A list of the most recent deficiencies for Pebble Creek Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-30 | 2023-12-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-30 | 2023-11-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-30 | 2023-11-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-29 | 2023-11-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-29 | 2023-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-29 | 2023-10-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-29 | 2023-10-30 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-09-29 | 2023-10-27 | Y |
| 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. | Health | 2023-07-17 | 2023-08-01 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-29 | 2023-07-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-28 | 2023-07-08 | Y |
| 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. | Health | 2023-04-05 | 2023-05-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-05 | 2023-04-28 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-04-05 | 2023-04-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-04-05 | 2023-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-05 | 2023-04-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-05 | 2023-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-05 | 2023-04-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-05 | 2023-04-20 | N |
| 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. | Health | 2023-04-05 | 2023-04-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-04-05 | 2023-04-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-05 | 2023-04-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-05 | 2023-04-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-05 | 2023-04-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-05 | 2023-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-05 | 2023-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-05 | 2023-04-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-10 | 2022-02-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-10 | 2022-02-25 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-02-10 | 2022-02-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-10 | 2022-02-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-10 | 2022-02-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-10 | 2022-02-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-02-10 | 2022-02-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-10 | 2022-02-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-08 | 2022-02-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-02-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-02 | 2021-12-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-14 | 2021-08-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-02-25 | 2021-03-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-02-25 | 2021-03-26 | N |
