F
33/100Pebble Creek Nursing Center Inspection Report, Violations & Safety Grade (El Paso, Texas)
11608 Scott Simpson Drive, El Paso, Texas 79936
Phone: 9158570071
CMS Overall:1/5
Overview & Bed Count
Certified Beds
120
Avg Residents/Day
96
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
County
El Paso
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing1/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.42 | 0.44 | -0.02 |
| Total Nurse Hours per Resident per Day | 3.08 | 3.42 | -0.33 |
| CMS Staffing Rating | 1/5 | 1.9/5 | - |
| Nursing Staff Turnover | 60.2% | 50.8% | - |
Health Citation History
58 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-15 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2026-07-15 | Nutrition and Dietary Deficiencies | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | E – Moderate Harm Potential |
| 2026-07-15 | Nutrition and Dietary Deficiencies | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | E – Moderate Harm Potential |
| 2026-07-15 | Nutrition and Dietary Deficiencies | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | E – Moderate Harm Potential |
| 2026-07-15 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2026-07-15 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2026-07-15 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-07-15 | Resident Assessment and Care Planning Deficiencies | Assess the resident when there is a significant change in condition | D – Moderate Harm Potential |
| 2026-07-15 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2026-07-15 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2026-07-15 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2026-07-15 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2026-07-15 | Nursing and Physician Services Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-07-15 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D – Moderate Harm Potential |
| 2026-07-15 | Nutrition and Dietary Deficiencies | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | D – Moderate Harm Potential |
| 2026-07-15 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-05-22 | Administration Deficiencies | Hire a qualified full-time social worker in a facility with more than 120 beds. | E – Moderate Harm Potential |
| 2026-05-22 | Infection Control Deficiencies | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | E – Moderate Harm Potential |
| 2026-04-23 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D – Moderate Harm Potential |
| 2026-03-31 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2026-03-31 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2026-03-17 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2026-01-22 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2026-01-22 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-09-09 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E – Moderate Harm Potential |
| 2025-09-09 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-05-20 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | K – Immediate Jeopardy |
| 2025-05-20 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | K – Immediate Jeopardy |
| 2025-05-20 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | J – Immediate Jeopardy |
| 2025-05-20 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E – Moderate Harm Potential |
| 2025-05-20 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | E – Moderate Harm Potential |
| 2025-05-20 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2025-05-20 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2025-05-20 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2025-05-20 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2025-05-20 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-05-20 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-01-23 | Resident Rights Deficiencies | Ensure residents have reasonable access to and privacy in their use of communication methods. | D – Moderate Harm Potential |
| 2025-01-23 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-09-20 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G – Actual Harm |
| 2024-09-20 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-07-02 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | C – Minimal Harm Potential |
| 2024-05-16 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2024-05-16 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-05-16 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2024-05-16 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2024-05-16 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-05-16 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-05-16 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2024-05-16 | Nursing and Physician Services Deficiencies | 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. | D – Moderate Harm Potential |
Showing 50 of 58 citations.
Fire Safety Citation History
16 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-15 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2026-07-15 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2026-07-15 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2026-07-15 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2025-05-20 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2025-05-20 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-05-20 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-05-20 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-05-20 | Gas, Vacuum, and Electrical Systems Deficiencies | Have a battery powered remote alarm panel in a location accessible by operating personnel. | F – Moderate Harm Potential |
| 2025-05-20 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-05-20 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2025-05-20 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2025-05-20 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2024-05-16 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2024-05-16 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | E – Moderate Harm Potential |
| 2024-05-16 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
Total Penalties & Fines
$145,184
Total Fine Amount (CMS)
2
Number of Fines
3
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-05-20 | Fine | $137,014 | - |
| 2025-05-20 | Payment Denial | - | 70 days starting 2025-06-19 |
| 2024-09-20 | Fine | $8,170 | - |
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the El Paso area at no cost.
Find Safe, Vetted Facilities Near El Paso
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.