Pecan Tree Rehab and Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was free from abuse for one (Resident #4) out of 5 residents reviewed for abuse and neglect. The facility failed to ensure the LVN did not cause mental anguish to Resident #4 when she accused her of pulling her I.V. out for attention. This failure could place residents at risk for abuse, neglect and a decline in psychosocial well-being. Record review of Resident #4's face sheet revealed she was an [AGE] year-old female who was admitted [DATE]. Her diagnoses included: Displaced Fracture of base of neck of Right Femur (serious hip injury where bone is broken and shifted out of place), Unspecified Fracture of Right Patella (broken kneecap), Essential Hypertension (high blood pressure), Unspecified Atrial Fibrillation (presence of rapid, irregular heart rhythm), and Dizziness (lightheaded). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive care consistent with professional standards of practice based on the comprehensive assessment for two (Resident #5 and Resident #75) of nine residents reviewed for pressure ulcers. The facility failed to ensure Resident #5, and Resident #75 were provided with a weekly skin assessment that reviewed total body skin surfaces with accurate clinical documentation of skin integrity. This oversight resulted in the development of skin injuries that were undocumented and untreated. The facility nursing staff failed to identify, document, or notify the primary physician for appropriate treatment and services. This failure could place all residents at risk of developing skin injuries and not receive appropriate treatment and services that affect quality of care and quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items were properly stored in the facility kitchen on 02/18/26. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 4 of 8 residents (Resident #42, Resident #53, Resident #76, and Resident#5) observed for infection control. 1-The facility failed to ensure LVN B sanitized the blood pressure cuff (a reusable equipment) between residents (Resident#53, and Resident#76) use on 02/17/2026. 2-The facility failed to ensure CNA A performed hand hygiene while providing incontinent care to Resident #42 on 02/17/2026. 3-The facility failed to ensure CNA A and CNA B performed hands hygiene while performing Resident#5 mechanical transfer from bed to a shower chair on 02/16/26 These failures could place residents at risk for development of infection. [...]

Inspectors wroteBased on interviews and record reviews, the facility to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #1's wound vac was providing the proper suction and failed to have her infected surgical wound assessed by the wound care physician or attending physician to determine the proper course of action, despite reports of complications. 2. The facility did not ensure proper management of Resident #1's clotted PICC line when it became clotted. Additionally, there was no dressing assessment documented for the PICC line. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accident hazards/supervision . The facility failed to implement and maintain 1:1 supervision for Resident #1 as was recommended by nursing management following a fall on 10/07/25. On 10/08/25, Resident #1 fell at the nurses' station while not under 1:1 supervision and sustained another fall, striking her head on the counter and fracturing her left hip. An IJ was identified on 10/17/25 at 11:48 AM. The IJ template was provided to the facility on [DATE] at 11:38 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician and responsible party of a significant change in condition for one (Resident #1) of five residents reviewed for notification of changes. 1. The facility failed to notify Resident #1's responsible party when the resident's urinary catheter was found removed with the balloon intact, when the resident's antibiotic therapy was modified from being administered through a PICC line to oral and when the PICC line became clogged and was unable to be used.2. The facility failed to notify the physician of Resident #1's missed IV antibiotic doses and refused medications. This failure could place residents at risk for delayed medical evaluation, treatment, lack of timely involvement by the responsible party in resident care decisions and the potential for worsening of the resident's condition.

Inspectors wroteBased on interview and record review, the facility failed to make prompt efforts to resolve grievances regarding the resident's care and treatment for one (Resident #1) of five residents reviewed for care concerns. The facility failed to document a grievance, respond and follow through on Resident #1's RP concerns when she voiced them to multiple management staff about poor nursing care and issues with her PICC line, wound vac, antibiotic medication and falls. This failure could place residents at risk for harm by allowing ongoing care concerns-including missed medications, PICC line and wound care issues, to go unaddressed, delaying necessary interventions and oversight.

Inspectors wroteBased on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement with a licensed pharmacy in a timely manner and that drugs are administered as ordered by the physician for one (Resident #1) of five residents reviewed for pharmacy services. The facility did not administer Resident #1's prescribed IV antibiotics through her PICC line or her ordered Lovenox injections following a surgery for a right hip fracture sustained from a prior fall. The facility also failed to ensure these medications were obtained from the pharmacy and available for timely administration as ordered by the physician. This failure placed residents at risk of not receiving medications as prescribed in order to meet residents needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents are free of any significant medication errors for one (Resident #1) of five residents reviewed for pharmacy services. The facility did not administer Resident #1's prescribed IV antibiotics through her PICC line or her ordered Lovenox injections following a surgery for a right hip fracture sustained from a prior fall. This failure placed residents at risk of not receiving medications as prescribed in order to meet residents needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time-frames to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. The facility failed to revise Resident #1's care plan after she fell on [DATE] to include updated fall prevention interventions and nursing management's identification of 1:1 supervision needs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of four residents (Resident #13) reviewed for catheter and incontinence care. 1. The facility failed to ensure NA E and CNA D maintained the foley catheter drainage bag below Resident #13's bladder during a mechanical lift transfer. 2. The facility failed to ensure CNA C did not place the urine catheter bag on the bed while performing incontinence care for Resident #13. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure that two dented cans were removed and separated from the other canned food. 2. The facility failed to ensure that two cans of oven cleaner and two bottles of bleach were stored separately from food items in the dry storage room. 3. The facility failed to ensure the dry storage room floor was free from all items. 4. The facility failed to ensure hair restraints were worn properly during food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the 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 four of 19 residents (Resident #77, Resident #15, Resident #13, and Resident #68) observed for infection control. 1. The facility failed to ensure LVN F used the required PPE for Resident #77, who was on enhanced barrier precautions due to her venous access device, while administering resident IV antibiotics on 11/11/24. 2. The facility failed to ensure that CNA B performed hand hygiene before moving to the clean supplies after completion of incontinence care to Resident #15 and before leaving the resident's room on 11/12/24. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 5 residents (Resident #77) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of the Resident #77, who was sitting in a wheelchair by the foot of the bed. This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable environment, including but not limited to receiving treatments and supports for daily living for 1 of 5 residents (Resident #102) reviewed for quality of life. Facility staff/Hospice Aide failed to provide Resident #102 with clean linens. These failures could affect the residents by causing infections and skin issues.

Inspectors wroteBased on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for one (Resident #8) of 5 residents reviewed for PASARR . The facility failed to refer Resident #8, who had an active diagnosis of Post Traumautic Stress Disorder (PTSD), to the appropriate state-designated authority for Level II PASARR evaluation. This failure could affect residents with mental disorders, intellectual disabilities, or a related condition by placing them at risk for not receiving needed treatment and services that could enhance their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of seven (Residents #77) residents reviewed for pharmacy services. The facility failed to ensure LVN F followed the procedure for accurate administration of Resident #77's Insulin Glargine Solution 15 unit when he held the daily dose of Insulin without notifying the physician on 11/11/24. These failures placed residents at risk of not receiving a therapeutic dosage of medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 3 of 4 halls (Hall 100, Hall 200, Hall 300), 1 of 1 nurses' station. The facility failed to ensure Hall 100, Hall 200, Hall 300, and nurses' station were free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 2 of 3 residents (Residents #2 and #67) reviewed for resident rights. The facility failed to ensure Hospitality Aide A treated Residents #2 and #67 with respect and dignity in her interactions with them in April 2023. This failure led to the residents having feelings of decreased self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of 11 of 13 residents reviewed for activities. The facility failed to ensure there were organized activities during the weekends according to 11 residents who attended the confidential group interview. The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 6 residents (Residents #37 and #72) reviewed for accidents and supervision. The facility failed to ensure Residents #37 and #72 were properly covered with a smoking apron while being supervised during smoking breaks. These deficient practices could place residents at risk for burns causing injury or harm.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 2 residents (Resident #97) reviewed for dialysis. The facility failed to ensure staff provided ongoing assessment of Resident #97's condition and monitoring for complications after dialysis treatments received at a certified dialysis facility. This failure placed the residents at risk of undetected complications post-dialysis.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in the facility's only kitchen. The facility failed to ensure various foods stored in the freezer were sealed, dated and labeled. This failure could place all residents at risk for food contamination and food borne illness.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to ensure staff did not prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Residents #24, #26, and #64) observed for infection control. The facility failed to ensure LVN C sanitized her re-useable blood pressure cuff between resident uses. This failure placed residents at risk of contracting or spreading infectious agents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 3 residents (Residents #2 and Resident #67) reviewed for abuse. The facility failed to ensure Hospitality Aide A did not abuse Residents #2 and #67 in April 2023. This failure left the residents feeling unsafe around Hospitality Aide A.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had complete admission orders for the resident's immediate care for 1 of 3 residents (Resident #97) reviewed for physician orders. The facility failed to ensure Resident #97 had dialysis orders in place when she was admitted . This failure placed residents at risk of not receiving the care they required.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 Residents (Resident #61) reviewed for quality of care. The facility failed to ensure Resident #61 was wearing compression wraps (a specialized hosiery designed to help prevent the occurrence of and guard against further progression of venous disorders such as swelling/inflammation and blood clots) as ordered by the physician. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #51) reviewed for enteral nutrition. The facility failed to follow Resident #51's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 2 of 18 residents (Resident #61 ad Resident #51) records reviewed for treatment documentation. 1. LVN E documented Resident #61 had been provided with his compression hose, but observation revealed resident was not provided with the care of compression hose. 2. LVN F documented Resident #51 had been connected to her g-tube feedings at 12:36 PM, but the resident was not connected to her g-tube feedings until 2:45 PM. These failures could affect the residents medical record not being an accurate representation of the residents medical condition or medical needs.