Pecan Tree Rehab and Healthcare Center
1900 E California St · Gainesville, TX · 76240 · 9406686263
122 certified beds Government - Hospital district Chain: Creative Solutions in Healthcare
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
Red flags
2 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Total nurse staffing below 3.0 hours per resident-day
2.45 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 2.45 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.39 | 0.55–0.75 |
| Weekend hours / resident-day | 2.17 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 1 · $25,530 |
Inspection citations (29 in the current record)
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Potential for harm · E February 18, 2026
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected February 19, 2026 · Quality of Life and Care
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Potential for harm · E February 18, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 19, 2026 · Nutrition and Dietary
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Potential for harm · E February 18, 2026
Provide and implement an infection prevention and control program.
Corrected February 19, 2026 · Infection Control
-
Immediate jeopardy · K October 18, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 19, 2025 · Quality of Life and Care
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Immediate jeopardy · J October 18, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 19, 2025 · Quality of Life and Care
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Potential for harm · E October 18, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected October 19, 2025 · Resident Rights
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Potential for harm · E October 18, 2025 · found via complaint
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected October 19, 2025 · Resident Rights
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Potential for harm · D October 18, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected October 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · E October 18, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected October 19, 2025 · Pharmacy Service
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Potential for harm · E October 18, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected October 19, 2025 · Pharmacy Service
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Potential for harm · D November 13, 2024
Reasonably accommodate the needs and preferences of each resident.
Corrected December 9, 2024 · Resident Rights
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Potential for harm · D November 13, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected December 11, 2024 · Resident Assessment and Care Planning
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Potential for harm · E November 13, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected December 9, 2024 · Quality of Life and Care
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Potential for harm · D November 13, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 9, 2024 · Pharmacy Service
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Potential for harm · E November 13, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 9, 2024 · Nutrition and Dietary
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Potential for harm · D November 13, 2024 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected December 9, 2024 · Resident Rights
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Potential for harm · E November 13, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected December 9, 2024 · Infection Control
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Potential for harm · D September 19, 2023
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected October 11, 2023 · Resident Assessment and Care Planning
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Potential for harm · E September 19, 2023
Provide activities to meet all resident's needs.
Corrected October 11, 2023 · Quality of Life and Care
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Potential for harm · D September 19, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 11, 2023 · Quality of Life and Care
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Potential for harm · E September 19, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 11, 2023 · Quality of Life and Care
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Potential for harm · D September 19, 2023
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected October 11, 2023 · Quality of Life and Care
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Potential for harm · E September 19, 2023
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected October 11, 2023 · Quality of Life and Care
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Potential for harm · E September 19, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 11, 2023 · Nutrition and Dietary
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Potential for harm · D September 19, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected October 11, 2023 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 18, 2025 | Fine | $25,530 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 675550 · certified since November 7, 1995. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.