Peach Tree Place
Peach Tree Place in Weatherford, TX — inspection on September 19, 2025.
Found 7 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
area on his right buttocks had decreased 44% since his last visit on 9/10/25. He stated 9/10/25 was the first time he saw Resident #8. He stated he was not notified prior to that date.
Record review of the facility policy titled Resident Rights dated revised 11/28/16, stated in part: The resident has a right to a dignified existence self-determination and communication with an access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity, and care for each resident in a manner and in an environment which promotes maintenance or enhancement of his or her quality of life.
Recognizing each resident's individuality, the facility must protect and promote the rights of the resident.
Notification of Changes - The facility must immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority resident representatives when there is an accident involving the resident which results in an injury and has the potential for requiring physician intervention. Of the significant change in the residence physical, mental, or psychosocial status that is a deterioration in health, mental, or psychosocial status, and either life threatening conditions or clinical complications.A need to alter treatment significantly, that is a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment, or a decision to transfer discharge resident from the facility.
676148 09/19/2025
Peach Tree Place 315 W Anderson St Weatherford, TX 76086
During an interview with CNA H (6AM - 6PM
and seclusion today, 8/26/25 and on 8/19/25.
She stated examples of abuse were: posting on social media about residents, talking bad or loud and screaming, or body harm that is sexual or physical or mental health.
She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing.
Even if the physician does know, then is it still a restraint and you shouldn't do that.
She stated, I would have to report it to the Administrator immediately.
Resident rights means that residents have the right to ask for snacks or anything they need .
They have the right to our respect and to be free from abuse or seclusion.
Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first.
Never do it without the permission of the physician.
She stated she would look in the or care plan for resident specific interventions.
During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents.
She stated you report abuse immediately.
She stated she had never witnessed abuse in the facility.
She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it.
She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility .
She stated they learned about rights.
They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to.
She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation.
Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to.
She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention.
She stated you can always try later after they are calm.
During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some s[TRUNCATED]
676148 09/19/2025
Peach Tree Place 315 W Anderson St Weatherford, TX 76086
During an interview on 8/26/25 at 10:40 AM with the AD she stated some types of behavior management required you to step back and give them some space.
She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. I would give them space provide one-on-one food and snacks go a long way you could take them to the bathroom start an activity just go down the list basically until something works you could look in their care plan and see if there's any interventions in there.- check to see if they are wet or hungry or thirsty.
She stated the facility is a restraint free facility.
She stated she was inserviced8/26/25 and earlier in the week by the RN corporate Nurse and she has a handout to keep in her pocket at all times for reference.
During an interview with CNA K on 8/26/25 at 11:10 AM.
She stated she was Inserviced on 8/19/.25 and 8/26/25 on abuse and Neglect, resident rights, Trauma Informed Care ( an approach to care that recognized the widespread prevalence of trauma and its impact on individuals and promotes creation of a safe and supportive environment on residents that promotes healing and recovery from traumatic experiences, and Abuse and Neglect.
She stated she learned about isolation.
She stated the corporate Nurse Inserviced all the staff again this morning and gave them a handout over the material to fold and keep in their pockets.
She stated all allegations of possible abuse must be reported immediately to the administrator, whether it's an interim or permanent administrator .
She stated abuse is to be reported immediately at the time it happens.
She stated residents have the right to be abuse free.
She stated that meant no restraints or involuntary seclusion and unnecessary confinement Trauma informed care assessment should be done on residents after incidents unauthorized restraint seclusion unreasonable confinement can cause unnecessary trauma.
She stated they learned to be sure that residents having aggressive b[TRUNCATED]
676148 09/19/2025
Peach Tree Place 315 W Anderson St Weatherford, TX 76086
During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types
a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. she said she would give them space, provide one-on-one, and food and snacks go a long way.
She said you could take them to the bathroom, start an activity, just go down the list basically until something works.
She said you could look in their care plan and see if there's any interventions in there.
She said check to see if they are wet or hungry or thirsty.
She stated the facility is a restraint free facility.
She stated she was inserviced 8/26/25 and earlier in the week by the RN Corporate Nurse and she has a handout to keep in her pocket at all times for reference.
During an interview with CNA K on 8/26/25 at 11:10 AM, she stated she was Inserviced on 8/19/25 and 8/26/25 on abuse and Neglect, resident rights, Trauma Informed Care She stated she learned about isolation.
She stated the Corporate Nurse Inserviced all the staff again this morning and gave them a handout over the material to fold and keep in their pockets.
She stated all allegations of possible abuse must be reported immediately to the Administrator, whether it's an interim or permanent Administrator.
She stated abuse is to be reported immediately at the time it happens.
She stated residents have the right to be abuse free.
She stated that meant no restraints or involuntary seclusion and unnecessary confinement.
She stated Trauma informed care assessments should be done on residents after incidents of unauthorized restraint or seclusion.
She said unreasonable confinement can cause unnecessary trauma.
She stated they learned to be sure that residents having aggressive behaviors are in an area where they will not harm themselves and redirect other residents from the area where the resident is being physically aggressive.
She stated, I know that you cannot restrain a resident, you cannot put them in a wheelchair and put the locks on if they can't get the lock off.
She stated the Abuse Coordinator is the Administrator.
During an interview with the DM on 8/26/25 at 11:15 AM, she stated she had an inservice on 8/19/25 by the administrator, and again today on 8/26/25.
She stated No restraints, involuntary seclusion, or unreasonable confinement are allowed.
All allegations of possible abuse must be reported immediately to my administrator right whether it's an interim or permanent administrator.
The restraint policy is no restraints. We learned about resident rights that they have the right to be abuse free.
Restraints, involuntary seclusion, and unnecessary confinement are all different types of abuse .
Trauma assessment should be done after any incident of abuse or aggression, an incident of abuse can cause mental trauma. We were given a little cheat sheet to keep in our pocket.
During an interview with the ADON on 8/26/25 at 11:40 AM, she stated she was inse[TRUNCATED]
676148 09/19/2025
Peach Tree Place 315 W Anderson St Weatherford, TX 76086
During an interview with the MDS Nurse on 8/26/25 at 11:40 AM, she stated she was Inserviced on 8/19/25.
She stated she had a sheet to keep with her at all times.
She stated the Inservice covered the following areas: Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent.
Resident Rights - that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement.
Trauma informed Care - the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident.
Behavior management - how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe.
De-escalate the behavior by giving the resident space.
Monitor the residents from a safe distance.
Provide 1:1 monitoring until further directed by the abuse coordinator.
Staff will not restrain a resident or seclude a resident involuntarily.
During an interview with the ADON on 8/26/25 at 11:40 AM, she stated she was inserviced one on one with the Corporate Nurse on 8/19/25.
The topics included: Restraint Policy - restraints are not to be used without reasonable rationale, assessment, physician orders, and consent.
She showed a copy of the handout to the surveyor that she was given to keep in her pocket and it .
Resident Rights -[TRUNCATED]
676148 09/19/2025
Peach Tree Place 315 W Anderson St Weatherford, TX 76086
During an interview with CNA H (6AM - 6PM safety shift) on 8/26/25 at 10:15 AM, she stated that she was Inserviced on abuse and neglect, restraints, and seclusion today, 8/26/25 and on 8/19/25.
She stated examples of abuse were: posting on social
mental health.
She stated, Resident restraining it's like from having something on them to keep them from moving or that the physician doesn't know that they are doing.
Even if the physician does know, then is it still a restraint and you shouldn't do that.
She stated, I would have to report it to the Administrator immediately.
Resident rights means that residents have the right to ask for snacks or anything they need .
They have the right to our respect and to be free from abuse or seclusion.
Behavior management is to distract them from the things that upset them before they get upset if you can by offering like snacks or drinks. A rationale for a restraint is when all other interventions have been attempted and a restraint evaluation would have to be completed, and an order obtained, and consent forms signed first.
Never do it without the permission of the physician.
She stated she would look in the Kardex or care plan for resident specific interventions.
During an interview with CNA I (6 PM to 6 AM shift) on 8/26/25 at 10:30 AM, she stated the types of abuse were verbal abuse, physical abuse, restraining any patient that's considered abuse, as well, locking them in their rooms, sexual and stealing from residents.
She stated you report abuse immediately.
She stated she had never witnessed abuse in the facility.
She stated if a resident became aggressive with staff or other residents she would make sure whoever's causing the abuse and also the other residents were safe first and then report it.
She stated she would report any kind of issues, even though it doesn't look that serious, to the Administrator or abuse coordinator for the facility .
She stated they learned about rights.
They have the right to not shower, if they don't want to leave the room to go in the hallways they don't have to.
She stated they have to respect their rights, and they have the right to be free from abuse, restraints, or isolation.
Isolation is when they are in their room because they can't get out, against their will or without their permission. It would be locking or holding them in their wheelchairs and not giving them their right to leave or move if they want to.
She stated for behavior management you could play a game to divert their attention, look in their care plan for interventions, or just give them some attention, or just walk away if they were safe and didn't want to do something or don't want your attention.
She stated you can always try later after they are calm.
During an interview on 8/26/25 at 10:40 AM with the AD, she stated some types of behavior management required you to step back and give them some space.
She said when you see a resident's eyes change you know they need personal space so this would be one technique you could use for behavior management. she said she would give them space, provide one-on-one, and food and snacks go a[TRUNCATED]
676148 09/19/2025
Peach Tree Place 315 W Anderson St Weatherford, TX 76086
The facility failed to ensure LVN A and RN B had annual dementia and restraint reduction training.
This failure could place residents at risk of receiving care from individuals who have not been properly trained.
Findings include:
Record review of employee training files reflected LVN A was hired 3/1/24 and her last dementia training was dated 3/15/24 .
There was no evidence of restraint reduction training in her file other than a copy of a restraint reduction policy that was signed on 10/13/24.
Record review of RN B's Employee files reflected the date of hire as 1/16/25.
Ungraded dementia test dated 1/16/25. No restraints training.
During an interview on 8/23/25 at 1:30 PM, LVN A stated Everyone that works in that building has had training for dementia and behaviors. We have in-services. We were supposed to do an in-person course not too long ago on behaviors and dementia, but it got cancelled. We have all our courses online now, and that is where the dementia and behavior is located. At the beginning of the month, Admin staff will go over stuff before we get our check.
The old ADM did it before.
The HR lady that quit has also done it before. It's just verbal and then you sign it at the end.
They read it and there has been other ones we read, and sign stated she doesn't remember dates. LVN A did not answer when her last training was on behaviors and dementia.
During an interview on 8/23/25 at 0:00, RN B she stated: I don't recall any training on dealing with behaviors.
They say no restraints or nothing like that, and I absolutely support that.
The interim administrator stated in an interview on 8/23/25 at 2:00 PM, the staff was responsible to complete their own training online.
She stated each employee knows how to sign in and the trainings are assigned by the program for them to do.
She stated the company had recently changed training programs which made it more difficult to keep up with the employee's progress.
The administrator stated the facility was currently without an HR person, she recently resigned.
She stated she would look for a training policy, a policy was not provided by the time of exit.
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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.