Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Tree Rehab And Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple fractures was verbally accused by an LVN of pulling out her IV for attention after the IV became dislodged. The resident said the accusation made her feel awful, and her family member reported hearing the LVN berate her and seeing her cry. Facility interviews confirmed the incident involved the LVN telling the resident she pulled the IV out on purpose, which was identified as abuse under the facility policy.
Two residents with diabetes, cognitive impairment, and limited mobility developed undocumented foot wounds that were not captured on weekly skin checks or shower review forms. CNAs observed skin changes on a resident’s left foot and another resident’s right toes, but the findings were not reported to the charge nurse, and the charge nurse, treatment nurse, and MD were unaware of the injuries at the time they were found. Interviews and record review showed the facility’s skin monitoring and communication process was inconsistent, with missing documentation and delayed notification of the PCP and wound care staff.
Improper Food Storage in Kitchen Refrigerator: A tray of uncovered pies was observed stored on top of raw frozen chicken in the kitchen refrigerator, and dietary staff acknowledged the pies should have been covered and raw meat should have been stored on the bottom shelf to prevent cross contamination. The DM stated staff had been trained on food handlers procedures and were last in-serviced on food storage procedures 6 months earlier.
Infection control lapses were observed during resident care and equipment use. An LVN used the same BP cuff on two residents without sanitizing it between uses, and a CNA provided incontinent care to a resident with severe cognitive impairment and incontinence while changing gloves multiple times without hand hygiene. Two CNAs also changed gloves repeatedly without hand hygiene during a Hoyer lift transfer of a resident on enhanced barrier precautions with a suprapubic catheter.
A resident with multiple medical conditions, including recent surgery and high fall risk, did not receive proper wound vac therapy, PICC line management, or post-fall neurological assessments. The wound vac was often dislodged and not consistently assessed, the PICC line became clotted and was not addressed before switching to oral antibiotics, and neurochecks were not completed after a fall. Communication lapses with the responsible party and lack of documentation further contributed to missed care and complications.
A resident with dementia, recent hip surgery, and a history of falls was not provided with the recommended 1:1 supervision after an initial fall. Due to unclear protocols, lack of available sitters, and poor communication among staff, the resident was left unsupervised at the nurses' station, resulting in another fall that caused a head injury and hip fracture.
A resident with complex medical needs experienced multiple significant changes in condition, including removal of a urinary catheter, missed IV antibiotic doses, and a switch from IV to oral antibiotics due to a clogged PICC line. Facility staff did not notify the responsible party or physician of these events as required, and documentation of such notifications was lacking, as confirmed by record review and staff interviews.
A resident's responsible party raised multiple concerns about poor nursing care, PICC line and wound vac issues, antibiotic medication changes, and falls, but the facility failed to document these grievances or provide a written response as required by policy. Despite the resident's complex medical needs and the responsible party's repeated communication with management, the concerns were not formally addressed through the facility's grievance process.
A resident with complex medical needs did not receive prescribed IV antibiotics and Lovenox injections as ordered due to delays in pharmacy delivery, issues with PICC line management, and inconsistent communication among staff. Missed doses were documented, and staff interviews revealed confusion about medication procurement and administration procedures, as well as lapses in notifying the physician and responsible party about changes in treatment.
A resident with a history of sepsis, hip fracture, and dementia did not receive multiple doses of prescribed IV antibiotics and Lovenox due to pharmacy delays, PICC line complications, and refusals, with inconsistent physician notification and lack of timely alternative medication administration. Nursing and administrative staff were not always aware of missed doses, and available emergency resources were not effectively used.
A resident with multiple high-risk conditions experienced a fall, but the facility did not promptly update the care plan to include new fall prevention interventions or 1:1 supervision, despite staff verbally implementing increased monitoring. The lack of timely documentation and formal communication in the care plan led to inconsistencies in care and delayed safety measures.
A resident with an indwelling catheter was at risk of urinary tract infections due to improper handling by staff. During a mechanical lift transfer, the catheter bag was placed above the bladder, and during incontinence care, it was placed on the bed, allowing urine to flow back. Despite training, staff did not maintain the catheter bag below the bladder, as required.
The facility failed to follow food service safety standards, with dented cans mixed with other foods, cleaning chemicals stored near food, and improper hair restraint use during food preparation. These lapses could risk contamination and foodborne illness.
The facility failed to maintain effective infection control practices, with staff not adhering to PPE and hand hygiene protocols. A resident on enhanced barrier precautions due to a venous access device did not receive care with the required gown usage by an LVN. Another resident experienced improper hand hygiene by a CNA during incontinence care. Additionally, staff failed to wear gowns for a resident with a foley catheter during care and transfers, and a CNA did not perform hand hygiene between glove changes for another resident.
A resident with severe cognitive impairment was found unable to reach the call light while seated in a wheelchair, as it was placed by the head of the bed. Facility staff, including an LVN and the DON, confirmed the oversight and acknowledged the importance of ensuring call lights are within reach to allow residents to call for assistance.
A resident with severe cognitive impairment and on hospice care was found with soiled bed linens that were not changed for several hours. The hospice aide responsible did not change the linens due to a lack of clean supplies and failed to communicate this to other staff. The facility lacked a policy for maintaining a clean and comfortable environment, posing a risk of infection and skin issues.
A resident with PTSD was not referred for a Level II PASARR evaluation due to a lack of awareness among facility staff about qualifying diagnoses. The MDS coordinator, responsible for PASARR Level 1, did not recognize PTSD as a condition requiring further evaluation, leading to the resident not being referred to the state authority. Interviews revealed unclear roles and responsibilities among staff regarding the PASARR process.
A resident with type 2 diabetes did not receive her prescribed Insulin Glargine dose because an LVN held the medication without notifying the physician, despite no parameters for withholding the routine insulin. The resident was severely cognitively impaired, and the facility's policy required physician notification for held medications without specific parameters.
Resident Accused of Removing IV for Attention
Penalty
Summary
The facility failed to ensure a resident was free from abuse when an LVN accused the resident of pulling out her IV for attention. Resident #4 was an elderly female admitted with diagnoses including a displaced fracture of the base of the right femur, an unspecified fracture of the right patella, hypertension, atrial fibrillation, and dizziness. Her MDS showed a BIMS score of 9, indicating moderate cognitive impairment, and her care plan noted an ADL self-care deficit and a history of trauma related to a verbal conversation with staff. According to the progress note, the LVN documented that Resident #4 had pulled her IV out of her arm with about 25% of the fluid remaining in the bag and that the resident reported she did not realize she had pulled it out. A report was later made to the state reporting system regarding alleged abuse by the LVN. During interviews, the resident stated the LVN accused her of taking the IV out on purpose, which made her feel awful because she did not do things like that. The resident’s family member stated she heard the LVN berating the resident and accusing her of pulling the IV out for attention, and said the resident was crying and denied doing it on purpose. The facility administrator, DON, ADON, SW, and family member all described the incident as involving the LVN telling the resident she had pulled the IV out for attention or on purpose. The SW stated she interviewed the resident for trauma and found nothing lingering, but the family member reported the resident was upset and afraid of the LVN afterward. The facility’s abuse/neglect policy stated residents have the right to be free from abuse and defined abuse to include verbal abuse and mental abuse, including humiliation and harassment.
Incomplete Skin Assessments and Missed Reporting of New Foot Wounds
Penalty
Summary
The facility failed to ensure that weekly skin assessments included accurate documentation of total body skin surfaces for two residents with significant medical complexity and impaired mobility. Resident #5 was admitted with acute cystitis with hematuria, type 2 diabetes mellitus, severe protein/calorie malnutrition, major depressive disorder, and encephalopathy. Resident #75 was admitted with COPD, Alzheimer’s disease, dysphagia, major depressive disorder, and type 2 diabetes mellitus. Both residents required extensive assistance from two staff for activities of daily living and had care plans identifying risk for skin integrity problems related to immobility, limited range of motion, and medically complex conditions. During observation, Resident #5 was transferred by Hoyer lift for a shower and was found to have a 1 cm by 1 cm by 0.5 cm deep round black area on the ball of the left foot with no bandage present. CNA staff stated they were unaware of the skin issue. Record review of multiple skin assessments and shower review worksheets for Resident #5 showed no documentation of the injury. Interviews with the CNAs and charge nurse showed the skin change was not reported to the charge nurse, and the charge nurse was unaware of the injury. The treatment nurse also stated she was unaware of the new skin injury when she later assessed the resident. Resident #75 was observed during a skin assessment to have 1 cm by 1 cm black areas with redness on the second and third toes of the right foot, and staff were unaware of the change. Record review of weekly skin assessments and shower review worksheets for Resident #75 showed no documentation of the skin changes. The medical director stated he was the primary care provider for both residents and was unaware of any change in skin condition. The wound care physician later stated she was notified by the facility after the skin issues were identified and that telehealth visits were conducted for both residents. Facility interviews also showed that staff relied on CNA verbal reporting and that prior skin and shower worksheets were no longer being used, while the charge nurse and treatment nurse described inconsistent communication and documentation practices.
Improper Food Storage in Kitchen Refrigerator
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in its only kitchen. On 02/18/26 at 9:10 AM, observation of the kitchen refrigerator showed a tray with six uncovered pies on the middle shelf placed on top of a container holding three packages of raw frozen chicken. The Dietary Manager stated that raw foods should be placed on the bottom rack in case they leak to avoid contamination, and that the pies should have been covered to prevent contamination. The Dietary Manager also stated kitchen staff completed food handlers training within the first 30 days of hire and were last in-serviced on food storage procedures 6 months ago. During interviews, the Dietary Aide stated she placed the pies on top of the container of chicken and left them uncovered because she did not think about it. She stated the pies should have been covered to prevent cross contamination and to prevent anything from falling on them. Another dietary staff member stated she placed three bags of chicken on the middle shelf of the refrigerator the night prior because there was not room on the bottom shelf, and acknowledged that raw meat should be placed on the bottom shelf in case it leaked and caused cross contamination. Review of the facility policy and cited food safety guidance reflected that thawing frozen items should be stored under refrigeration, refrigerated foods should be kept covered, and chicken should be stored on the bottom shelf in a sealed container or wrapped securely so juices do not leak onto other foods.
Infection Control Lapses During Resident Care and Equipment Use
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for four residents observed for infection control. During observation, an LVN checked one resident’s blood pressure and then used the same reusable blood pressure cuff on another resident without sanitizing it between uses. The LVN stated she sanitized the cuff sometimes but not every time between residents, and acknowledged the cuff should be sanitized each time it is used and before it is used on another resident. CNA A was observed providing incontinent care to a resident with severe cognitive impairment, urinary and bowel incontinence, and diagnoses including hypertension, type 2 diabetes, and cerebrovascular accident. During the care, CNA A washed hands at the start, put on gloves, and cleaned the resident’s front area, but then removed and replaced gloves multiple times without performing hand hygiene. CNA A also removed the dirty brief, changed gloves without hand hygiene, and applied the clean brief without changing gloves. In interview, CNA A stated she was supposed to complete hand hygiene before and after care and after removing the dirty brief, and that she forgot to bring hand sanitizer with her. During a mechanical transfer of another resident by Hoyer lift from bed to a shower chair, two CNAs were observed putting on PPE and changing gloves four times each without performing hand hygiene between glove changes. The resident was on enhanced barrier precautions and had a suprapubic urinary catheter. Record review showed the resident required extensive assistance with ADLs and transfers by Hoyer lift with two CNAs. The facility’s infection control and hand hygiene policies stated that non-invasive resident care equipment should be cleaned between use and that gloves must be changed between resident contacts with hands washed after gloves are removed.
Failure to Provide Proper Wound, IV, and Fall Management for Resident with Complex Needs
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident with complex medical needs. The resident, who had a history of sepsis, right femur fracture, dementia, Alzheimer's disease, and recent major surgery, required specialized wound care, IV antibiotics via a PICC line, and was at high risk for falls. Despite these needs, the facility did not ensure that the wound vac was functioning properly, did not have the infected surgical wound assessed by a wound care or attending physician after reports of complications, and failed to document or address issues with the wound vac, even after concerns were raised by the responsible party (RP). The wound vac was frequently dislodged, and there was no evidence of timely follow-up or adjustment to the care plan to address the resident's non-compliance or the device's malfunction. Additionally, the facility did not properly manage the resident's clotted PICC line. When the line became clotted and could not be flushed, IV antibiotics were discontinued and oral antibiotics were started without addressing the compromised central line. There was no documentation of a dressing assessment for the PICC line, and the switch from IV to oral antibiotics was made without clear communication to the RP. The resident missed several doses of prescribed IV antibiotics, and the oral medication provided was not appropriate for her dietary restrictions, as she was on a puree diet and had difficulty swallowing large tablets. The facility also failed to follow fall prevention and post-fall protocols. After an unwitnessed fall, neurochecks were not completed per protocol, and the resident subsequently experienced another fall resulting in a head injury and a left hip fracture. The RP was not notified of major changes in the resident's condition or treatment, including the discontinuation of the wound vac, issues with the PICC line, missed medication doses, and falls. The lack of communication, documentation, and adherence to care protocols contributed to the resident's avoidable decline and multiple complications.
Failure to Implement and Maintain 1:1 Supervision for High-Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident identified as high risk for falls. The resident, who had a history of falls, dementia with behavioral disturbance, Alzheimer's disease, and recent hip surgery, was dependent on staff for activities of daily living and used a wheelchair for mobility. After an initial unwitnessed fall in her room, nursing management recommended 1:1 supervision, but this intervention was not consistently implemented or maintained. Despite the recommendation for 1:1 supervision, staff interviews revealed confusion and lack of clarity regarding the protocol for providing such supervision. Several staff members, including CNAs and LVNs, reported that there were no actual sitters available and that the facility was not equipped to provide 1:1 care. The resident was left unsupervised at the nurses' station, where she attempted to stand, fell, and sustained a head injury and a fractured hip. Documentation and communication lapses were evident, as not all staff were aware of the 1:1 supervision requirement, and the care plan was not promptly updated to reflect the new intervention. The failure to implement and maintain the recommended 1:1 supervision placed the resident at risk for significant injury. The resident's responsible party had repeatedly requested closer monitoring, but no effective supervision plan was put in place. The lack of clear protocols, insufficient staffing, and inadequate communication among staff contributed to the resident's subsequent fall and injury.
Failure to Notify Responsible Party and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The facility failed to notify a resident's responsible party (RP) and physician of significant changes in the resident's condition and treatment. Specifically, there was no documentation that the RP was notified when the resident's urinary catheter was found removed with the balloon intact, when antibiotic therapy was changed from IV via PICC line to oral administration, and when the PICC line became clogged and unusable. Additionally, the physician was not notified of missed IV antibiotic doses and refused medications. These failures were identified through record review and interviews with staff and the RP. The resident involved was an elderly female with multiple complex medical conditions, including sepsis, a recent femur fracture, dementia with behavioral disturbance, Alzheimer's disease, and a surgical wound requiring specialized care. She was dependent on staff for activities of daily living, had impaired mobility, and was at risk for pressure injuries. The resident had a history of pulling out medical devices, including her PICC line and urinary catheter, and required high-risk medications and special treatments such as IV antibiotics and wound therapy. Nursing notes and interviews revealed that staff did not consistently notify the RP or physician of these significant events. For example, when the resident pulled out her PICC line and catheter, there was no documentation of RP notification. When the PICC line became clotted and IV antibiotics were missed or changed to oral, the RP was not informed at the time of the change. Staff interviews confirmed that notification did not occur as required, and the facility's own policy and INTERACT tool indicated that such notifications should have been made and documented.
Failure to Promptly Address and Document Grievances Related to Resident Care
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances regarding a resident's care and treatment, as required by regulation. The responsible party (RP) for a resident voiced multiple concerns to various management staff about poor nursing care, issues with the resident's PICC line, wound vac, antibiotic medication, and falls. Despite these concerns being communicated, the facility did not document the grievance, nor did they respond or follow through according to their grievance policy. Interviews with facility staff confirmed that no grievance was entered into the system for these concerns, and the responsible party was not provided with written grievance decisions as outlined in the facility's policy. The resident involved had significant medical needs, including a history of sepsis, a closed fracture of the right femur, dementia with behavioral disturbance, Alzheimer's disease, and a recent major surgery. She required extensive wound care, IV therapy, and was administered high-risk medications such as anticoagulants and antibiotics. The resident was dependent on staff for activities of daily living and was at risk for pressure ulcers and falls. The responsible party reported not being notified about critical changes in the resident's care, such as the inability to flush the PICC line, the switch from IV to oral antibiotics, and the dislodgement of a urinary catheter. These concerns were not formally documented as grievances, and the responsible party was not kept informed as expected. Facility interviews revealed a lack of clarity and consistency in the grievance process. While some staff believed that communication and documentation in the resident's chart were sufficient, others acknowledged that the concerns raised should have been treated as formal grievances. The facility's policy required that all grievances be documented, investigated, and responded to in writing, but this process was not followed for the concerns raised by the responsible party. The failure to document and address these grievances meant that the resident's care concerns, including missed medications and issues with wound and IV care, were not properly investigated or resolved.
Failure to Provide Timely and Ordered Pharmaceutical Services
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident as ordered by the physician, specifically not administering prescribed IV antibiotics through a PICC line and ordered Lovenox injections following surgery for a right hip fracture. The resident, who had a complex medical history including sepsis, dementia, Alzheimer's disease, and a recent hip fracture, was dependent on staff for activities of daily living and required special treatments such as IV antibiotics and anticoagulant therapy. Upon admission and re-admission, there were multiple documented instances where the facility did not have the necessary medications available in a timely manner, resulting in missed doses of critical medications such as Cefazolin, Ertapenem, and Lovenox. Nursing notes and interviews revealed that the resident's PICC line was pulled out and later replaced, but there were delays in obtaining and administering IV antibiotics due to pharmacy delivery issues and uncertainty about which infusion company to contact for PICC line replacement. Staff documented that medications were not administered because they were awaiting delivery from the pharmacy, and there was confusion regarding the process for obtaining stat medications or using the facility's emergency kit. Additionally, the resident frequently refused injections, and while staff attempted to notify the physician and obtain alternative orders, there were lapses in communication and documentation, including not notifying the responsible party of changes in treatment. Interviews with nursing staff, the DON, and administrative personnel indicated a lack of formalized tracking for medication delivery timeliness and inconsistent procedures for handling medication refusals, missed doses, and PICC line complications. The facility's own policies required timely administration of medications and physician notification when doses were missed, but these were not consistently followed. The failure to ensure timely availability and administration of prescribed medications, as well as inadequate communication and follow-up, led to the resident not receiving necessary treatments as ordered.
Failure to Administer Prescribed IV Antibiotics and Anticoagulant
Penalty
Summary
A deficiency occurred when a resident with a history of sepsis, right hip fracture, dementia, and recent surgery was not administered prescribed IV antibiotics and anticoagulant (Lovenox) as ordered. Upon admission and re-admission, the resident required IV antibiotics via a PICC line and daily Lovenox injections. The facility failed to administer several doses of Cefazolin due to issues such as awaiting pharmacy delivery and problems with the PICC line, including it being pulled out or becoming clotted. Documentation showed that the resident missed multiple doses of both antibiotics and Lovenox, with refusals and technical issues cited, but there was inconsistent and delayed communication with the physician and responsible party regarding these missed doses and changes in medication route. Nursing staff interviews revealed confusion and lack of clarity regarding the process for replacing or unclogging the PICC line, as well as uncertainty about the availability of medications in the facility's emergency kit. Staff reported that the resident was difficult to medicate due to behavioral issues, such as swatting at nurses and pulling at the PICC line, but there was no consistent protocol followed for timely physician notification or for obtaining alternative medication routes. The facility's own policies required prompt administration of medications and immediate physician notification if a dose was missed, but these procedures were not consistently followed. Further, administrative and clinical leadership, including the DON and ADON, were not always aware of the missed doses or the status of the PICC line until after the fact. There was no formal tracking system for medication delivery timeliness, and communication between nursing, pharmacy, and providers was not always immediate or documented. The facility had resources such as an emergency kit and contracts for stat medication delivery, but these were not effectively utilized to prevent missed doses of critical medications for the resident.
Failure to Update Care Plan with Fall Prevention Interventions After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following a fall, as required by policy and regulation. After the resident, who had a history of falls and multiple high-risk diagnoses including dementia, Alzheimer's disease, and a recent femur fracture, experienced an unwitnessed fall, the care plan was not promptly updated to reflect new fall prevention interventions or the need for 1:1 supervision. Although staff verbally discussed and implemented increased supervision, this intervention was not formally documented in the resident's care plan or communicated consistently across all shifts. The resident was identified as high risk for falls upon admission, with a Fall Risk Assessment score indicating the need for heightened precautions. Despite this, after the initial fall, the care plan interventions remained generic and did not include specific, measurable objectives or timeframes tailored to the resident's updated needs. Staff interviews revealed that while there was an understanding among caregivers and nurses that the resident required constant monitoring, this was not reflected in the written care plan or the Kardex, which serves as a quick reference for CNAs. Facility policy required that care plans be updated immediately following a fall or change in condition, with new interventions documented by the end of the shift. However, both nursing and administrative staff acknowledged that the care plan was not revised in a timely manner to include the 1:1 supervision intervention. This lack of documentation and formal communication led to inconsistencies in care and delayed the implementation of necessary safety measures for the resident.
Improper Catheter Care and Handling in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to potential risks of urinary tract infections. During a mechanical lift transfer, the nursing assistants did not maintain the foley catheter drainage bag below the resident's bladder, which could cause urine to flow back into the bladder. This improper handling was observed when the catheter bag was placed on the arm of the mechanical lift, above the bladder level, during the transfer from a wheelchair to a bed. Additionally, during incontinence care, a certified nursing assistant placed the urine catheter bag on the bed, which was not below the bladder, allowing urine to flow back toward the resident. This action was observed by the Assistant Director of Nursing, who intervened to correct the placement of the catheter bag. The CNA acknowledged that the catheter bag should not be placed on the bed as it could lead to urine backing up into the bladder. The resident involved was moderately cognitively impaired, required substantial assistance with activities of daily living, and had an indwelling catheter due to obstructive uropathy. The facility's Director of Nursing confirmed that the staff had been trained to keep the catheter bag below the bladder to prevent urinary tract infections and cross-contamination. However, the facility's policy on perineal care did not address foley catheter care, and despite skills competency checks indicating staff were competent, the observed practices did not align with the expected standards.
Food Safety and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Two dented cans of apple slices were found mixed with other canned foods in the dry storage room, contrary to the facility's policy of separating and designating a specific area for such items. Additionally, two cans of oven cleaner and two bottles of bleach were improperly stored alongside food items, posing a risk of contamination. The dry storage room floor was cluttered with items, including a box of cup lids, which should have been stored on shelves. During lunch service, several dietary aides were observed not wearing hair restraints properly, with hair exposed while they prepared and served food to residents. This was against the facility's policy, which requires all hair to be covered to prevent contamination of food and food-contact surfaces. Interviews with the dietary aides confirmed their awareness of the policy, yet they were unaware of their non-compliance at the time of observation. The Dietary Supervisor and Administrator acknowledged the deficiencies, noting that the dented cans should have been stored separately, and cleaning chemicals should have been kept in a locked area away from food. The facility's policies, as well as the U.S. FDA Food Code, emphasize the importance of proper storage and handling of food and chemicals to prevent contamination and ensure food safety. These lapses in adherence to established protocols could potentially place residents at risk for foodborne illness.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of staff not adhering to required protocols for personal protective equipment (PPE) and hand hygiene. For Resident #77, who was on enhanced barrier precautions due to a venous access device, LVN F did not wear a gown while administering intravenous antibiotics, despite being aware of the requirement. This oversight was acknowledged by LVN F, who admitted to forgetting the protocol despite having been trained on it. Resident #15, who required substantial assistance with activities of daily living and was always incontinent, was subject to improper hand hygiene practices by CNA B. During incontinence care, CNA B failed to change gloves and perform hand hygiene before handling clean supplies, and left the resident's room without washing hands. This lapse was noted by ADON A, who had to prompt CNA B to follow proper procedures, highlighting a gap in adherence to infection control practices. For Resident #13, who was on enhanced barrier precautions due to a foley catheter, both CNA C and ADON A failed to wear gowns during catheter and incontinence care. Similarly, during a mechanical lift transfer, CNA D and NA E did not wear gowns, contrary to the facility's policy for residents with catheters. These repeated failures to follow enhanced barrier precautions were acknowledged by the staff involved, who cited forgetfulness as the reason for non-compliance. Additionally, CNA G did not perform hand hygiene between glove changes while providing incontinence care to Resident #68, further indicating lapses in infection control practices.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had reasonable accommodation for their needs and preferences, specifically regarding the accessibility of the call light system. During an observation, it was noted that the call light was not within reach of a resident who was sitting in a wheelchair by the foot of the bed, while the call light was positioned by the head of the bed. This resident, an elderly female with severe cognitive impairment, was totally dependent on staff for activities of daily living (ADLs) and was unable to reach the call light to request assistance. Interviews with facility staff, including an LVN and the Director of Nursing (DON), confirmed that the call light was not within reach of the resident, which is against the facility's policy. The LVN acknowledged the oversight and repositioned the call light within the resident's reach. Both the LVN and the DON stated that it is the responsibility of all staff to ensure that call lights are accessible to residents at all times to prevent residents from being unable to call for help when needed.
Failure to Maintain Clean Linens for Resident
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident with severe cognitive impairment, Alzheimer's disease, and dementia, who was dependent on staff for activities of daily living and receiving hospice services. The resident's bed linen was observed to be soiled with feces, and it remained unchanged for several hours. The hospice aide responsible for changing the linen after the resident's shower did not do so, citing an inability to find clean linen and a lack of communication with other staff members about the issue. Interviews with facility staff, including a nursing assistant and a licensed vocational nurse, confirmed that they were unaware of the soiled linen and had not been notified by the hospice aide. The Director of Nursing acknowledged that the hospice aide should have communicated the issue to management and that the failure to change the linen posed a risk of infection and skin issues to the resident. The facility administrator admitted that there was no policy in place for maintaining a safe, clean, and comfortable environment, and no such policy was submitted by the time of the survey exit.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with an active diagnosis of Post-Traumatic Stress Disorder (PTSD) for a Level II PASARR evaluation upon a significant change in status assessment. This oversight was identified during a review of the resident's records, which showed that the resident had been diagnosed with PTSD and other conditions such as hypertension, diabetes, anxiety, and depression. Despite these diagnoses, the PASARR Level 1 screen conducted did not recognize PTSD as a qualifying condition for further evaluation, resulting in the resident not being referred to the appropriate state-designated authority for a Level II PASARR evaluation. Interviews with facility staff revealed a lack of understanding and communication regarding the PASARR process. The MDS coordinator, responsible for completing the PASARR Level 1, admitted to not knowing that PTSD was a qualifying diagnosis for a Level II evaluation. The Social Worker and the MDS coordinator had unclear roles, with the Social Worker stating she was not responsible for PASARR Level 1, and the MDS coordinator acknowledging that the follow-up for PASARR Level 1 was her responsibility. The Director of Nursing also confirmed that the MDS coordinator handled PASARR reports and expressed concern that the resident might not receive necessary services if the assessment was not completed properly.
Failure in Insulin Administration Procedure
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident with type 2 diabetes mellitus and osteomyelitis. The resident, who was severely cognitively impaired, was prescribed a daily dose of Insulin Glargine Solution to manage her diabetes. On a specific day, an LVN performed a blood sugar test on the resident and decided to hold the insulin dose because he was concerned about the resident's blood sugar level, which was 113, potentially dropping too low. However, the LVN did not notify the physician about holding the insulin, despite there being no parameters for withholding the routine insulin dose. The facility's Director of Nursing (DON) and the pharmacy consultant both acknowledged that holding a medication without physician notification could result in the resident not receiving a therapeutic dose, potentially worsening her condition. The facility's policy required that any medication held without specific parameters should be reported to the physician. The LVN had been deemed competent in medication administration, yet failed to follow the procedure, which led to the deficiency in pharmaceutical services for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 38 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Renaissance Care Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Gainesville Convalescent Center | 0.8 mi | ★★★★★ | 18 | 0 |
| Avir At River Valley | 2.1 mi | ★★★★★ | 1 | 0 |
| Whitesboro Health And Rehabilitation Center | 13.4 mi | ★★★★★ | 5 | 1 |
| Cedar Ridge Rehabilitation And Healthcare Center | 18 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pecan Tree Rehab And Healthcare Center.
100% money-back within 48 hours.
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.