Inspection Reports for Pebble Creek Nursing Center

The facility failed to ensure residents were assisted with feeding while staff were seated at eye level, and failed to ask residents if they wanted to wear clothing protectors, impacting dignity. Additionally, the facility failed to maintain proper infection control during wound care, specifically the wound care nurse did not change gloves between contaminated and clean tasks, risking cross contamination.

The complaint involved neglect related to failure to administer prescribed anticonvulsant medication to Resident #16, resulting in a seizure on 03/10/25. The facility delayed investigation and protective actions. Medication aides admitted to not administering medication and falsifying records. The Administrator was notified late and did not report to HHSC promptly.

The facility failed to ensure Resident #16 received prescribed Levetiracetam medication on 03/08/25 and 03/09/25, leading to a seizure. The facility did not immediately implement protective measures or report the neglect allegation promptly. Medication aides failed to administer medication and falsified documentation. The facility initiated corrective actions including termination of the responsible aide, counseling, medication audits, and staff training.

The facility failed to ensure residents had reasonable access to private telephone use, specifically for Resident #1, and failed to implement fall risk care plans properly by not placing fall mats next to beds for Residents #1 and #8, placing residents at risk of privacy violations and potential injury.

The complaint was substantiated based on video evidence and interviews. CNA A was observed being verbally and physically abusive to Resident #2 during perineal care on 08/01/24. Bruises were documented on Resident #2 on 08/02/24. The family member reported the incident and did not wish to prosecute. CNA A was terminated. The facility reported the incident to the Health and Human Services Commission and local police.

The facility failed to ensure Resident #2 was free from physical and verbal abuse by CNA A, who was observed on video using force and being verbally abusive while providing perineal care. Bruises were found on Resident #2 the following day. CNA A was terminated following the investigation. Additionally, the facility failed to ensure proper perineal care and infection control practices were followed by CNA A and CNA K for Residents #2 and #7 respectively.

The facility failed to post and maintain required nursing staffing information, including facility name, current date, resident census, and total hours worked by licensed and unlicensed nursing staff for June 29 and July 1, 2024. This failure could place residents and visitors at risk of not having access to staffing and census information.

The facility was found deficient in multiple areas including failure to obtain informed consent for medications, inadequate accommodation of resident needs, inaccurate resident assessments, failure to provide adequate personal hygiene care, unsafe environment hazards, improper catheter care, lack of nurse aide competency in colostomy care, unlocked medication carts, food safety violations, and failure to follow infection prevention protocols.

The facility failed to obtain informed consent for psychotropic medications for several residents, did not reasonably accommodate resident needs such as call light accessibility, failed to provide adequate personal hygiene care, had unsafe sharps disposal practices, improper catheter care, allowed untrained staff to perform colostomy care, left medication carts unlocked, had food safety violations, and failed to maintain proper infection control practices including gown use for residents on enhanced precautions.

The facility failed to ensure call lights were within reach for two residents, did not develop comprehensive care plans including necessary interventions such as head of bed elevation for enteral feeding, and failed to maintain proper head of bed positioning during enteral feedings for two residents, placing them at risk of unmet needs and aspiration.

The complaint investigation focused on delayed call light responses, with substantiated findings that call lights were not answered timely, including one instance of a 47-minute delay. Additional concerns included lack of care planning for oxygen therapy and missing oxygen signage.

The facility failed to respond timely to call lights for multiple residents, with one call light going unanswered for 47 minutes, posing risk of harm. Additionally, the facility failed to develop comprehensive care plans for oxygen therapy for Resident #7 and failed to post oxygen signs outside rooms of residents on oxygen therapy, increasing risk of fire or injury.

The complaint investigation revealed failures related to notification of room changes, physician notification, care planning, medication administration, oxygen therapy, and pest control. Resident #9 was moved due to ants without timely notification to the responsible party. Resident #8 had unresolved loose stools that were not reported to the physician, lacked a care plan for loose stools, and did not receive prescribed medication consistently. Resident #8's oxygen tank was found empty during therapy. The facility had ants in Resident #9's room and failed to maintain an effective pest control program until corrective actions were taken.

The facility failed to notify Resident #9's responsible party of a room change due to ants in the room, failed to notify the physician of Resident #8's unresolved loose stools, failed to develop a care plan addressing Resident #8's loose stools, failed to administer prescribed diarrhea medication (Imodium) consistently, failed to ensure Resident #8's oxygen tank was full during oxygen therapy, and failed to maintain an effective pest control program to prevent ants in Resident #9's room.

The complaint investigation found that the facility did not notify the hospice agency of Resident #1's critical lab result or medication change as required. Hospice was only notified when the resident revoked hospice care and was sent to the hospital. The failure to notify hospice could result in the resident having more seizures and receiving care not coordinated with hospice.

The facility failed to notify the hospice agency immediately about a critically high Levetiracetam blood level and subsequent medication dosage reduction for Resident #1. Interviews with nursing staff and hospice personnel confirmed the lack of timely notification, which could potentially lead to adverse health outcomes for the resident under hospice care.

The complaint investigation found that the facility did not report an allegation of abuse to HHSC within 2 hours when Resident #6 slapped Resident #7 on 05/22/2023. The incident was reported on 05/23/2023. The Administrator acknowledged the delay and stated it was due to interviewing and assessing residents. No injuries were noted.

The facility failed to report an allegation of abuse within the required 2-hour timeframe after Resident #6 slapped Resident #7. The incident was reported the following day, which violated facility policy and state law. Both residents were not injured, and the facility had interventions in place for Resident #6's behavioral issues.

The facility was found deficient in multiple areas including failure to post survey results accessibly, improper use and documentation of restraints, inaccurate resident assessments and care plans, inadequate infection control practices, medication errors including expired insulin administration, failure to ensure oxygen therapy compliance, food safety violations, and inaccurate medical record documentation.

The facility was found deficient in several areas including failure to accurately assess and document dementia-related behaviors for Resident #31, failure to notify appropriate authorities for significant changes in mental health status for Resident #34, inadequate respiratory care practices including failure to change and date oxygen equipment for Residents #4 and #76, incomplete care plans not addressing residents' behavioral symptoms, and improper food storage and sanitation practices in the kitchen.