Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pecan Bayou Nursing And Rehabilitation during CMS and state inspections, most recent first.
Kitchen staff did not adhere to food safety protocols by failing to wash hands when changing gloves, using the same gloved hand to handle multiple food items and utensils, and continuing to use soiled serving utensils during meal service. These actions were observed and confirmed by interviews, with staff attributing the lapses to being hurried and nervous, in violation of facility policies for food handling and hygiene.
Staff failed to consistently monitor and log temperatures for personal refrigerators used by three residents, resulting in missing or outdated temperature logs. Interviews revealed that assigned staff, including an ADON and a medical records staff member, did not complete required checks due to oversight and miscommunication, despite the expectation for daily monitoring.
A resident with a history of breast cancer and high blood pressure experienced a significant change in condition, including low oxygen saturation, but the facility failed to notify the physician. Despite the resident's care plan indicating a full code status, no respiratory assessment or physician notification was documented. The resident was later found unresponsive and pronounced dead after hospital transfer. Interviews revealed the physician was not informed of the change, which was considered significant enough to require immediate intervention.
A resident with a history of cancer and muscle weakness experienced a significant change in condition, including low oxygen saturation and vomiting, which was not adequately assessed or communicated to the physician by the nursing staff. Despite the resident's full code status, the lack of timely intervention and monitoring led to cardiac and respiratory arrest, resulting in the resident's death after hospital transfer.
The facility failed to update comprehensive care plans for three residents, potentially risking unmet individual needs. A resident with obstructive sleep apnea was observed using oxygen, but her care plan did not reflect this. Another resident with an elbow fracture wore a back brace and ankle boot, which were not included in his care plan. A third resident with respiratory failure used oxygen, but her care plan was outdated. Staff interviews revealed inconsistent monitoring and updating of care plans, contrary to facility policy.
The facility failed to properly store, label, and monitor food items in the kitchen, leading to potential risks for residents. Observations revealed expired sour cream in the refrigerator, unsealed breadcrumbs in dry storage, and unlabeled cakes in the freezer. Interviews with the DM and ADMN confirmed expectations for proper labeling and disposal of expired goods, but reasons for the lapses were unknown despite regular monitoring.
A facility failed to provide proper pharmaceutical services by having expired Promethazine cream in a medication cart for a resident without an order for it. The resident, admitted for respite care and hospice services, had diagnoses of dementia, high blood pressure, and overactive bladder. Interviews revealed that the responsibility for checking and removing expired medications lay with the medication nurse and ultimately the DON. The facility's policy required that expired drugs be returned or destroyed.
The facility failed to label insulin pens according to professional principles on the Hall B medication cart. Two residents' insulin pens were found without pharmacy labels, as they were home medications brought in for respite care. The DON stated that the pharmacy would not label medications they did not fill, and the facility policy required proper labeling. The Administrator noted that nurses should have ensured proper labeling before accepting the medications.
A resident with severe cognitive impairment and multiple health issues did not have a working call light within reach, as required by her care plan. Observations showed the call light was not plugged in or accessible, and staff interviews revealed a lack of awareness and responsibility for ensuring the call light's presence. The facility's policy mandates call lights be plugged in and reachable, which was not followed in this instance.
Failure to Follow Food Safety Standards During Meal Preparation
Penalty
Summary
Kitchen staff failed to follow professional standards for food service safety during meal preparations. Specifically, a staff member used the same gloved hand to touch plates, serving utensils, and then pick up rolls, without changing gloves or washing hands in between tasks. The staff member also left the food service line to retrieve plate warmers, changed gloves without washing hands, and continued to use soiled tongs that had been dropped into a pan of cooked chicken. These actions were observed during a meal service and were confirmed through staff interviews. Interviews with the Dietary Department Manager (DDM) and the Dietary Manager (DM) revealed that their expectations were not met, as staff should have washed hands when changing gloves, used tongs to handle bread, and replaced serving utensils that became soiled. The staff member involved acknowledged not following proper procedures, attributing the failures to being in a hurry and feeling nervous. Facility policies reviewed indicated that proper hand washing, glove use, and utensil handling are required to minimize the risk of foodborne illness and cross-contamination.
Failure to Monitor and Log Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, specifically in relation to the monitoring and logging of personal refrigerator temperatures for three residents. Observations revealed that two residents' personal refrigerators either lacked a temperature log or had not been logged since a specific date, and a third resident's refrigerator did not have a temperature log present at all. All three refrigerators contained drinks at the time of observation. Interviews with staff members responsible for monitoring these refrigerators indicated that the expected practice was to check and log refrigerator temperatures daily, but this was not consistently done due to oversight and miscommunication among staff. The administrator confirmed that department managers were assigned to make daily rounds and check refrigerator temperatures, but acknowledged that there was no formal policy in place for this process. Staff members assigned to check the refrigerators admitted to missing the required checks and logs, citing oversight as the reason for the lapse. The absence of temperature logs and inconsistent monitoring could have resulted in residents having spoiled food in their refrigerators, as noted by the staff during interviews.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to immediately consult with the physician regarding a significant change in the condition of a resident, identified as Resident #63. The resident, who had a history of breast cancer and high blood pressure, was admitted with a fractured femur and muscle weakness. Despite having a BIMS score indicating no cognitive impairment and a care plan that specified a full code status, the facility did not notify the physician when the resident experienced a significant change in condition, including low oxygen saturation and the need for oxygen administration. On the night of the incident, the resident complained of weakness and pain, and their oxygen saturation dropped to 81% on room air, prompting the application of supplemental oxygen. However, there was no evidence of a respiratory or lung assessment, nor was there any documentation of physician notification or follow-up monitoring after the oxygen was administered. The following morning, the resident was found unresponsive and was later pronounced dead after being transferred to the hospital. Interviews with facility staff revealed that the physician was not notified of the resident's change in condition, which the physician considered significant enough to warrant immediate medical intervention. The Director of Nursing (DON) acknowledged that the physician and family should have been informed and that a change of condition assessment should have been completed. The failure to notify the physician and perform necessary assessments and monitoring contributed to a delay in care, potentially impacting the resident's outcome.
Removal Plan
- An audit was completed by the DON and/or designee to identify all residents who were at risk for having a change in condition related to their disease process including reviewing all Oxygen orders. No residents were identified to be affected.
- DON and ADON were educated by CSD on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents.
- Change in condition will be reported/monitored with the Stop and Watch tool and SBAR.
- When a change in condition has been identified it will be placed on the shift-to-shift charge nurse report and also reported in the morning clinical meeting by the charge nurse.
- The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record.
- An in-service was initiated for all Licensed Nurses, on change of condition, notifying the physician of changes. All staff who are unable to attend will be required to complete training before their next scheduled shift.
- Inservice was completed and will be monitored and review for effectiveness by DON During QAPI.
- An in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. All nursing staff unable to attend will be required to complete training before their next scheduled shift.
- Inservice was completed and will be monitored and review for effectiveness by DON During QAPI.
- The ADON, DON and/or designee will review the facilities hour summary report in PCC 5 days per week in the morning clinical meeting to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention.
- Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented.
- Any identified concerns will be addressed immediately, and additional training will be provided as needed.
- The DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified.
- The weekend supervisor and/or designee was in-serviced by DON on how to review the hour report from PCC and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified.
- Nursing staff will contact the physician and ensure appropriate orders and interventions are in place.
- Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician during orientation by the DON or designee.
- Staff unable to come to receive training will be required to completed training before their next scheduled shift.
Failure to Recognize and Respond to Change in Condition
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident, leading to a significant deficiency. The resident, an elderly female with a history of fractured femur, breast cancer, and muscle weakness, was admitted to the facility without any respiratory or cardiac diagnoses. Despite having a full code status, the resident experienced a change in condition, including low oxygen saturation, vomiting, and pain, which were not adequately assessed or addressed by the nursing staff. LVN A, who was responsible for the resident's care, did not recognize the change in condition as significant and failed to notify the physician or perform necessary assessments. The resident's oxygen saturation was critically low, and although supplemental oxygen was administered, no follow-up assessments or monitoring were conducted. The lack of proper documentation and communication with the physician resulted in a delay in care, ultimately leading to the resident's cardiac and respiratory arrest and subsequent death after being transferred to the hospital. Interviews with facility staff, including the DON and the physician, revealed that the physician was not informed of the resident's condition change, which was considered significant. The physician stated that had she been notified, she would have initiated treatment or transferred the resident to the emergency room earlier, potentially preventing the adverse outcome. The facility's failure to adhere to its policies on change of condition and oxygen administration contributed to the deficiency, placing residents at risk of not receiving timely emergency care and life-saving treatments.
Removal Plan
- An audit was completed by the DON and/or designee to identify all residents who were at risk for having a change in condition related to their disease process including reviewing all Oxygen orders. No residents were identified to be affected.
- DON and ADON were educated by CSD on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents.
- Change in condition will be reported/monitored with the Stop and Watch tool and SBAR.
- When a change in condition has been identified it will be placed on the shift-to-shift charge nurse report and also reported in the morning clinical meeting by the charge nurse.
- The physician will be notified via telephone, if no response the nurse will call the DON and/or Administrator and the Medical Director will be notified. The notification will be documented in the resident medical record.
- An in-service was initiated for all Licensed Nurses, on change of condition, notifying the physician of changes. All staff who are unable to attend will be required to complete training before their next scheduled shift. Inservice was completed and will be monitored and review for effectiveness by DON During QAPI.
- An in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. All nursing staff unable to attend will be required to complete training before their next scheduled shift. Inservice was completed and will be monitored and review for effectiveness by DON During QAPI.
- The ADON, DON and/or designee will review the facilities hour summary report in PCC 5 days per week in the morning clinical meeting for 4 weeks and then ongoing to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention.
- Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented. Any identified concerns will be addressed immediately, and additional training will be provided as needed.
- The DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified.
- The weekend supervisor and/or designee was in-serviced by DON on how to review the hour report from PCC and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified.
- Nursing staff will contact the physician and ensure appropriate orders and interventions are in place.
- Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician during orientation by the DON or designee. Staff unable to come to receive training will be required to completed training before their next scheduled shift.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for three residents, which could potentially place them at risk for not having their individual needs met. Resident #13, a female with obstructive sleep apnea and anxiety, was observed using oxygen via nasal cannula, but her care plan did not reflect this need. Similarly, Resident #22, a male with muscle weakness and an elbow fracture, was observed wearing a back brace and ankle boot, yet these were not included in his care plan. Resident #33, a female with acute and chronic respiratory failure and congestive heart failure, was also observed using oxygen, but her care plan did not accurately reflect her current needs. Interviews with facility staff, including the Director of Nursing (DON), Licensed Vocational Nurses (LVNs), and the MDS Corporate Consultant, revealed a lack of consistent monitoring and updating of care plans. The DON acknowledged that orders for oxygen and braces should have been included in the care plans and noted that the responsibility for updating care plans lay with the DON, MDS, and ADON, although the latter two were new to the facility. The previous MDS Coordinator and LVNs also indicated that care plans should be updated as needed, but there was a failure to do so in these cases. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives and be revised as residents' conditions change. However, the care plans for the residents in question were not updated to reflect their current medical orders and needs. Despite the staff's belief that there was no negative impact on the residents' care, the lack of updated care plans represents a deficiency in meeting regulatory requirements for comprehensive care planning.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not ensure that foods were properly sealed and labeled in the freezer and dry storage areas, nor did it ensure that all food items were within their expiration dates. During an observation, it was noted that Refrigerator #1 contained an unopened container of sour cream past its best-by date. In the dry storage area, a package of breadcrumbs was found open and exposed to air. In the freezer, two packages of cake were sealed but lacked item descriptions or dates. Interviews with the Dietary Manager (DM) and the Administrator (ADMN) revealed that both expected food items stored outside their original containers to be labeled and dated, and for expired goods to be discarded. The DM acknowledged that improper food storage could lead to residents becoming sick, while the ADMN confirmed that all residents ate from the dining room unless food was brought in by family members. Despite regular monitoring by the DM and contracted dietary staff, the reasons for the improper storage were unknown. The facility's policies on food storage were reviewed, highlighting the requirement for proper labeling, sealing, and monitoring to prevent contamination.
Expired Medication Found in Resident's Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by having expired medication in the medication cart. Specifically, Promethazine cream with an expiration date of 06/28/2024 was found in the B Hall medication cart for a resident who did not have an order for this medication. This oversight was identified during an observation on 07/22/2024. The resident involved was a female with diagnoses of dementia, high blood pressure, and overactive bladder, admitted for respite care and hospice services. Interviews with the nursing staff and the Director of Nursing (DON) revealed that expired or discontinued medications should be removed from the medication cart immediately. The responsibility for checking the medication cart daily for expired medications was assigned to the medication nurse. The DON acknowledged that it was ultimately her responsibility to ensure that expired medications were removed. The facility's policy on medication storage, last revised in April 2007, stated that discontinued, outdated, or deteriorated drugs should not be used and must be returned to the pharmacy or destroyed. The Administrator noted that the issue arose because the resident provided their own medications, and the nurses failed to check expiration dates before accepting and storing them in the cart.
Unlabeled Insulin Pens Found in Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional principles, specifically on the Hall B medication cart. During an observation, it was found that two Fiasp flex pen insulins for one resident and one Novolin R flex pen insulin for another resident were not labeled by the pharmacy. These medications were residents' home medications, and the residents were in the facility for respite care. The Director of Nursing (DON) acknowledged that the pharmacy would not label medications they did not fill, and the facility policy required all prescription medications to be properly labeled by a pharmacy. The facility's policy on medication storage, last revised in April 2007, mandates that all drugs and biologicals must be stored in the packaging or containers in which they are received, and any drugs with missing or incorrect labels should be returned to the pharmacy for proper labeling. The Administrator stated that the nurses should have ensured all medications were properly labeled before accepting them and placing them in the medication cart. The failure to label these medications could place residents at risk of receiving the wrong medications.
Failure to Provide Working Call System for Resident
Penalty
Summary
The facility failed to provide a working communication system for Resident #20, which would allow her to safely call for staff assistance. Resident #20, a [AGE] year-old female with severe cognitive impairment, was admitted with multiple diagnoses including cerebral infarction, peripheral vascular disease, and an above-knee amputation. She was dependent on staff for mobility and transfers. Observations revealed that the call light was not plugged in or within reach in her room on multiple occasions, despite her care plan indicating the need for a reachable call light to ensure her safety and prevent falls. Interviews with facility staff, including the Maintenance Director, RN C, the DON, and the ADMN, revealed a lack of awareness and responsibility regarding the absence of the call light in Resident #20's room. The Maintenance Director was informed by RN C about the missing call light and rectified the situation, but neither could explain why it was missing initially. The DON and ADMN acknowledged the expectation for all residents to have a call light within reach, but they were unaware of who was responsible for monitoring this. The facility's policy emphasized the importance of having call lights plugged in and within easy reach, yet this was not adhered to in Resident #20's case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brownwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Ridge Manor | 0.2 mi | ★★★★★ | 5 | 0 |
| Songbird Lodge | 0.3 mi | ★★★★★ | 15 | 0 |
| Brownwood Nursing And Rehabilitation | 0.3 mi | ★★★★★ | 11 | 0 |
| Cross Country Healthcare Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Care Nursing & Rehabilitation | 6.5 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.