Pecan Creek Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 13 of 13 confidential residents who were reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 9 of 13 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in residents' psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 facility observed in that:1. Throughout the facility, the wall base strips were loose and peeling off the wall. 2. The exit door in Hall 5 was soft and unstable. These failures could affect resident safety and environmental cleanliness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in according with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure a dedicated hand-washing sink was placed in the kitchen.2. The facility failed to ensure the kitchen ceiling vents were dust-free and clean. 3. The facility failed to ensure milk was assessed for appropriate temperature of 40 degrees Fahrenheit or below prior to being served. These failures could place residents at risk of foodborne illness and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #4) of 6 residents reviewed for resident rights. The facility failed to obtain an informed consent for the use of Brexpiprazole (an antipsychotic medication) used for Resident #4. This failure could place residents at risk of receiving medications without prior consent and without the option to choose alternative treatment or decline based on awareness of risk and benefits of the medications.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) and refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for 1 (Resident #4) of 6 residents reviewed for PASARR screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #4. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (schizoaffective disorder) was present upon Resident #4's admission date on 09/20/25. This failure could place residents at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 6 residents reviewed (Resident #15) for infection control. CNA D failed to change her gloves or clean her hands when moving from a dirty to clean site while performing peri care for Resident #15 on 06/10/26 at 11:01 a.m. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to have the results of the most recent survey of the facility posted in a place readily available to residents, family members, and legal representatives for 1 of 1 survey results books. The facility failed to ensure a binder placed in a bin at the entrance of the facility and titled Survey Results contained the results of the most recent health recertification survey. This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store food following professional standards for food service safety for one of one kitchen reviewed in that: - Food items were not labeled and/or dated correctly in the walk-in fridge. - Out of date food in the walk-in fridge These failures could place residents who received meals from the main kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #4) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when RNA provided wound care for Resident #4. This deficient practice could place residents at-risk for spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident, who was incontinent of bladder, the appropriate treatment, and services to prevent urinary tract infections, to the extent possible, for 1 of 7 residents (Resident #71) reviewed for catheter care. Resident #71's urinary catheter bag with urine was not anchored to his bed frame and was lying directly on the floor. This failure could place residents at risk of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident had appropriate treatment and services to prevent complications of enteral feeding for 1 of 7 resident (Resident #72) reviewed for enteral feeding. Resident #72's peg tube gauze was not changed for 9 days. This failure placed the resident at risk of feeding tube complications and infections.