Pecan Valley Rehabilitation And Healthcare
PECAN VALLEY REHABILITATION AND HEALTHCARE in SAN ANTONIO, TX — inspection on April 29, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 04/29/2026 at 4:29 p.m., the DON revealed medication
an hour before and an hour after need to be documented in the progress note, the reason it was administered late, would require notification to the doctor.
The DON stated she was aware of late medication entries by LVN A.
The DON stated if residents want to talk, LVN A would not interrupt them, and this could potentially cause her to document medication administration later than time it was administered, and this would cause a medication error.
The DON stated she had not counseled LVN A on medication administration late entries.
Attempted interview with LVN A, on 04/29/2026 at 5:06 p.m., no return call received.
During an interview on 04/29/2026 at 5:22 p.m., the Administrator revealed staff were to follow physician orders.
She stated there could be an adverse reaction depending on type of medication if medication was administered outside of physician's orders.
During an interview on 04/29/2026 at 5:58 p.m., Human Resources revealed LVN A had not been counseled on the numerous medication administration late entries identified during the investigation.
Record review of In-Service Acknowledgement titled Rights of Medication Administration, dated 04/3/2026 revealed ADON was the instructor and staff education included: Right Time: Administer at the prescribed frequency and time.
Right Documentation: Record medication given, time, dose, and route immediately.
Record review of In-Service Acknowledgement titled Insulin Administration, dated 03/24/2026, revealed ADON was the instructor and staff education included: Always read the order completely The Six Rights of Safe Medication Administration. 4.
Right Time.
Does the administration time match the order? . 6.
Right Documentation.
Document immediately after the medication is administered.
Record review of policy titled, Your Rights in a Nursing Facility dated January 2025, revealed .You have the right to: Receive all care necessary to have the highest possible level of health.
Record review of policy titled, Charting and Documentation, dated 05/2007, revealed .The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. Is also necessary to include data needed for identification and communication with family and friends.
Complete history of resident and present illness is required under current law and regulations at the time of admission.[Importance And Use of the Record] 1.To the resident is saves time if needed at a future date. 2. To the institution it reflects the quality of care given to the resident. 3. To the physician, it guides him in his treatment, use and effects of drugs and plan for care.6. To the nurse, it provides a multidisciplinary record of the physical and mental status of the resident. [Rules for Charting] 1.
Notes are to be written on all long-term residents by day, evening and night shifts; frequency is determined by the individual nursing service.
- Daily notes are required as the necessary arises.
676250 04/29/2026
Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222
During an interview on 04/29/2026 at 2:42 p.m., ADON G revealed all medication errors and notification to the physician and management team were to be documented in the resident's electronic medical record immediately. ADON G further stated failure to do so could negatively impact a residents' care.
During an interview on 04/29/2026 at 3:10 p.m., ADON H revealed medication errors are required to be documented in the resident's electronic medical record.
She stated this process will help staff recall reasons for late medication administration entries.
During an interview on 04/29/2026 at 4:29 p.m., the DON revealed all staff who identify a medication administration error need to document the electronic medical record immediately.
She stated the documentation in progress notes would help management understand why there was a late entry for medication administration.
The DON stated failure to document medication errors could have an impact on the residents by not having accurate medical records.
Record review of In-Service Acknowledgement titled Rights of Medication Administration, dated 04/3/2026 revealed ADON was the instructor and staff education included: Right Documentation: Record medication given, time, dose, and route immediately.
Record review of In-Service Acknowledgement titled Insulin Administration, dated 03/24/2026, revealed ADON was the instructor and staff education included: The Six Rights of Safe Medication Administration. 6.
Right Documentation.
Document immediately after the medication is administered.
Record review of policy titled, Charting and Documentation, dated 05/2007, revealed .The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. [Rules for Charting] 1.
Notes are to be written on all long-term residents by day, evening and night shifts; frequency is determined by the individual nursing service. 2.
Daily notes are required as the necessary arises.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.