Pecan Valley Rehab: Insulin Delays Go Unreported - TX
The resident, identified in inspection records as Resident 2, had an order for Insulin Glargine, a long-acting insulin, to be administered every evening at 6 p.m. The medication administration record told a different story. On April 2, the injection went in at 9:09 p.m. On April 13, at 9:04 p.m. On April 20, at 9:01 p.m. On April 21, at 9:22 p.m. On April 22, at 9:05 p.m. Each time, the same nurse, identified in records as LVN A, administered the dose. Each time, the delay exceeded three hours.
None of it appeared in the resident's progress notes.
Inspectors reviewed Resident 2's progress notes covering March 30 through April 30, 2026, and found no entry identifying a medication administration error, no record of anyone contacting the prescribing physician, and no documentation that management had been informed. A month of late insulin doses, and the clinical record was silent.
The facility's own training said otherwise. An in-service acknowledgment dated March 24, 2026, on insulin administration, with an assistant director of nursing listed as instructor, included the sixth right of safe medication administration: document immediately after the medication is administered. A separate in-service from April 3, 2026, titled Rights of Medication Administration, covered the same ground. Document the medication given, the time, the dose, and the route, immediately. Both trainings had taken place within weeks of the errors.
When inspectors interviewed the assistant director of nursing identified as ADON G on the afternoon of April 29, she said all medication errors and notifications to the physician and management were to be documented in the resident's electronic medical record right away. She said failure to do so could negatively impact a resident's care.
A second assistant director of nursing, ADON H, said the same thing in a separate interview that afternoon. Documenting errors in the electronic record, she said, would help staff remember why a late administration entry had been made.
The director of nursing, interviewed at 4:29 p.m. the same day, said all staff who identify a medication administration error need to document the electronic medical record immediately. She said the progress notes would help management understand why there was a late entry. Then she said the quiet part plainly: failure to document medication errors could have an impact on the residents by not having accurate medical records.
Three supervisors. Three interviews. Three versions of the same answer about what should have happened. None of them addressed why it didn't.
The facility's own charting and documentation policy, dated May 2007, describes the clinical record as a concise account of treatment, care, response to care, signs, symptoms, and the progress of the resident's condition. Daily notes are required as the need arises.
The need arose five times in April. Nobody wrote anything down.
What that silence means for Resident 2's care is not something the inspection record resolves. The physician who prescribed the insulin, the one who was supposed to be notified when doses ran three hours behind schedule, had no way of knowing the pattern was happening. The management team responsible for identifying and correcting medication errors had no record to review. If the delays affected the resident's blood sugar, or their sleep, or their health in ways that required follow-up, the clinical record contains no evidence anyone was watching.
The in-service on insulin administration was held five days before the first documented delay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pecan Valley Rehabilitation and Healthcare from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
PECAN VALLEY REHABILITATION AND HEALTHCARE in SAN ANTONIO, TX was cited for violations during a health inspection on April 29, 2026.
The medication administration record told a different story.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.