Pebble Creek Healthcare Center

In the surveyor’s words

From the most serious findings on record at Pebble Creek Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 2, 2021

  The following deficiency represents an incident of past noncompliance that was subsequently corrected prior to this survey. Based on closed medical record review, staff interviews, review of witness statements, review of the Emergency Medical Service (EMS) care record, review of the facility policies related to Cardiopulmonary Resuscitation (CPR) and choking, the facility failed to ensure the correct code status was verified for former Resident #2. This resulted in Immediate Jeopardy that was actual harm when Resident #2 had cessation of vital signs, and CPR was not initiated as ordered. The resident subsequently expired at the facility. This affected one of one resident reviewed for full code and death. […]

• Actual harm, isolatedF684Mar 27, 2025

  Based on observation, resident and staff interview, medical record review, hospital documentation review, and policy review, the facility failed to ensure a resident received appropriate care and services to monitor for neurological changes and obtain laboratory values for a resident with know history of hepatic encephalopathy. Actual harm occurred to Resident #9 when the resident's ordered medication used to prevent hepatic encephalopathy was changed from being administered on a scheduled basis to only given as needed. Additionally, the facility did not implement monitoring for altered mental status changes as care planned and did not obtain ammonia laboratory values as ordered to determine the need for administering the as needed medication or additional interventions. […]

• No harm, potential for more than minimal, widespreadF880Nov 29, 2021

  Based on observation, interview, facility policy review, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of Covid-19, and review of the CDC Covid Tracker website, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This had the potential to affect all residents residing in the facility. Facility census was 130. Finding include: Observation of the 700 unit on 11/29/21 at 5:10 A.M. revealed Licensed Practical Nurse (LPN) #138 was not wearing eye protection. Interview with LPN #138 at time of observation revealed she was aware she was required to wear eye protection while in the facility. Observation on the 700 unit on 11/29/21 at 5:13 A.M. revealed LPN #139 was not wearing eye protection. […]

• No harm, potential for more than minimal, widespreadF880Mar 18, 2021

  Based on observation, record review and interview the facility failed to ensure personal protective equipment (PPE) was utilized appropriately to prevent the spread of Covid 19. This had the potential to affect all residents residing in the facility. The facility census was 144. Findings include: Interview with Registered Nurse (RN) #204 on 03/17/21 at 4:04 A.M. revealed she was caring for a Covid positive resident and non Covid positive residents. RN #204 stated she wore an N95 mask, face shield, gown and gloves during care and disposed of the PPE prior to leaving the Covid positive resident's room. She further stated after she doffed the PPE she performed hand hygiene. At time of interview RN #204 was wearing a surgical mask and no eye protection. […]

• No harm, potential for more than minimal, isolatedF580Dec 18, 2025

  Based on review of the medical record, review of the concern log, review of the incident log, interview with the staff, and review of the facility policy, the facility failed to ensure the resident representative for Resident #146 was notified of a fall. This affected one resident (Resident #146) of three reviewed for falls.Findings Include: Review of the medical record revealed Resident #146 was admitted to the facility on [DATE]. Diagnoses included Parkinsonism, benign neoplasm of the cerebral meninges, hypertensive heart disease, paranoid schizophrenia, anxiety disorder, heart failure, repeated falls, insomnia, major depressive disorder, head injury, muscle weakness and unsteadiness on feet. […]