El Paso, TX

Pebble Creek Nursing Center

1-star overall rating with 1-star inspections with abuse icon flag with $151,360 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

11608 Scott Simpson Dr, El Paso, TX

(915) 857-0071

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Creative Solutions In Healthcare

Operator or chain grouping

Approved since

1987-11-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

149 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.36

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.70

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.88

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.18

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.37

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.42

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.38

CMS adjusted RN staffing hours

Adjusted total hours

3.09

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

51%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,677

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

11.10

Composite VBP score used to determine payment impact.

Payment multiplier

0.9810

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 20.84% · Performance 22.46% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 6.54% · Performance 8.35% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.14

Baseline 38.18% · Performance 46.77% · Measure score 4.14 · Achievement 4.14 · Improvement 0

Adjusted total nurse staffing

0.30

Baseline 2.56 hours · Performance 2.82 hours · Measure score 0.30 · Achievement 0 · Improvement 0.30

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.88%	10.72% 0.8 pts better	No Different than the National Rate · Eligible stays 30 · Observed rate 3.33% · Lower 95% interval 6.72%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.38	1.02 0.4 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 27 · Denominator 27
Falls with major injury	7.41%	0.77% 6.6 pts worse	Numerator 2 · Denominator 27
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 27 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.35%	7.12% 1.2 pts worse	No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 4.39%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 117
Staff flu vaccination coverage	56.94%	42% 14.9 pts better	Numerator 82 · Denominator 144
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.0%	3.3% 1.7 pts worse	3.3% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.5% · Q3 5.4% · Q4 2.3% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.9%	2.7% 1.8 pts better	11.4% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 0.9%
Percentage of long-stay residents who lose too much weight	3.3%	3.3% About the same	5.4% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 4.9% · Q4 4.9% · 4Q avg 3.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.2%	18.9% 7.7 pts better	19.6% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.5% · Q3 13.3% · Q4 8.6% · 4Q avg 11.2%
Percentage of long-stay residents who received an antipsychotic medication	8.1%	10.8% 2.7 pts better	16.7% 8.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 9.6% · Q3 6.2% · Q4 7.4% · 4Q avg 8.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	13.4%	15.4% 2 pts better	16.3% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 4.0% · Q3 14.9% · 4Q avg 13.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	15.1%	16.1% 1 pts better	14.9% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.9% · Q3 11.4% · Q4 33.8% · 4Q avg 15.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.4%	0.8% 0.6 pts worse	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 1.1% · Q4 2.3% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.7%	15.0% 4.7 pts worse	19.8% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 21.5% · Q3 17.8% · Q4 20.2% · 4Q avg 19.7%
Percentage of long-stay residents with pressure ulcers	8.2%	4.2% 4 pts worse	5.1% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 8.3% · Q3 9.2% · Q4 8.0% · 4Q avg 8.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.3%	89.7% 7.6 pts better	81.7% 15.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.9% · Q4 92.6% · 4Q avg 97.3%
Percentage of short-stay residents who had an outpatient emergency department visit	8.4%	12.0% 3.6 pts better	12.0% 3.6 pts better	Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 8.7% · Expected 11.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.0% 12 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.9%	25.9% 1 pts better	23.9% 1 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 26.1% · Expected 25.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-16 · Fire 2024-05-16

14 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2023-04-05 · Fire 2023-04-05

22 health deficiencies

Top issue: Resident Assessment and Care Planning (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-02-10 · Fire 2022-02-10

22 health deficiencies

Top issue: Resident Assessment and Care Planning (8 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-16

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-06-21

E · Potential for more than minimal harm 2024-05-16

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-07-12

E · Potential for more than minimal harm 2024-05-16

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-05-30

C · Minimal harm 2022-02-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-02-25

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-09

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-09-16

D · Potential for more than minimal harm 2025-09-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-16

K · Immediate jeopardy 2025-05-20

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-05-25

K · Immediate jeopardy 2025-05-20

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-05-25

J · Immediate jeopardy 2025-05-20

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-05-25

D · Potential for more than minimal harm 2025-01-23

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2025-02-07

D · Potential for more than minimal harm 2025-01-23

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-02-07

G · Actual harm 2024-09-20

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-09-20

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-10-11

C · Minimal harm 2024-07-02

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-07-25

E · Potential for more than minimal harm 2024-05-16

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-03

E · Potential for more than minimal harm 2024-05-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-03

D · Potential for more than minimal harm 2024-05-16

F552 · Resident Rights Deficiencies

Health

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

Corrected 2024-06-03

D · Potential for more than minimal harm 2024-05-16

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-06-03

D · Potential for more than minimal harm 2024-05-16

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-06-03

D · Potential for more than minimal harm 2024-05-16

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-03

D · Potential for more than minimal harm 2024-05-16

F690 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-03

D · Potential for more than minimal harm 2024-05-16

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2024-06-03

D · Potential for more than minimal harm 2024-05-16

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-06-03

D · Potential for more than minimal harm 2024-05-16

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2024-06-03

E · Potential for more than minimal harm 2024-02-15

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-03-01

D · Potential for more than minimal harm 2024-02-15

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-03-29

D · Potential for more than minimal harm 2024-02-15

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-03-01

E · Potential for more than minimal harm 2023-10-30

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-12-04

D · Potential for more than minimal harm 2023-10-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-11-30

D · Potential for more than minimal harm 2023-10-30

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-30

E · Potential for more than minimal harm 2023-09-29

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-10-30

D · Potential for more than minimal harm 2023-09-29

F559 · Resident Rights Deficiencies

Health

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

Corrected 2023-10-27

D · Potential for more than minimal harm 2023-09-29

F580 · Resident Rights Deficiencies

Health

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

Corrected 2023-10-30

D · Potential for more than minimal harm 2023-09-29

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-11-02

D · Potential for more than minimal harm 2023-09-29

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-10-30

D · Potential for more than minimal harm 2023-09-29

F925 · Environmental Deficiencies

Health

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

Corrected 2023-07-25

D · Potential for more than minimal harm 2023-07-17

F849 · Administration Deficiencies

Health

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.

Corrected 2023-08-01

D · Potential for more than minimal harm 2023-06-28

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2023-07-08

E · Potential for more than minimal harm 2023-04-05

F577 · Resident Rights Deficiencies

Health

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

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-04-05

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-04-05

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-04-05

F694 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-04-05

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-04-05

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-04-20