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Health Inspection Summary
Pebble Creek Nursing Center
11608 Scott Simpson Dr
El Paso, TX 79936
(915) 857-0071

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Deficiency Category
Inspection Date:
5/16/24
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
4/5/23
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
2/10/22
Complaint Reporting Period:
3/1/22 - 2/28/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies120
Quality of Life and Care Deficiencies482
Infection Control Deficiencies100
Resident Assessment and Care Planning Deficiencies175
Nursing and Physician Services Deficiencies200
Resident Rights Deficiencies250
Nutrition and Dietary Deficiencies111
Pharmacy Service Deficiencies150
Environmental Deficiencies010
Administration Deficiencies010

Detailed result for inspection on 5/16/24
Date of last standard health inspection:5/16/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:13
Average number of Health Deficiencies in Texas:8.7
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

9/20/248/2/24
3 - Actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide care and assistance to perform activities of daily living for any resident who is unable.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Some

Provide care and assistance to perform activities of daily living for any resident who is unable.

9/20/2410/11/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives an accurate assessment.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Post nurse staffing information every day.

7/2/247/25/24
1 - Potential for minimal harm
Many

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Reasonably accommodate the needs and preferences of each resident.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are fully informed and understand their health status, care and treatments.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 4/5/23
Date of last standard health inspection:4/5/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:30
Average number of Health Deficiencies in Texas:8.6
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

6/28/237/8/23
2 - Minimal harm or potential for actual harm
Few

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Few

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.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Some

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

9/29/2310/30/23
2 - Minimal harm or potential for actual harm
Some

Provide safe and appropriate respiratory care for a resident when needed.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Some

Provide safe and appropriate respiratory care for a resident when needed.

10/30/2311/30/23
2 - Minimal harm or potential for actual harm
Few

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Some

Provide safe and appropriate respiratory care for a resident when needed.

9/29/2310/30/23
2 - Minimal harm or potential for actual harm
Few

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.

2/15/243/1/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Some

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

10/30/2311/30/23
2 - Minimal harm or potential for actual harm
Few

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

9/29/2311/2/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2/15/243/29/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

9/29/2310/30/23
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

10/30/2312/4/23
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

9/29/2310/27/23
2 - Minimal harm or potential for actual harm
Few

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Some

Reasonably accommodate the needs and preferences of each resident.

2/15/243/1/24
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that residents are free from significant medication errors.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

4/5/234/28/23
2 - Minimal harm or potential for actual harm
Few

Ensure medication error rates are not 5 percent or greater.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

4/5/235/2/23
2 - Minimal harm or potential for actual harm
Few

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

4/5/234/20/23
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

9/29/237/25/23
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

7/17/238/1/23
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 2/10/22
Date of last standard health inspection:2/10/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23
No complaint inspections
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23
Total number of Health Deficiencies for this nursing home:8
Average number of Health Deficiencies in Texas:6.4
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide safe and appropriate respiratory care for a resident when needed.

2/10/222/25/22
2 - Minimal harm or potential for actual harm
Some

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

2/10/222/25/22
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

2/10/222/25/22
2 - Minimal harm or potential for actual harm
Some

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

2/10/222/25/22
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

2/10/222/25/22
2 - Minimal harm or potential for actual harm
Some

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2/10/222/25/22
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

2/10/222/25/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

2/10/222/25/22
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

9/20/248/2/24
3 - Actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Some

Provide care and assistance to perform activities of daily living for any resident who is unable.

9/20/2410/11/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives an accurate assessment.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Post nurse staffing information every day.

7/2/247/25/24
1 - Potential for minimal harm
Many

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are fully informed and understand their health status, care and treatments.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

5/16/246/3/24
2 - Minimal harm or potential for actual harm
Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

6/28/237/8/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

9/29/2310/30/23
2 - Minimal harm or potential for actual harm
Some

Provide safe and appropriate respiratory care for a resident when needed.

10/30/2311/30/23
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

9/29/2310/30/23
2 - Minimal harm or potential for actual harm
Few

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.

2/15/243/1/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

10/30/2311/30/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

9/29/2311/2/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2/15/243/29/24
2 - Minimal harm or potential for actual harm
Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

9/29/2310/30/23
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

10/30/2312/4/23
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

9/29/2310/27/23
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

2/15/243/1/24
2 - Minimal harm or potential for actual harm
Some

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

9/29/237/25/23
2 - Minimal harm or potential for actual harm
Few

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

7/17/238/1/23
2 - Minimal harm or potential for actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years.
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