Pecan Valley Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Pecan Valley Rehabilitation and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 19, 2023

  Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 4 of 6 residents (Resident #1, #2, #3, and #4) reviewed for abuse, in that: The facility failed to supervise and protect Resident #1, who did not have the ability to consent, from harm when Resident #2 was observed performing a sex act on Resident #1 on 10/24/2022, and failed to develop/implement interventions to prevent additional residents from harm when Resident #2 (who had dementia) had physical contact with multiple female residents including Resident #3, who did not have the ability to consent and Resident #4 who stated she did not like male attention. An IJ was identified on 4/11/2023. […]

• Immediate jeopardy, patternF607Apr 19, 2023

  Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and establish policies and procedures to include notification of law enforcement for 5 of 6 residents (Resident #1, #2, #3, #4 and #12) reviewed for complaints of abuse, in that: The facility failed to develop and implement written policies and procedures for abuse to include written definition of sexual abuse including a resident with dementia or impaired cognition or who was not able to give consent, defining how consent was determined in a resident with dementia or impaired cognition and notification of law enforcement for abuse. An IJ was identified on 4/13/2023. […]

• Immediate jeopardy, isolatedF689Jul 7, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accidents and hazards: The facility failed to ensure Resident #1's environment was free of choking hazards when Resident #1 expired on 6/24/2025 as a result of asphyxiation by choking[PH1] [SA2] . An Immediate Jeopardy (IJ) was identified as past non-compliance on 7/07/2025. The Noncompliance began on 6/24/2025 and ended on 6/25/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health and or death. […]

• Actual harm, isolatedF689Apr 19, 2023

  Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 28 residents (Resident #8 and #7) reviewed for accidents and hazards in that: 1. CNA G utilized a Hoyer lift by herself when transferring Resident #8 from bed to chair and chair to bed. 2. CNA G and CNA H did not utilize a Hoyer lift when transferring Resident #7 from the shower chair to the bed resulting in an unsuccessful transfer and Resident #7 fracturing her right leg. These deficient practices could place the residents at risk for pain, and serious injury. The findings were: 1. […]

• No harm, potential for more than minimal, widespreadF837Oct 31, 2024

  Based on interview and record review, the facility failed to ensure the governing body appointed an administrator who was licensed by the State, where licensing is required; responsible for management of the facility; and reports to and is accountable to the governing body for 1 of 1 facility reviewed for the governing body, in that: The governing body failed to appoint an administrator who was responsible for the management of the facility. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. […]