Pecan Valley Rehabilitation and Healthcare

Inspectors wroteBased on interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 3 residents (Residents #1 and #2) reviewed for pharmacy services. 1. The facility failed to ensure Resident #1's prescribed medications of Insulin Glargine Subcutaneous Solution and NovoLOG Injection Solution 100 UNIT/ML were administered according to physician orders for the months of February 2026 - April 2026.2. The facility failed to ensure Resident #2's prescribed medications of Insulin Glargine and NovoLOG FlexPen Subcutaneous were administered according to physician orders for the month of April 2026. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 3 residents (Residents #1 and #2) reviewed for medical records. 1. The facility failed to maintain progress notes and documentation of notification to physician when medication errors were identified for Resident #1's prescribed medications, Insulin Glargine Subcutaneous Solution and NovoLOG Injection Solution 100 UNIT/ML for the months April 2026.2. The facility failed to maintain progress notes and documentation of notification to physician and management team when medication errors were identified for Resident #2's prescribed medications, Insulin Glargine and NovoLOG FlexPen Subcutaneous for the month of April 2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct an initial comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity for one of 32 residents (Resident #45) reviewed for comprehensive assessments. The facility failed to complete and transmit an admission assessment for Resident #45 within 14 days of the resident's admission. This failure placed residents at risk of not having their needs, strengths, goals, life history and preferences assessed to ensure they received appropriate care.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an encoded, accurate and complete discharge MDS was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 4 residents (Resident #20) reviewed for discharge MDS assessments. The facility failed to ensure a discharge MDS was completed and transmitted for Resident #20's within 14 days of his discharge to the hospital. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one resident (Resident #53) reviewed for range of motion. The facility failed to ensure Resident #53's right hand splint (medical device used to treat hand contractures, permanent tightening of the muscles, tendons, skin and surrounding tissues that causes stiffness, placed in the hands to help improve range of motion) was in place to her right hand. This failure could place the resident at risk for decrease in mobility and range of motion and contribute to worsening of contractures. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 5 residents' refrigerators reviewed. The personal refrigerator in the resident's room [ROOM NUMBER]A contained unlabeled, undated food items. This failure could place residents at risk of foodborne illness from consuming spoiled food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 1 kitchen reviewed for sanitation. The facility failed to ensure the Dietary Manager used hair restraints properly while working in the kitchen. This failure could place residents who received meals or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accidents and hazards: The facility failed to ensure Resident #1's environment was free of choking hazards when Resident #1 expired on 6/24/2025 as a result of asphyxiation by choking[PH1] [SA2] . An Immediate Jeopardy (IJ) was identified as past non-compliance on 7/07/2025. The Noncompliance began on 6/24/2025 and ended on 6/25/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health and or death.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to voice grievances to include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 2 of 8 residents (Residents #1 and #2) reviewed for grievances. On 11/9/2024 Resident #1 made a grievance to Medication Aide A (MA A) which she did not document or report to the DON. The grievance alleged he did not receive medications on 11/8/2024. On 11/19/2024 Resident #2 made a grievance to Case Manager D (CM D) which she did not document or report to the DON. Resident #2 alleged he was left at the doctor's office for hours without return home transportation. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 8 residents (Resident #3) reviewed for quality of care. Resident #3 had a cardiology appointment on 11/13/2024, for an echocardiogram (an exam which uses sound waves to make pictures of the heart), and the facility failed to attempt to provide a chaperone to the appointment when her representative was late; subsequently Resident #3 missed her appointment. This failure could place residents at risk for decreased quality of care due to delayed health status reports to the physicians.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #3) reviewed for resident records. The facility failed to ensure the wound administration records (WAR) for Resident #3 accurately reflected the wound care that was provided to her sacrum (large triangular bone at base of the spine) wound and ischium (the curved bone forming the base of the pelvis) wound on 5 different treatment days in November and December 2024. This failure could put residents at risk of inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the governing body appointed an administrator who was licensed by the State, where licensing is required; responsible for management of the facility; and reports to and is accountable to the governing body for 1 of 1 facility reviewed for the governing body, in that: The governing body failed to appoint an administrator who was responsible for the management of the facility. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 (Resident #67) of 6 residents reviewed for clinical records. The facility failed to ensure CNA F documented oral hygiene care that was offered, performed or refused by Resident #67 on 10/4/2024, 10/7/2024, 10/11/2024, 10/15/2024, 10/25/2024, 10/28/2024 and 10/29/2024. This deficient practice could place residents at risk of improper care due to inaccurate medical records.

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 disease and infection for 3 of 15 residents (Residents #67, #49 and #6) reviewed for infection control, in that: 1. While providing incontinent care for Resident #67, CNA D did not change her gloves or wash her hands after touching the privacy curtain before starting to provide care. 2. While observing LVN I perform an accu-check test on Resident #49, a used lancet (a sharp pointed medical instrument used to puncture the skin to obtain a small amount of blood for testing) was observed on Resident #49's bedside table that was parallel next to her bed, within her reach and lying next to some candy wrappers. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 6 residents (Resident # 67) observed for resident rights. The facility failed to ensure CNA F sat down while feeding Resident #67 in her room on 10/29/2024. This failure could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 residents (Resident #351) reviewed for privacy, in that: 1. LVN A and LVN B failed to provide privacy to Resident #351 while providing wound care by not closing completely Resident #351's privacy curtain. 2. LVN A failed to protect Resident #351's record by not locking the screen of her laptop. These deficient practices could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 7 residents (Resident #48) whose assessments were reviewed, in that: Resident #48's quarterly MDS assessment incorrectly documented the resident as not receiving an anticoagulant medication. This failure could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 6 residents (Resident #67) reviewed for hygiene, in that. The facility failed to ensure Resident #67 received a shower or bath as scheduled on 10/12/2024 and 10/14/2024. This deficient practice could place residents who were dependent on staff for ADL care at risk for loss of dignity, and/or a diminished quality of life.

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 reviewed for kitchen sanitation. The facility failed to store, label and date two containers of milk properly in the walk-in cooler. This failure 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 a to dispose of garbage and refuse properly for 2 of 2 dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage. 1. The facility failed to ensure the waste in dumpster #1 was removed to allow the top lid to close 2. The facility failed to ensure dumpster #2 had a drainage plug and the right door was completely shut These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident, for 2 of 9 residents (Residents #187 and #81) reviewed for baseline care plan, in that: 1. Resident #187's baseline care plan did not include the resident's code status, diet order, need for care of multiple wound sites, need for sternal precautions due to surgery, or need for isolation due to an infectious disease diagnosis. 2. Resident #81's baseline care plan did not include the resident's need for a gluten free diet due to a diagnosis of celiac disease. This deficient practice could affect all residents who require staff assistance and interventions to maintain the highest practicable level of health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 18 residents (Resident #6) reviewed for advanced directives, in that: Resident #6's OOH-DNR form was improperly executed via family member's signature, not Resident #6. This deficient practice could place residents at-risk of having their end of life wishes dishonored and of having CPR performed against their will.

Inspectors wroteBased on interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, not less than once every 12 months, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 18 residents (Resident #34) reviewed for comprehensive assessments and timing, in that: The facility failed to ensure an MDS Annual Assessment for Resident #34 was completed every 12 months. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide or obtain laboratory services for 1 of 18 residents (Resident #18) reviewed for laboratory services, in that: Resident #18's Depakote levels were not checked every three months while prescribed Depakote as ordered by Resident #18's physician. This failure placed residents at risk for not having lab services completed resulting in delayed treatment or residents' needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 (Resident #187) of 29 residents reviewed, in that: Resident #187's medical diagnoses were not reflected on her face sheet. This deficient practice could place residents at risk of improper care due to inaccurate medical records.