Pecan Tree Rehab and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Pecan Tree Rehab and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF684Oct 18, 2025

  Based on interviews and record reviews, the facility to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for quality of care. 1. The facility failed to ensure Resident #1's wound vac was providing the proper suction and failed to have her infected surgical wound assessed by the wound care physician or attending physician to determine the proper course of action, despite reports of complications. 2. The facility did not ensure proper management of Resident #1's clotted PICC line when it became clotted. Additionally, there was no dressing assessment documented for the PICC line. […]

• Immediate jeopardy, isolatedF689Oct 18, 2025

  Based on interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accident hazards/supervision . The facility failed to implement and maintain 1:1 supervision for Resident #1 as was recommended by nursing management following a fall on 10/07/25. On 10/08/25, Resident #1 fell at the nurses' station while not under 1:1 supervision and sustained another fall, striking her head on the counter and fracturing her left hip. An IJ was identified on 10/17/25 at 11:48 AM. The IJ template was provided to the facility on [DATE] at 11:38 AM. […]

• No harm, potential for more than minimal, widespreadF925Sep 19, 2023

  Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 3 of 4 halls (Hall 100, Hall 200, Hall 300), 1 of 1 nurses' station. The facility failed to ensure Hall 100, Hall 200, Hall 300, and nurses' station were free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings included: Observation of Hall 100 on 09/17/23 11:16 AM, Hall 100 revealed gnats circling in Resident #61's room and landing on his bedside table with personal items. […]

• No harm, potential for more than minimal, patternF686Feb 18, 2026

  Based on observation, interview and record review, the facility failed to ensure that residents receive care consistent with professional standards of practice based on the comprehensive assessment for two (Resident #5 and Resident #75) of nine residents reviewed for pressure ulcers.The facility failed to ensure Resident #5, and Resident #75 were provided with a weekly skin assessment that reviewed total body skin surfaces with accurate clinical documentation of skin integrity. This oversight resulted in the development of skin injuries that were undocumented and untreated. […]

• No harm, potential for more than minimal, patternF812Feb 18, 2026

  Based on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items were properly stored in the facility kitchen on 02/18/26. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination.Findings included: Observation on 02/18/26 at 9:10 AM of the refrigerator in the kitchen area revealed a tray containing six uncovered pies on the middle shelf placed on top of a container full of 3 packages of raw frozen chicken. […]