Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pecan Creek Healthcare Center during CMS and state inspections, most recent first.
Resident council meetings were held in the dining room and were repeatedly interrupted by staff entering and exiting the area, despite the meetings being intended as confidential. The ombudsman observed multiple staff disruptions, and residents stated this was typical. Staff and administration acknowledged the meetings were meant to be private, but there were no signs posted and staff were not clearly aware of the confidentiality expectation.
Failure to Deliver Resident Mail on Weekends: The facility did not ensure residents received mail on weekends. A group of residents stated Saturday mail was not distributed until Monday, and the AD, BOM/HR, and ADM confirmed there was no one designated to deliver weekend mail. The BOM/HR stated mail was handled Monday through Friday, while the ADM said the expectation was for unopened mail to be delivered on the weekend.
Unsafe and Poorly Maintained Environment: Surveyors observed loose, peeling, and missing wall base strips throughout the facility, including dusty areas beside a resident's bed and missing trim in resident rooms. The Hall 5 exit door was also observed to be soft and unstable with severe water damage. The MS and ADM acknowledged the maintenance issues and discussed work orders and staff in-services for reporting concerns.
Kitchen sanitation and food service safety failures were identified when staff washed hands at a 3-compartment sink because no dedicated hand-washing sink was present, a ceiling vent over the prep area was dusty, and milk was served without being checked first and measured 48 degrees F before being discarded. The DM, Cook A, and DA B acknowledged the handwashing setup was incorrect, and facility policy required hand-washing sinks near food prep areas and potentially hazardous foods like milk to be held below 41 degrees F or above 135 degrees F.
Incomplete Consent for Antipsychotic Medication: A cognitively intact resident with anxiety, depression, and schizoaffective disorder was receiving brexpiprazole for behavior management. The consent form for the antipsychotic was signed, but the sections for diagnosis criteria, risks and side effects, and the need and benefits of treatment were left blank. The DON stated the consent should have been completed and that the ADON and DON were responsible for monitoring consents.
Incorrect PASRR Screening for a Resident with Schizoaffective Disorder: A resident with anxiety, depression, schizoaffective disorder, and COPD had a PASRR Level 1 screening that incorrectly marked mental illness as absent, despite the diagnosis being present on admission. The resident’s care plan also addressed mood problems and psychotropic medication use, and the MDS C and DON stated the PASRR was incorrect and should have reflected the need for a PASRR Level 2 assessment.
Hand hygiene was not maintained during perineal care for a resident with urinary and bowel incontinence, cognitive decline, and limited mobility. A CNA removed a soiled brief and then applied a clean brief without changing gloves or washing hands when moving from a dirty to a clean surface. The CNA acknowledged the error, and the DON confirmed handwashing and glove removal were required when moving from contaminated to clean areas.
Survey Results Binder Not Kept Up to Date: A white three-ring binder labeled "Survey Results" was observed at the entrance, but it did not contain the most recent recertification survey results or several 2567 reports. In a group interview, 13 of 13 residents said they did not know where recent inspection results were located and did not believe they were available to them. The ADM stated it was her responsibility to ensure survey and investigation results were available for residents and the public to view.
Surveyors found that food items in the kitchen's refrigerator and freezer were not consistently labeled or dated according to professional standards, with several items missing expiration dates or found past their expiration. Staff interviews confirmed that daily checks were intended but not always effective, and the facility's food storage policy was not followed, resulting in improper food storage practices.
A resident with multiple wounds and indwelling devices did not receive proper Enhanced Barrier Precautions during wound care, as a contracted wound care nurse wore gloves but failed to don a gown, despite facility policy and care plan requirements for both gown and glove use during high-contact care activities.
Resident Council Meetings Not Held Privately
Penalty
Summary
The facility failed to provide a private meeting space for residents' monthly resident council meetings for 13 of 13 confidential residents reviewed for resident council. During a confidential group interview, multiple staff were observed coming in and out of the dining room while the meeting was in progress, and the ombudsman stated that the interruptions and distractions needed to stop because the meeting was supposed to be confidential and uninterrupted. The 13 residents stated this was typical and that their meetings were regularly interrupted because they were held in the dining room. Interviews with staff and administration showed the resident council meetings were held in the main dining room on the first Thursday of every month, with both dining room doors shut, but without signs indicating a confidential meeting was in progress. Staff stated they were not aware the meetings were confidential or the purpose of resident council, and several described entering the area to retrieve items or pass through the kitchen/dish room during the meeting. The AD stated resident council was intended for residents to discuss concerns and that the expectation was for the meeting to be private and confidential. The facility Resident Rights policy stated residents have the right to privacy and confidentiality and to communicate in person with privacy.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods by not delivering mail to residents on weekends. During a confidential group interview, 9 of 13 residents stated that mail was not distributed on Saturdays and was not delivered until Monday or picked up until Monday. The deficiency involved the facility's handling of resident mail, including mail delivered on the weekend being left in the mailbox rather than being given to residents. During interviews, the AD stated weekend mail stayed in the mailbox because staff had been instructed by the BOM/HR not to touch it, and that the mail would be picked up on Monday or by the AD. The BOM/HR stated mail was delivered to residents Monday through Friday and that there was no one designated to pass mail on the weekend, although she acknowledged it was a resident right to receive mail on the weekend. The ADM stated that prior to the survey there was nobody designated to deliver mail to residents on the weekend and that the expectation was for mail to be delivered unopened on the weekend.
Unsafe and Poorly Maintained Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when surveyors observed loose and peeling wall base strips throughout the building. On 06/09/2026, the wall baseboard strips in one resident room in Hall 6 had come off on the side of the resident's bed and were dusty, there was no wall base strip on one side of another resident room in Hall 5, and wall base strips in Hall 1 next to a resident room were coming off the wall. The report also noted that throughout the facility the wall base strips were loose and peeling off the wall. Surveyors also observed the exit door in Hall 5 to be soft and unstable, with severe water damage. During interview, the MS stated the door should not be soft because it could allow someone to break in, and the ADM stated the soft, unrigid door could be potentially forced open. The MS stated he had fixed one resident room's wall base strips and submitted a work order for the Hall 5 exit door, and the ADM stated she had seen wall base strips come off in multiple rooms and that staff were being in-serviced on creating work orders in PCC for maintenance concerns.
Kitchen sanitation and food temperature control failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one reviewed kitchen. During observation, the kitchen did not have a dedicated hand-washing sink, and staff were observed washing hands at the three-compartment sink. The soap and paper towel dispensers were positioned far apart, and the trash can was located on the opposite side of the kitchen from the sink area. The DM stated the hand-washing sink had been missing for about 2 years because it was removed due to plumbing issues and was never reinstated. The kitchen ceiling vent next to the preparation area was observed to be dusty. The DM, Cook A, DA B, and the MS all acknowledged that dust from vents over food preparation areas could fall into food. The MS stated he had cleaned the vent area and replaced the filter, and he was not aware the hand-washing sink was missing until the survey visit. The CD stated that washing hands in the three-compartment sink was not in policy, and that staff could wash hands in the dishwashing room, which had a separate hand-washing sink. Just before lunch was served, milk in a glass container for residents had not been checked for temperature before service. When the surveyor asked for the temperature to be taken, the milk measured 48 degrees Fahrenheit, and the kitchen aide discarded it and prepared new milk at 39.5 degrees Fahrenheit. The DM, Cook A, and DA B stated they had been trained on taking food temperatures before serving, and the facility policy stated potentially hazardous foods such as milk must be maintained below 41 degrees Fahrenheit or above 135 degrees Fahrenheit.
Incomplete Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that Resident #4 was fully informed of and consented to treatment with Brexpiprazole (Rexulti), an antipsychotic medication. Resident #4’s quarterly MDS reflected diagnoses of anxiety, depression, schizoaffective disorder, and COPD, and she was coded as cognitively intact with a BIMS score of 15. Her care plan identified use of brexpiprazole for behavior management and listed monitoring for adverse reactions associated with psychotropic medications. Record review showed a form 3713 consent for antipsychotic or neuroleptic medication treatment for Rexulti that was signed by Resident #4 and the prescribing person, but the sections for diagnosis criteria, significant side effects and risks, and the need and benefits of the proposed treatment were left blank. The physician order summary later reflected an order for Brexpiprazole 2 mg daily related to schizoaffective disorder. During interview, the DON stated the consent form should have been completed and that the ADON and DON were responsible for monitoring consents to ensure they were completed.
Incorrect PASRR Screening for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program and failed to refer a resident with a mental illness for the required PASRR review. Resident #4’s quarterly MDS assessment documented diagnoses of anxiety, depression, schizoaffective disorder, and COPD, and also showed that the resident was partially/moderately assisted with showering and had a BIMS score of 15, indicating cognitive intactness. The resident’s PASRR Level 1 screening, dated 09/20/25, marked Section C Mental Illness as “no,” even though schizoaffective disorder was present on the admission date. Resident #4’s care plan, dated 09/24/25, identified a mood problem related to bipolar disorder and noted use of the psychotropic medication brexpiprazole for behavior management. During interview, the MDS C stated the resident had schizoaffective disorder and that the original PASRR was incorrect, and stated the resident should have had a PASRR Level 2 assessment completed because of the diagnosis. The DON stated the PASRR should have been corrected and resubmitted when it came from the hospital incorrect, and that it was the MDS Coordinator’s responsibility to ensure the PASRR Level 1 was completed correctly.
Hand Hygiene Not Performed During Perineal Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for one resident reviewed, Resident #15, during perineal care. Resident #15 was admitted on 04/17/26 with diagnoses including atrial fibrillation, heart failure, high blood pressure, and age-related cognitive decline. The admission MDS indicated the resident required a wheelchair for mobility, needed partial moderate assistance with personal hygiene, and was always incontinent of urine and frequently incontinent of bowel. The care plan stated staff were to perform or assist with incontinent care during daily care and as needed, and to wash, rinse, and dry the perineum and change clothing as needed after incontinence episodes. During an observation on 06/10/26 at 11:01 a.m., CNA D provided perineal care for Resident #15 and cleansed from front to back. After removing the soiled brief and discarding it, CNA D applied a clean brief without changing gloves or washing hands when moving from a dirty surface to a clean surface. In interview, CNA D stated she should have washed her hands and changed her gloves after removing the dirty brief and before applying the clean brief, and said she had been trained on infection control and handwashing. The DON stated CNA D absolutely needed to wash her hands and remove gloves when going from dirty to clean surface area, and the facility policy required hand hygiene before moving from a contaminated body site to a clean body site on the same resident and after glove removal.
Survey Results Binder Not Kept Up to Date
Penalty
Summary
The facility failed to have the results of the most recent survey posted in a place readily available to residents, family members, and legal representatives. Observation revealed a white three-ring binder, chained to a bin next to the entrance door and labeled "Survey Results," but the binder did not contain the results of the most recent full recertification survey held from 04/28/25 to 04/30/25. The binder also did not include additional 2567 reports from visits on 10/07/25, 10/15/25, and 06/03/26; it only contained results from an LSC visit dated 07/07/25 and a health follow-up visit dated 06/03/25. During a confidential group interview, 13 of 13 residents stated they did not know where the results of the recent health inspections or investigations were located and did not believe they were made available to them. The ADM stated it was the Administrator's responsibility to ensure previous survey and investigation results were available for residents and the public to view without having to ask, and that the binder should always be up to date and accessible to everyone, including residents in a wc. Review of the facility Resident Rights policy revised February 2021 reflected that residents have the right to examine survey results.
Failure to Properly Label, Date, and Store Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards for food service safety. During inspection of the walk-in refrigerator and freezer, multiple food items were found either not labeled or not dated correctly, and several items were past their expiration dates. Specific examples included refrigerated cornbread, tortillas, lunch meat, scrambled eggs, sausage, pancakes, and coleslaw without expiration dates, as well as tamale pie and gelatine that were past their labeled expiration dates. In the freezer, items such as beef and chili burritos, chicken breast fillets, hush puppies, chicken pieces, Salisbury steak, and corn dogs were found with missing or incomplete expiration dates, and some lacked the year entirely. Interviews with dietary staff and management confirmed that the kitchen was supposed to be checked daily for out-of-date products, and that items should be labeled with the product name, the date placed in storage, and the expiration date. Staff acknowledged that sometimes items were missed during checks, and that improper labeling could result in expired food being served. Review of the facility's food storage policy indicated that all foods should be dated and rotated on a first in/first out basis, and that frozen products should be labeled with a description, date wrapped, and placed in the freezer. The observed practices did not align with these policies.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that Enhanced Barrier Precautions (EBP) were implemented during wound care for a resident. Observation revealed that, although signage and personal protective equipment (PPE) were available outside the resident's room, the contracted wound care nurse only donned gloves and did not wear a gown while performing wound care. The facility's policy required both gown and glove use during high-contact resident care activities, such as wound care, for residents with wounds or indwelling medical devices. The resident involved was an older woman with a history of chronic embolism, thrombosis, an indwelling urinary catheter, a colostomy, multiple stage 2 pressure ulcers, unstageable pressure injuries, and a venous/arterial ulcer. Her care plan specifically indicated the need for EBP, including the use of gowns and gloves during wound care. Despite these documented requirements and the presence of appropriate signage and supplies, the contracted wound care nurse did not follow the established protocol during the observed wound care procedure.
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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 Hamilton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Hamilton | 0.6 mi | ★★★★★ | 0 | 0 |
| Hico Nursing And Rehabilitation | 20.1 mi | ★★★★★ | 3 | 0 |
| Coryell Health Rehabliving At The Meadows | 26.9 mi | ★★★★★ | 6 | 0 |
| Hillside Medical Lodge | 30.3 mi | ★★★★★ | 8 | 0 |
| The Hilltop On Main | 31 mi | ★★★★★ | 7 | 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 August 2026) and official state health department websites.