Pecan Tree Rehab And Healthcare Center

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.

675550 10/18/2025

Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

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.

675550 10/18/2025

Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

WCRN-B stated she did not think Resident #1 needed a wound vac in her opinion and felt it did not

jeopardy to resident health or suction was if there were no error messages on the machine and when it was turned onto negative safety pressure, the foam hardened and became rigid.

The WCRN-B stated she did initial measurements when Resident #1 admitted but not when she re-admitted on [DATE].

She said Resident #1 was not

was not clear if she had a follow up with the surgeon that did her surgery because if she did, she didn't need to see the wound doctor here. WCRN-B said the wound doctor that rounded at the facility came on Tuesdays but had not seen Resident #1 when she was at the facility on 10/07/25.

Additionally, WCRN-B said she did not know if Resident #1 had a follow-up appointment to the surgeon but stated, Our wound doctor does not see residents still under the care of a surgeon. An interview with LVN D on 10/15/25 at 12:32 PM revealed Resident #1 pulled her wound vac dressing off frequently, even though she never saw her do it.

She said Resident #1 also pulled at her catheter quite a bit and would itch around the area and felt it irritated her skin but she never saw her pull it out.

She said at one point, Resident #1 did pull out her PICC line and it was replaced by the infusion company.

LVN D stated she was able to get one dose of antibiotic medication through her PICC line and reached out to the doctor to see about an oral route because the resident wanted to pull at the line. LVN D stated, It made it hard because I would have to sit here and hold her hands so she didn't' mess with it.

She said she would try to entertain Resident #1 and would sit her by the medication cart and talk to her.

She said she did contact [MD C] to get an oral antibiotic 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], 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

675550 10/18/2025

Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

the charge will be documented in the chart via fall note or progress note every shift for minimum of

jeopardy to resident health or Plan of Removal implementation occurred on 10/17/25 through 10/18/25.

Facility monitoring safety activities included review of 24-hour reports, risk management logs, fall documentation and supervision assignment sheets to identify any additional incidents involving falls, inadequate

on enhanced supervision. A 100% sweep was conducted for all residents to re-assess their fall risk score and ensure it was accurate and care plan were reviewed for accuracy.

Staff competency validations and in-service training records were reviewed for nursing staff related to fall protocols and supervision needs. 16 nursing and management staff were interviewed across all shifts (ADO, LVN A, WCRN B, RN F, ADON G, VPCO, MD K, LVN L, RN M, RN O, LVN R, LVN S, CNA T, CNA U, RN V, RNC) and demonstrated awareness of the facility's protocols related to increased supervision, fall prevention and documentation expectations.

All staff monitored demonstrated understanding of when to initiated and document 1:1 supervision and how to escalate concerns to the licensed nurse of DON.

A monitoring interview with ADON G was conducted on 10/18/25 at 12:26 PM regarding fall protocols and supervision for high-risk residents following the IT determination. ADON G stated 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, and 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.

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

675550 10/18/2025

Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

physician.10.

Medications are administered within one hour of the scheduled time, unless the

regularly scheduled medication is withheld, refused or given at other than the scheduled time, the

physician must be notified when a dose of medication has not been given.

675550 10/18/2025

Pecan Tree Rehab and Healthcare Center 1900 E California St Gainesville, TX 76240

space provided on the front of the MAR for that dosage administration is initialed and circled.The