Federal inspectors found that Pecan Tree Rehab and Healthcare Center wasn't following its own policies for updating resident care plans immediately after falls occurred. The facility's Assistant Director of Nursing acknowledged that while interventions like one-on-one supervision were being ordered, they weren't always being communicated clearly to all shifts.
The inspection revealed a gap between what administrators expected and what actually happened on the nursing floors. After one fall incident, inspectors found that 1:1 supervision had been selected as an intervention on the fall incident report, but the Assistant Director of Nursing wasn't sure whether this critical safety measure had been communicated clearly to all shifts working with the resident.
"She said ADON G entered the intervention but was unsure whether it had been communicated clearly to all shifts," the inspection report stated. The Assistant Director of Nursing admitted she assumed staff were aware of the supervision expectation but acknowledged that it may not have been documented in the care plan.
When interviewed, ADON G explained the facility's policy required care plan updates at the time of incidents, with new interventions documented by the end of the shift. The charge nurse was responsible for those updates with help from MDS staff when available.
"Waiting 24-hours to update the care plan was too long because documentation should reflect current risks and care being provided," ADON G told inspectors. "If we are adjusting interventions, we need to record that."
The system relied heavily on verbal communication before formal documentation was complete. ADON G said charge nurses were responsible for initiating care plan revisions following falls, and that CNAs were notified of new interventions verbally before the plan was formally updated.
During a follow-up interview, the Assistant Director of Operations revealed her expectation that care plans should be reviewed and updated during the same shift when an event or change in condition occurred.
"During our daily morning stand-up, risk management is reviewed by the IDT team and interventions and updates are made at that time," the ADO explained. "The care plan revision-we can do them then. That's the gold standard."
She clarified that charge nurses could place immediate interventions after a fall or change in condition. "If I am the DON, you're calling me after a resident falls, and I expect you to intervene and make it right. I try to communicate to my nurses to put a plan in place."
The facility used a system called the Kardex for communicating new interventions to certified nursing assistants. The ADO described this online documentation system as "the CNAs' quick look for what residents needed." New interventions were supposed to be communicated through both Kardex updates and verbal handoffs between shifts.
The facility's own Fall Policy stated that fall risk assessments should be completed after each fall occurrence, with appropriate interventions addressed immediately on the interdisciplinary plan of care. The policy required reassessment after each fall with resident-centered interventions.
Similarly, the facility's Comprehensive Care Plan Policy specified that each resident should have a person-centered care plan addressing medical, physical, mental and psychosocial needs. The policy stated that interventions are "the specific care and services that will be implemented" and that care plans should be revised "in response to current interventions."
The inspection findings highlighted the difference between written policies and actual practice. While the facility had clear policies requiring immediate care plan updates after falls, the reality on the nursing floors showed delays and uncertainty about whether critical safety interventions were being properly communicated to the staff responsible for implementing them.
This documentation gap created potential safety risks for residents who had fallen and needed enhanced supervision or other interventions. When care plans aren't updated promptly and clearly communicated across all shifts, residents may not receive the level of monitoring and care that administrators have determined they need following a fall incident.
The inspection classified this as a violation causing minimal harm or potential for actual harm, affecting few residents. However, the systemic nature of the documentation delays suggests the problem could affect any resident who experiences a fall at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pecan Tree Rehab and Healthcare Center from 2025-10-18 including all violations, facility responses, and corrective action plans.
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