Pecan Tree Rehab And Healthcare Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

it was a sad situation. The ADO stated maybe Resident #1's RP was not contacted about the catheter removal because the nurse did not think there was a medical change of condition. She stated, If it happens

on your shift, you own it. The oncoming nurse isn't responsible because they weren't there. An interview with the VPCO on 10/16/25 at 10:40 AM revealed when she reviewed Resident #1's nursing documentation and chart, she did not see where the RP was notified of the catheter removal. An interview with the DON on 10/16/25 at 1:00 PM revealed he had heard Resident #1's catheter had been pulled out and the RP should have been notified by the nurse on the hall at the time. He stated it was important because we always want to keep families up to date with any changes. Review of the facility's policy titled, Notifying the Physician of Change in Status (revised 03/11/2013) reflected, The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilized the INTERACT tool, ‘Change in Condition-When to Notify the MD/NP/PA' to

review resident conditions and guide the nurse when to notify he physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work Day notification of the physician.5) The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 7) The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative,

the physician's response, the physician's order and the resident's status and response to interventions.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pecan Tree Rehab and Healthcare Center

1900 E California St Gainesville, TX 76240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

12:26 PM revealed she had recently learned that any staff member could enter a grievance into their e-charting system. She said once those were entered online, they were routed to the appropriate department for review. ADON G stated, It takes the burden off one person. Typically, our social worker did them before. ADON G added that when families made multiple or serious complaints, the determination whether it qualified as a formal grievance depended on the grievance and what was involved. If the issue was complex, ADON G said it could require additional resources and multiple department members. ADON G stated staff were expected to check with a supervisor or management before deciding not to initiate a grievance so they could ensure every concern was documented.A follow up interview with the ADO on 10/18/25 at 12:43 PM revealed when a resident had a concern or complaint, she expected anyone with PCC access (a cloud-based software platform for the senior and long-term care industry that helps manage electronic health records, billing, and resident engagement)-with the exception of CNAs-to open a grievance and start it. The ADO stated grievances were entered electronically and management reviewed them daily and during monthly QAPI meetings. The ADO stated her expectation was that any concern was documented, and If there's frustration, anger, or genuine concerns-it's a grievance. She said if a resident/family member were emotionally attached or anxious about a concern, that was when staff should recognize something is wrong and initiate a grievance. The ADO said when Resident #1's RP raised concerns about wound care and supervision, the ADO and the DON reviewed documentation and determined whether a grievance was warranted. The ADO stated, Looking through the chart, it looked like communication had been happening through the PICC line issue and staff were documenting. I didn't think

a grievance was needed at that time, but I did a self-report for the fall with injury and the RP's concern that

the facility was not caring for her [Resident #1]. The ADO confirmed that a self-report was submitted to the State and that she and a corporate clinical RN investigated it that same evening and discovered Resident #1's PICC line was clotted and that an oral antibiotic was subsequently obtained. She stated she saw that

the resident's antibiotics were changed and the wound vac was replaced. When asked if the RP's concerns fit the definition of a grievance under the facility's policy, the ADO replied, Personally, I do not, because we addressed it with a self-report.Review of the facility's Provider Investigation Report to HHSC for Resident #1 dated 10/08/25 reflected the incident category listed was Other and the description of the allegation by

the ADO who reported it was, Resident stood up at the nurses station and fell. The self-report did not indicate any concerns of abuse/neglect of Resident #1 or concerns that the RP felt the resident's care was

a concern.Review of the facility's policy titled, Grievances (Revised 11/02/2016) reflected, The resident has

a right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances 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. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have.Procedure:.2. The grievance official of this facility if the administrator or their designee. 3. The grievance official will: Oversee the grievance process, Receive and track grievances to their conclusion.Issue written grievance decisions to the resident.6. All written grievances decisions will include: 1) The date the grievance was received, 2) A summary statement of the resident's grievance, 3) The steps taken to investigate the grievance, 4) A summary of the pertinent findings or conclusions regarding the resident's concern(s), 5) A statement as to whether the grievance was confirmed or not confirmed, 6) Any corrective action taken or to be taken by the facility as a result of the grievance and 7) The date the written decision was issued.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pecan Tree Rehab and Healthcare Center

1900 E California St Gainesville, TX 76240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

fall incident report, it reflected 1:1 supervision had been selected as the intervention. She said ADON G entered the intervention but was unsure whether it had been communicated clearly to all shifts. The ADON said she assumed staff were aware of the supervision expectation but acknowledged that it may not have been documented in the care plan. An interview with ADON G was conducted on 10/18/25 at 12:26 PM and revealed the facility's policy when a resident fell was to update the care plan at the time of the incident and new interventions were expected to be documented by the end of the shift. ADON G stated the charge nurse was responsible for those updates with the assistance of MDS staff if available. ADON G said that waiting 24-hours to update the care plan was too long because documentation should reflect current risks and care being provided. She stated, If we are adjusting interventions, we need to record that. ADON G stated the charge nurse was responsible for initiating the care plan revision following a fall and that CNAs were notified of new interventions verbally before the plan was formally updated. A follow-up interview with

the ADO on 10/18/25 at 12:43 PM revealed her expectation was that care plans were to be reviewed and updated during the same shift when an event or change in condition occurred. The ADO stated, During our daily morning stand-up, risk management is reviewed by the IDT team and interventions and updates are made at that time. The care plan revision-we can do them then. That's the gold standard. She clarified that charge nurses were responsible for initiating revisions and could place immediate interventions after a fall or change in condition. The ADO stated, 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. She said new interventions post falls should be communicated to CNAs by updating the Kardex (a online documentation system, originally a brand name for a paper-based system, used primarily by nurses to keep

a quick, organized summary of essential patient information) and through verbal handoff. She said the Kardex was the CNAs' quick look for what residents needed. Review of the facility's policy titled, Fall Policy (not dated) reflected, The Fall risk Assessment Tool will be completed at admission and after each fall occurrence. The assessment should be completed by reviewing the resident's medical history, social history and functional status. Information may be obtained by reviewing current medical records, interview with resident/family or conference with the interdisciplinary team members. The assessment tool should be scored and interventions implemented as indicated.Appropriate interventions will be addressed immediately on the interdisciplinary plan of care; reassessment will occur after each fall. Interventions will be resident centered. Record review of the facility's Comprehensive Care Plan Policy (not dated) reflected, Each person will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.Interventions are the specific care and services that will be implemented.The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS Assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pecan Tree Rehab and Healthcare Center

1900 E California St Gainesville, TX 76240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

approved. She stated Resident #1 would take oral medications much easier but she said she did not notify

the RP of the order change. LVN D said the change of dose from IV to oral change happened before her shift started, but she was still responsible to call and order it from the pharmacy. LVN D stated the nurse who got the order change was responsible for calling the RP. She did not know who got the order change.

LVN D stated if the RP had wanted to continue with a PICC line, they would have had to find an alternative way to find those doses and it would have been up to the facility and family. She stated the potential harm of not notifying family of changes in treatment, Issues could be any, I don't know, they could not agree maybe with what the facility was doing. LVN D denied having any issues with the PICC line. LVN D stated

she was not qualified to change a sterile PICC line dressing. An interview with LVN A on 10/15/25 at 3:55 PM revealed the wound vac functioned as far as she knew and when she sent Resident #1 to the ER on her shift the day after her admission for vomiting, I accidentally let it (wound vac) go with her. But we got it back and everything was functioning properly. LVN A stated she was the charge nurse who did Resident #1's initial, sent her out on day two and did her subsequent re-admission. LVN A stated Resident #1 pulled out her PICC line when she initially admitted because it was observed on the floor, but no one saw the resident pull it out. LVN A said she examined the PICC line site area and it was fine. She did a dressing over it and notified the physician and the RP. LVN A did not recall any problems flushing the PICC line the first night, but on the second admission on [DATE REDACTED], Resident #1 had removed the hub off the IV bag and it was on the floor. LVN A said she got another one and re-attached it but was unable to flush the line because i

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pecan Tree Rehab and Healthcare Center

1900 E California St Gainesville, TX 76240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

of MDS staff if available. ADON G said that waiting 24-hours to update the care plan was too long, because documentation should reflect current risks and care being provided. She stated, If we are adjusting interventions, we need to record that. ADON G stated the charge nurse was responsible for initiating the care plan revision following a fall and that CNAs were notified of new interventions verbally before the plan was formally updated. She said nursing management verified that neurochecks and supervision interventions were implemented by reviewing them daily. ADON G stated after the IT was identified, the facility began daily review of critical systems-including abuse/neglect, wound vac, PICC line care, catheter management, change of condition and fall prevention and staff received in-servicing on each of those areas. She described new expectations for enhanced supervision and 1:1 monitoring. ADON G stated orders for 1:1 supervision were going to be issued by the physician, documented on paper forms and the charge nurse was to ensure follow through. The ADON said for a change in condition and neurochecks, nurses were expected to notify the physician immediately, initiate the fall protocol and record all neurological checks per policy. She said that supervision and neurochecks compliance was now being verified daily through management review. An interview on 10/18/25 at 12:43 PM with the ADO revealed care plans were to be reviewed and updated during the same shift when an event or change in condition occurred. She said, During our daily morning stand-up, risk management is reviewed by the IDT team and interventions and updates are made at that time. The care plan revision-we can do them then. That's the gold standard. She clarified that charge nurses were responsible for initiating revisions and could place immediate interventions after a fall or change in condition. The ADO stated, If I am the DON, you're calling me after a resident falls, and I expect you to interve

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pecan Tree Rehab and Healthcare Center

1900 E California St Gainesville, TX 76240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated, When they arrive to the facility, we enter meds into e-MAR which immediately sends the order to the pharmacy. She said the pharmacy delivered in the evenings, but if not, the facility had an extensive e-kit available to utilize. The ADO described that for time-sensitive medications, such as IV antibiotics or anticoagulants, if the item was not in stock and needed urgently, We can call pharmacy and they can STAT

a med out. We also have contracts with local pharmacies so it can be ‘hot-shotted' to the facility. The ADO said the administrative nurses (ADONs and DON) were supposed to verify admissions and ensure the pharmacy had been contacted. The ADO stated, It's a team effort to admit a resident, but med entry is a priority after initial assessment because we know we have to get them in-it's an immediate process. The ADO stated for monitoring missed or delayed medications, We review our dashboard. The DON and I

review it during morning meeting, and if we see any missed meds, then we address it right then. She added that if a PICC line was dislodged or malfunctioned, nurses were expected to notify the physician immediately, obtain orders for replacement and if necessary, Call immediately to our PICC line vendor, and if it will delay to next dose, then get alternate med or hold if not critical for the resident. Review of the facility's e-Kit medication list provided by the ADO on 10/18/25 reflected there were two tablets available for Sulfamethoxazole/Trimethoprim (also known as Bactrim) . The e-kit inventory list also reflected the facility had emergency access in the kit to the blood thinners Eliquis, Xarelto and Warfarin as well as alternative oral antibiotics of Amoxicillin-Clavulanate, Ceftriaxone, Ciprofloxacin and Azithromycin. Review of the facility's policy titled, Medication Administration and General Guidelines (dated March 2025) reflected, Medications are administered in accordance with written orders of the attending physician.10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time.Unless otherwise specified by the physician, routine medications are administered according to the established administration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled.The physician must be notified when a dose of medication has not been given.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pecan Tree Rehab and Healthcare Center

1900 E California St Gainesville, TX 76240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

was not in stock and needed urgently, We can call pharmacy and they can STAT a med out. We also have contracts with local pharmacies so it can be ‘hot-shotted' to the facility. The ADO said the administrative nurses (ADONs and DON) were supposed to verify admissions and ensure the pharmacy had been contacted. The ADO stated, It's a team effort to admit a resident, but med entry is a priority after initial assessment because we know we have to get them in-it's an immediate process. The ADO stated for monitoring missed or delayed medications, We review our dashboard. The DON and I review it during morning meeting, and if we see any missed meds, then we address it right then. She added that if a PICC line was dislodged or malfunctioned, nurses were expected to notify the physician immediately, obtain orders for replacement and if necessary, Call immediately to our PICC line vendor, and if it will delay to next dose, then get alternate med or hold if not critical for the resident. Review of the facility's e-Kit medication list provided by the ADO on 10/18/25 reflected there were two tablets available for Sulfamethoxazole/Trimethoprim (also known as Bactrim) . The e-kit inventory list also reflected the facility had emergency access in the kit to the blood thinners Eliquis, Xarelto and Warfarin as well as alternative oral antibiotics of Amoxicillin-Clavulanate, Ceftriaxone, Ciprofloxacin and Azithromycin. Review of the facility's policy titled, Medication Administration and General Guidelines (dated March 2025) reflected, Medications are administered in accordance with written orders of the attending physician.10. Medications are administered within one hour of the scheduled time, unless the physician specifies a specific time.Unless otherwise specified by the physician, routine medications are administered according to the established administration schedule for the facility.12. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled.The physician must be notified when a dose of medication has not been given.

Event ID:

Facility ID:

If continuation sheet