D was unsure where the privacy bag was, and the ADON and DON stated the bag should have been covered for the resident's dignity.
A resident with psychomotor deficit, expressive aphasia, and severe cognitive impairment was observed in bed with the call light on the floor behind the bed and not within reach. CNA C stated the call light had been attached to a stuffed bear, moved to the side of the bed, and then fallen to the floor; the ADON and DON stated the call light should have been in reach so the resident could call staff.
A resident with COPD and moderate cognitive impairment returned from the hospital after a respiratory change, but her care plan was not revised to reflect updated interventions, including using a straw for fluids and medication changes. The DON, Regional Compliance Nurse, Regional MDS Nurse, and MDS Nurse all acknowledged the care plan should have been updated to include the resident’s changed needs.
A resident with Parkinson's disease, severe cognitive impairment, hospice services, and a fall risk care plan had a fall mat that was not properly positioned beside the bed. Staff observed the mat split into two pieces, with one section near the head of the bed and the other at the foot of the bed, and an RN, ADON, and DON all stated it should have been placed next to the bed to protect the resident if he fell.
A CNA failed to follow the care plan requiring two-person assistance for a resident with severe cognitive and physical impairments, performing incontinent care and repositioning alone. This resulted in the resident falling from an elevated bed and sustaining a hip fracture, head lacerations, and a hematoma. Staff interviews and documentation confirmed the CNA was aware of the required assistance level but did not seek help, directly leading to the incident.
A resident with Alzheimer's disease and a history of exit-seeking behavior eloped from a facility due to inadequate supervision and malfunctioning door alarms. Despite being at risk for elopement, the resident was moved from a secure unit and continued to exhibit exit-seeking behaviors. The facility's door alarms were not functioning properly, and staff interventions were limited to redirection and the use of a wander guard system, failing to prevent the resident from exiting the building.
A resident in an LTC facility received incorrect medication dosages and administration routes due to discrepancies between pharmacy labels and electronic orders. The resident was given 0.5mg of alprazolam instead of the prescribed 0.25mg, and medications intended for gastrostomy tube administration were labeled for oral use. Additionally, the resident's losartan potassium order was not updated to reflect physician clarifications, leading to potential medication errors.
The facility failed to serve adequate meal portions during a lunch meal, as the Dietary Manager served half portions of egg rolls instead of whole ones, contrary to the preplanned menu. The Administrator noted the Dietary Manager was new and required more training, acknowledging the risk of weight loss due to improper portion sizes.
The facility failed to provide palatable and appropriately tempered food for four residents, as observed during a survey. Residents reported cold, overcooked, and bland meals. A review showed excessively high food temperatures at serving time. The Dietary Manager acknowledged issues with the meal's flavor and temperature during a test tray interview. The Administrator was surprised by the complaints, having believed past issues were resolved, and could not provide a policy on meal palatability.
The facility failed to maintain food safety and sanitation standards, with issues such as unclean equipment, improper food storage, and inadequate personal hygiene practices among dietary staff. Observations included a dirty can opener, fryer, and skillets, improperly labeled and covered food, and staff not wearing hair nets effectively. Additionally, improper cleaning of a food processor and unsanitary handling of ice were noted.
A LTC facility failed to maintain an effective infection control program, as evidenced by improper incontinent care for two residents and inadequate handling of clean linens. A resident with dementia did not receive proper perineal care from an RN, while another resident with Alzheimer's Disease was not adequately cleaned by a CNA, who also neglected hand hygiene. Additionally, a housekeeper left a clean linen cart uncovered, exposing linens to contamination. These deficiencies highlight lapses in infection control practices.
A resident's room in the facility had a malfunctioning door that dragged on the floor, causing noise and disturbance. Despite being aware of the issue, the Maintenance Director had not repaired it, and the Administrator was unaware of the problem. The resident, with severe cognitive impairment, was disturbed by the noise, and the maintenance logs lacked documentation of the repair request.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies. One resident's wandering behavior was not reflected in the MDS, despite documentation indicating a risk for wandering and elopement. Another resident's MDS inaccurately indicated antibiotic use, unsupported by medical records. The absence of a dedicated MDS nurse may have contributed to these inaccuracies.
A facility failed to include PASRR status in a resident's care plan, despite her being identified with mental illness and intellectual disability. The resident's care plan did not address her PASRR status, which is essential for providing specialized services. Staff interviews indicated this was an oversight, and the facility's policy requires comprehensive care plans to meet residents' needs.
Two residents in an LTC facility were at risk for urinary tract infections due to inadequate incontinent care. A resident with dementia did not have her perineal area cleaned by an RN, while another resident with Alzheimer's Disease did not receive proper perineal care from a CNA, who also failed to perform hand hygiene between glove changes. Both staff members acknowledged their mistakes, and the facility's monitoring system was insufficient to prevent these deficiencies.
A resident with COPD did not receive proper respiratory care due to a malfunctioning oxygen concentrator and improper oxygen administration. The flow meter was difficult to read, leading to incorrect oxygen levels being administered. Staff failed to report the issue, and there was no formal policy for equipment maintenance. The resident's oxygen levels were below the recommended threshold until the equipment was replaced.
The facility failed to provide necessary adaptive eating equipment for two residents, leading to potential dignity issues and health risks. One resident with encephalopathy required a sippy cup with lids but was observed using a regular cup, while another resident with dementia needed a two-handled cup with a lid but used a cup without a lid. The dietary staff reported a shortage of lids, an issue persisting for months, which was only brought to the Administrator's attention during the survey.
A facility failed to coordinate hospice care for a resident with dementia, resulting in discrepancies in the hospice plan of care and medication regimen. Interviews revealed a lack of communication between facility staff and hospice representatives, leading to inadequate documentation and coordination of care.
A resident in an LTC facility received 55 units of Humalog instead of the prescribed Lantus due to a nurse's distraction during medication administration. The nurse realized the error post-administration and took immediate action by notifying the physician and sending the resident to the ER for monitoring. The resident, with a history of diabetes and other conditions, was treated for an accidental insulin overdose.
Failure to Coordinate Hospice Care Before Labs and IV Hydration
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate hospice care for a resident receiving hospice services. The resident was a female with diagnoses including COPD, Alzheimer’s disease, hypertension, peripheral vascular disease, and insomnia. Her quarterly MDS showed severe cognitive impairment with a BIMS score of 0, dependence in eating, maximum assistance needed for toileting, bed mobility, and transfers, and moderate assistance needed for upper and lower body dressing. Her care plan identified a terminal prognosis and hospice services, with interventions to work cooperatively with the hospice team and to avoid laboratory services, weights, or other diagnostic services unless ordered by hospice. On 04/09/2026, the attending physician ordered laboratory tests for BNP, CBC, and CMP, followed by an order for IV hydration with 0.9% Sodium Chloride at 60 cc per hour until 04/11/2026. The IV fluids were entered into the EMR and administered by LVN A. The record contained no documentation that facility staff notified the hospice agency before the labs were obtained or before the IV fluids were started. Nursing progress notes did not show communication with hospice regarding these orders. During interviews, the hospice nurse stated she was not notified of the lab or IV fluid orders before they were implemented and said services should be coordinated with hospice prior to implementation. The ADON stated she was aware the resident received IV fluids but did not contact hospice. The DON stated the facility received the attending physician’s orders, obtained the IV fluids based on blood work results, and did not contact hospice because she believed the attending physician and facility were acting in the resident’s best interest. LVN A stated she entered the orders and initiated the IV fluids based on directions from the DON and MDS Nurse, and the MDS Nurse stated she assumed the charge nurse would contact hospice. The facility policy stated the DON was responsible for coordinating care with hospice representatives and communicating with them regarding care for residents receiving hospice services.
Unclean and Damaged Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for 9 of 15 resident rooms on Hall 2 and Hall 3. Observations of multiple rooms showed thick brownish dirt stains on floors near fall mats, grayish stains near sinks and toilets, brownish stains on bathroom walls and floors, dark stains on nightstands, spotted dirt stains near waste baskets, and dark dirt stains along door jambs. Several bathrooms also had brownish stains circling the toilet, and one room had a dark stain inside the toilet bowl. The survey also identified physical hazards in several rooms, including broken floor tiles near a resident's bed and leading into the bathroom, gaps between the room floor and bathroom floor, and bathroom linoleum peeling away from the floor near the entrance and a wall. During interviews, the Administrator stated she did not see a risk to residents and viewed the condition as more of an aesthetic issue. The Housekeeping Supervisor stated it was housekeeping's responsibility to thoroughly clean the rooms, that she did not check all rooms daily, and that some stains were difficult to remove. Housekeeping staff and the Maintenance Supervisor stated the toilets and flooring needed special cleaning, repair, or replacement, and that supplies were being obtained.
Ice Machine Not Cleaned
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen reviewed for food and nutrition services. During an observation on 12/16/25 at 9:08 AM, the ice machine in the dining room was found to have a thick white substance along the inside walls and on the inside door. The Administrator opened the ice machine and observed the same thick white substance on the inside door and upper section of the machine. In interview, the Administrator stated housekeeping or maintenance was responsible for cleaning the ice machine, but she was not sure. The Dietary Manager was later advised of the condition of the ice machine and stated that she and the lead cook were responsible for cleaning it weekly, but it was not cleaned the prior week. She stated that if the ice machine was not cleaned, the ice could become contaminated and residents could get ill. The facility policy on Dietary Food Service Personnel Policy and Procedures and the referenced FDA food manufacturing standards were reviewed.
Catheter Bag Left Uncovered
Penalty
Summary
The facility failed to treat Resident #7 with dignity and respect when his indwelling urinary catheter bag was not placed in a privacy bag. Resident #7 was a cognitively intact male with a BIMS score of 13 and diagnoses including obstructive and reflux uropathy. His comprehensive MDS assessment reflected an indwelling urinary catheter, and his care plan included the intervention to position the catheter bag and tubing below the level of the bladder and in a privacy bag. During an observation, Resident #7 was lying in bed awake with the catheter bag hanging on the side of the bed facing the door, and it was not covered in a privacy bag. He stated he did not know if it was covered and said he did not leave his room very often. RN D stated she was not sure where the privacy bag was and acknowledged that it was important to keep the catheter bag covered for privacy. The ADON and DON also stated the catheter bag should have been covered for the resident's dignity. The facility's Resident Rights policy reflected that residents must be treated with dignity and respect and receive services and items in the plan of care, and the facility did not have a policy related to covering catheter bags.
Call light not accessible to resident with severe cognitive impairment
Penalty
Summary
The facility failed to ensure the call light system in Resident #42's room was positioned so it was accessible to the resident. Resident #42 was a [AGE] year-old female admitted on [DATE] with psychomotor deficit following a nontraumatic subarachnoid hemorrhage, and her MDS assessment dated 11/28/2025 reflected severe cognitive impairment with a BIMS score of 00. Section GG indicated she was dependent on staff for self-care and mobility needs, and her care plan dated 11/04/2025 identified a communication problem related to expressive aphasia and included an intervention to ensure the call light was within reach. On 12/16/2025 at 9:13 AM, an observation found Resident #42 lying in bed awake with the call light on the floor behind her bed and not within reach. When asked about the call light, the resident did not answer. During an interview shortly afterward, CNA C stated the call light should have been placed where the resident could reach it and explained it had been attached to a stuffed bear, moved to the side of the bed, and then fallen to the floor. CNA C then picked up the call light and placed it near the resident. The ADON and DON later stated the call light should have been in reach and that residents should be able to call staff.
Care Plan Not Updated After Hospital Return
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #5 that included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #5 was a female with a diagnosis of COPD and moderate cognitive impairment on the Quarterly MDS assessment. Her comprehensive care plan for oxygen therapy and swallowing problems had last been reviewed on 7/07/25, and the record showed she was transferred to the hospital for a change in respiratory status and returned to the facility on 8/28/25. After the resident returned from the hospital, the care plan was not revised to reflect the updated interventions, including the recommendation to use a straw when drinking fluids to reduce choking risk and the change in medication. The DON stated the care plan should have been revised after the hospital return and acknowledged it had not been updated. The Regional Compliance Nurse, Regional MDS Nurse, and MDS Nurse also stated the care plan should have been revised to include changes to the resident’s care, and that the omission was overlooked.
Fall mat not properly placed beside resident's bed
Penalty
Summary
The facility failed to ensure Resident #2's environment remained as free from accident hazards as possible when his fall mat was not properly placed next to his bed. Resident #2 was a [AGE]-year-old male who had diagnoses including Parkinson's disease and muscle wasting and atrophy, was on hospice services, and had severely impaired cognition with a BIMS score of 05. His quarterly assessment also reflected one fall with no injury, and his care plan identified him as at risk for falls due to gait and balance problems, lack of awareness of safety needs, and vision and hearing problems. The care plan directed staff to place a fall mat at the right side of the bed. During observation, Resident #2 was lying in bed awake, and the fall mat was found in two separate pieces rather than properly positioned beside the bed. One section was near the upper part of his body, while the other was at the end of the bed, approximately two feet past the bedside table. CNA C stated the mat was not supposed to be placed that way and explained how it should fit under the bedside table to remain next to the bed. RN D stated it was important for the fall mat to be in place in case the resident rolled out of bed and that it did no good if it was not placed where it was supposed to be. The ADON and DON also stated the fall mat should have been properly placed next to the resident's bed.
Failure to Follow Two-Person Assist Protocol Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident who required two-person assistance for bed mobility and incontinent care. The CNA performed incontinent care and repositioning alone, despite the resident's care plan and Kardex clearly indicating the need for two staff members due to the resident's severe cognitive impairment, hemiplegia, and functional limitations in all extremities. The CNA did not seek assistance, stating that other staff were busy, and attempted to complete the task alone. During the process of changing the resident and repositioning her in bed, the CNA rolled the resident too close to the edge of the elevated bed, resulting in the resident falling to the floor. The resident was found face down, unable to use her arms to break the fall, and sustained significant injuries including a left hip fracture, lacerations above the left eye, and a hematoma on the forehead. The resident was assessed by nursing staff and subsequently sent to the emergency room for further evaluation and treatment. Interviews with facility staff confirmed that the CNA was aware of the resident's need for two-person assistance and had received prior in-service training on using the Kardex to determine required assistance levels. Documentation and staff statements indicated that the CNA knowingly disregarded established protocols and the resident's care plan, directly leading to the resident's fall and injuries. The incident was identified as a failure to ensure the resident environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Systems
Penalty
Summary
The facility failed to ensure a safe environment for a resident with Alzheimer's disease, who was at risk for elopement. The resident, who had a severely impaired cognition with a BIMS score of 4, was admitted with a history of exit-seeking behavior. Despite being initially placed in a secure unit, the resident was moved to a non-secure area, where he continued to exhibit exit-seeking behaviors. On multiple occasions, the resident attempted to leave the facility, and on one occasion, successfully exited the building and was found in the parking lot. The facility's door alarms were not functioning properly, as observed during a survey. The front door alarm was not audible throughout the facility, and several exit doors did not alarm when opened. The Maintenance Supervisor, who was responsible for checking the alarms, was unsure why they were not activated. Additionally, the resident's care plan interventions, which included wearing a wander alert bracelet and frequent monitoring, were not effectively implemented to prevent the resident from eloping. Interviews with staff revealed that the resident's exit-seeking behavior was known, yet the interventions were limited to redirection and the use of a wander guard system. The facility's policy on elopement prevention was not adequately followed, as the resident was not reassessed after previous elopement attempts, and the risk of elopement was not sufficiently addressed. The lack of proper supervision and functioning alarm systems placed the resident at risk of serious injury or harm.
Medication Administration Errors and Inaccurate Labeling
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Specifically, the facility did not administer the correct dosage of alprazolam, an antianxiety medication, to the resident. The resident was given 0.5mg instead of the prescribed 0.25mg, as the order had been changed to attempt a gradual dose reduction. This discrepancy was not communicated during the staff report, and the medication card from the pharmacy did not reflect the updated order. Additionally, the facility did not ensure that the medication labels for alprazolam and Tylenol #3 matched the orders in the electronic charting system. The labels indicated administration by mouth, while the resident received medications via a gastrostomy tube. The RN involved did not verify the route of administration on the medication cards, assuming the resident only received medications through the feeding tube. This oversight was compounded by the lack of protocol awareness for checking medications received from the pharmacy. Furthermore, the facility failed to update the resident's losartan potassium order to match the physician's clarification orders. The RN was aware of the clarification regarding the heart rate parameters but did not update the electronic charting system accordingly. The medication card still instructed to hold the medication for a heart rate less than 60, which was not applicable as per the physician's clarification. This lack of updating and communication could lead to medication errors and adverse effects.
Failure to Serve Adequate Meal Portions
Penalty
Summary
The facility failed to ensure that the meals served met the nutritional needs of residents during a lunch meal. On September 26, 2024, the facility's menu included a whole egg roll as part of the meal, but the Dietary Manager (DM) was observed cutting the egg rolls in half and serving only half portions to residents. The DM admitted to not having enough egg rolls and had to purchase them for the lunch, indicating a lack of preparation and understanding of the required serving size. This action was contrary to the preplanned menu, which was reviewed by a Registered Dietitian to meet the residents' nutritional needs. The Administrator acknowledged the issue, stating that the DM was new and required more training, which was already planned. The Administrator expressed uncertainty about the shortage of egg rolls despite large food orders and recognized that not serving the appropriate portion sizes could lead to weight loss among residents. The facility's Dietary Services policy, last revised in 2012, mandates that preplanned menus be followed to ensure meals are adequate for residents' nutritional needs.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for four out of seven confidential residents reviewed for food and nutrition services. During a confidential group interview, residents reported that the food trays served were cold, overcooked, and not flavorful. A review of the food temperature log indicated that the temperatures of various food items at the time of serving were excessively high, with regular meat at 180 degrees Fahrenheit, cooked noodles/vegetables at 189 degrees Fahrenheit, mechanical soft chicken at 187 degrees Fahrenheit, pureed noodles at 147 degrees Fahrenheit, and pureed and regular egg rolls at 165 degrees Fahrenheit. Observations on the day of the survey revealed that the Dietary Manager (DM) completed the plating of trays, including pureeing an egg roll, before the tray cart left the kitchen. The trays were passed to residents starting at 12:59 p.m. and ending at 1:08 p.m. During a test tray interview, the DM acknowledged that the egg roll was cool, the noodle/vegetable mix was warm and bland, and the chicken teriyaki lacked seasoning flavor, although the gingerbread cake was moist and flavorful. The DM expressed satisfaction with the meal and did not believe it affected the residents. However, the facility's Administrator, who expected meals to be palatable, was surprised by the complaints as she regularly ate from the kitchen and enjoyed the meals. The Administrator admitted to having received past complaints about food palatability but believed they were resolved, and she failed to provide a policy regarding meal palatability.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The can opener blade was found to have a black substance on it, indicating it was not cleaned properly after use. The steam table wells contained cloudy water with food particles, and the fryer had dark brown oil with food debris, suggesting inadequate cleaning practices. Additionally, fryer baskets had hard-cooked food residues, and three skillets were found with carbon build-up, indicating they were not properly maintained. The stove top burner wells also had black, burned-on material, further highlighting the lack of cleanliness in the kitchen. In the walk-in cooler, a large bag of food was found unlabeled and undated, and two large containers of pudding and Oreo cheesecake were improperly covered with aluminum foil instead of sealing lids. This lack of proper labeling and covering of food items poses a risk of contamination. Furthermore, the dietary staff, including the Dietary Manager (DM), two cooks, and a dietary aide, were observed not wearing their hair nets effectively, leaving hair exposed, which could lead to contamination of food. The facility also failed to ensure proper sanitation practices were followed during food preparation. Cook M did not adequately clean the food processor between pureeing different foods, leaving remnants of green peas in the processor before pureeing meatloaf. Additionally, Cook L used a resident's beverage cup to scoop ice with an ungloved hand, which is a breach of sanitary practices. The DM admitted to not being trained yet and acknowledged the need for improvement in kitchen sanitation to prevent foodborne illness.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper incontinent care provided to two residents and inadequate handling of clean linens. Resident #40, a female with dementia, was observed receiving inadequate perineal care from RN G, who failed to clean the resident's perineal area during incontinent care. This oversight was acknowledged by RN G, who admitted to not performing the care correctly, thereby placing the resident at risk for infections. The resident's care plan emphasized the need for proper hygiene to prevent skin breakdown and infections, yet these protocols were not followed. Similarly, Resident #42, a male with Alzheimer's Disease, was also subjected to improper incontinent care by CNA F. During an observation, CNA F failed to cleanse the resident's genitals and did not perform hand hygiene between glove changes. This lapse in care was recognized by CNA F, who admitted to not completing the care as required, which could lead to an increased risk of infection for the resident. The resident's care plan required regular incontinent care to prevent complications, but these measures were not adequately implemented. Additionally, the facility did not ensure that clean linen carts were properly covered during distribution, as observed with Housekeeper H. The linen cart was left uncovered, exposing clean linens to potential contamination. The Housekeeping Supervisor acknowledged the importance of keeping linen carts covered to prevent cross-contamination but noted that the staff might have been nervous or unaware of the proper procedures. This failure in maintaining infection control standards further highlights the deficiencies in the facility's infection prevention and control program.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for a resident, as evidenced by the malfunctioning door in the resident's room. The door was dragging on the floor, creating skid marks and making loud noises when opened, which disturbed the resident's sleep. The resident, who had severe cognitive impairment due to Alzheimer's Disease and heart failure, expressed that the noise from the door was bothersome. The issue was known to the staff, including the CNAs and the Maintenance Director, but had not been addressed in a timely manner. The Maintenance Director acknowledged awareness of the problem but had not yet repaired the door, despite being responsible for room maintenance and conducting monthly checks. The Administrator was unaware of the issue and expected the Maintenance Director to handle such repairs. The maintenance logs did not show any request for the door repair, indicating a lapse in communication or documentation. The facility's policy on resident rights emphasizes the importance of maintaining a safe and homelike environment, which was not upheld in this instance.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in the Minimum Data Set (MDS) assessments. Resident #42's MDS assessment was inaccurately coded, failing to reflect his wandering behavior. Despite documentation in the care plan and progress notes indicating a risk for wandering and elopement, the MDS assessment did not capture these behaviors. The resident, diagnosed with Alzheimer's, was noted to be agitated and confused, wandering the hallways, yet the MDS assessment did not reflect this, potentially impacting the care and interventions provided. Resident #43's MDS assessment inaccurately indicated antibiotic use, which was not supported by the resident's medical records. The resident, also diagnosed with Alzheimer's, had a severely impaired cognition score, and the MDS assessment incorrectly noted antibiotic administration within the look-back period. However, a review of the medication administration records and care plan showed no evidence of antibiotic orders or administration, highlighting a discrepancy in the assessment process. Interviews with facility staff revealed that the facility was without a dedicated MDS nurse at the time of the assessments, with a regional reimbursement nurse temporarily handling the responsibilities. This lack of a dedicated MDS nurse may have contributed to the inaccuracies in the assessments. The facility's policy emphasizes the importance of accurate MDS assessments, yet the absence of qualified staff familiar with the residents' conditions led to these deficiencies.
Failure to Include PASRR in Resident Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with mental illness and intellectual disability, as identified in the comprehensive assessment. The resident, a female with schizoaffective disorder, bipolar type, and intellectual disabilities, was found to be PASRR positive for mental illness and intellectual disability. Despite this, her care plan did not address her PASRR status, which is crucial for ensuring that specialized services are provided to meet her needs. Interviews with facility staff revealed that the omission of PASRR in the resident's care plan was an oversight. The Regional Compliance Nurse acknowledged that the care plan should have included PASRR and stated that it was the responsibility of the MDS nurse to ensure its inclusion. The facility's policy on comprehensive care plans mandates the development of a care plan that includes measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case.
Inadequate Incontinent Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for two residents, leading to a risk of urinary tract infections. Resident #40, a female with dementia, was observed receiving inadequate care from RN G, who did not clean the resident's perineal area during incontinent care. Despite being checked off as satisfactory in infection control, RN G admitted to forgetting this crucial step, acknowledging the risk of infection due to improper care. Similarly, Resident #42, a male with Alzheimer's Disease, did not receive proper perineal care from CNA F. During an observation, CNA F failed to cleanse the resident's genitals and did not perform hand hygiene between glove changes. CNA F recognized her mistake and admitted that neglecting to clean the perineal area could lead to infections. The facility's policies on perineal care and infection control were not adhered to by the staff, as evidenced by the observations. The Assistant Director of Nursing (ADON) and the Administrator acknowledged the importance of proper perineal care and the potential for urinary tract infections if not performed correctly. The facility's monitoring system, which includes annual check-offs and spot checks, was not effective in preventing these deficiencies.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with COPD, as evidenced by the improper administration of oxygen and malfunctioning equipment. The resident, who had severe cognitive impairment, was observed with an oxygen concentrator that had a flow meter covered in a white powdery substance, making it difficult to read. The oxygen flow was set at approximately 1 LPM, contrary to the physician's order of 2-4 LPM. Despite the resident not showing immediate signs of respiratory distress, the oxygen level was found to be below the recommended threshold when checked by the LVN. The LVN acknowledged the difficulty in reading the flow meter and admitted that the issue had not been reported to management. Upon further examination, the resident's oxygen saturation levels were found to be fluctuating and dropping below 90%, prompting the LVN to increase the oxygen flow and eventually replace the concentrator with a functioning one. The LVN and other staff members, including the CNA responsible for medical records, were unaware of the malfunctioning equipment until the incident occurred, indicating a lapse in communication and equipment maintenance. Interviews with facility staff, including the ADON and Regional Compliance Nurse, revealed a lack of a formal policy for the maintenance of oxygen concentrators. Staff were expected to ensure equipment was functioning properly, but there was no clear protocol for regular checks or reporting defects. The administrator emphasized the importance of maintaining clear and readable oxygen flow meters and ensuring equipment was set according to physician orders to prevent respiratory issues in residents.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for residents who needed them, specifically for two residents who required adaptive devices to prevent spillage during meals. Resident #19, who had encephalopathy and required a sippy cup with lids, was observed using a regular cup without a lid, leading to potential spillage. The dietary staff reported a lack of lids for the sippy cups, an issue that had persisted for about four months. The Dietary Manager and the ADON acknowledged the problem, noting it as a dignity issue, but the Administrator was only made aware of the situation during the survey. Resident #4, diagnosed with dementia and difficulty swallowing, was also affected by the lack of appropriate adaptive equipment. She required a two-handled cup with a lid to prevent spillage due to her arm dropping. However, she was observed using a cup without a lid, which could lead to dehydration or weight loss. The dietary staff confirmed the shortage of lids, and the ADON admitted that they could have purchased the necessary equipment locally if they had known about the shortage. The facility's policy on adaptive eating devices, dated 2012, stated that residents should be provided with appropriate equipment to maintain their highest practicable level of eating independence. However, the dietary department failed to ensure the availability of necessary adaptive devices, leading to potential dignity issues and health risks for the residents. The Administrator expected the dietary staff to inform her of such shortages, but this communication did not occur until the survey intervention.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified during interviews and record reviews, which revealed that the facility did not obtain the most recent updated hospice plan of care for the resident. Additionally, the facility did not ensure that the resident's hospice plan of care accurately reflected her medication regimen, which could lead to inadequate end-of-life care due to a lack of documentation, coordination, and communication of resident needs. The resident in question was an elderly female with a diagnosis of dementia, who was receiving hospice services. The comprehensive care plan indicated that the resident had a terminal diagnosis related to Alzheimer's dementia and was admitted to a hospice provider. The care plan's goal was to ensure the resident remained comfortable, with interventions to work cooperatively with the hospice team to meet her spiritual, emotional, intellectual, physical, and social needs. However, discrepancies were found between the hospice plan of care and the facility's records, particularly concerning the resident's medication regimen and the frequency of hospice aide visits. Interviews with facility staff and hospice representatives highlighted a lack of communication and coordination. The RN responsible for the resident's care was not always informed of hospice visits unless necessary, and there was uncertainty about the provision of chaplain, social work, or bereavement services. The hospice DON expected the hospice provider to supply the facility with the plan of care for each certification period, but this was not consistently done. The facility's ADON and Administrator acknowledged the risk of the resident not receiving desired services due to the lack of current and available hospice documentation.
Significant Medication Error with Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a nurse administered 55 units of Humalog, a short-acting insulin, instead of the prescribed 55 units of Lantus, a long-acting insulin. This error occurred during a medication administration on the evening of June 2, 2024. The resident, who had a history of diabetes, aphasia, stroke, hypertension, and COPD, was at risk due to this medication error, which could have led to severe hypoglycemia. The error was discovered by the nurse who administered the insulin, LVN A, who realized the mistake after the administration. The nurse had been distracted by the resident during the medication preparation and inadvertently picked up the wrong insulin vial. The nurse immediately notified the physician and emergency services, and the resident was sent to the emergency room for glucose monitoring. The resident's blood sugar levels were closely monitored, and the hospital records indicated that the resident was treated for an accidental insulin overdose. Interviews with the facility staff revealed that the nurse involved in the incident was aware of the 5 Rights of Medication Administration but failed to adhere to them due to distraction. The nurse also mistakenly believed that Humalog and Novolog were interchangeable without a physician's order. The Director of Nursing (DON) and other staff members confirmed that the resident's Novolog was available on the medication cart, but the nurse had overlooked it, leading to the error.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Honey Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clyde W Cosper Texas State Veterans Home | 15.4 mi | ★★★★★ | 20 | 0 |
| Seven Oaks Nursing & Rehabilitation | 15.4 mi | ★★★★★ | 2 | 0 |
| North Star Ranch Rehabilitation And Health Care Ce | 16.4 mi | ★★★★★ | 7 | 0 |
| Birchwood Nursing And Rehabilitation | 18.5 mi | ★★★★★ | 1 | 0 |
| Legend Healthcare And Rehabilitation - Paris | 20.9 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.