Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pebble Creek Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and cognitive impairment experienced a fall without injury. Although the physician and unit managers were notified, the resident's MPOA was not informed as required by facility policy. The omission was discovered after a family member raised a concern about lack of notification, and it was confirmed that the nurse did not contact the MPOA due to a misunderstanding about the responsible party listed in the records.
A resident with cognitive and behavioral diagnoses reported to police that she was assaulted at the facility, but the incident was not documented or reported by staff as required. The case worker and DON were either unaware of the abuse allegation or did not recognize it as such, resulting in a failure to follow facility policy for immediate reporting and investigation.
A resident with hepatic encephalopathy did not receive scheduled Lactulose as ordered, and the facility failed to monitor for neurological changes or obtain ammonia levels as required. The lack of appropriate monitoring and medication administration led to a change in mental status and hospitalization for elevated ammonia levels. Staff interviews and record reviews confirmed the absence of necessary care and documentation during the period in question.
A resident with multiple risk factors for falls did not receive all care-planned fall prevention interventions, including the use of Dycem during transfers with a mechanical lift. Staff failed to consistently implement these interventions, and the resident experienced a fall from her wheelchair. Observations confirmed that required safety measures were not always in place, and staff acknowledged the lapse.
A resident with multiple chronic conditions and impaired mobility did not receive timely incontinence care, resulting in prolonged exposure to soiling and the development of large red areas on both buttocks. Staff confirmed that care was delayed during meal times due to their responsibilities with meal service and feeding, contrary to facility policy requiring prompt perineal care to prevent skin breakdown.
Two residents did not receive pressure ulcer care as ordered, including failure to identify and treat new or worsening wounds in a timely manner and not following physician orders for wound care supplies, resulting in untreated skin injuries and unnecessary pain. Staff were unaware of active treatment orders, and documentation of wound care was incomplete.
A resident with paraplegia and colostomy status was found in a state of neglect, covered in feces and urine, with his colostomy bag not attached. Despite expressing a desire to manage his own care, the facility failed to provide necessary assistance, leading to the resident's hospitalization for multiple decubitus ulcers and suspected neglect.
A resident with a history of opioid abuse was found unresponsive, and a telehealth physician ordered Narcan for a suspected overdose. However, an LPN was unable to retrieve the medication from the Omnicell due to searching under the brand name instead of the generic name, Naloxone. The resident was subsequently sent to the hospital. The facility had both nasal spray and injectable forms of Naloxone available.
Failure to Notify Resident Representative of Fall Incident
Penalty
Summary
The facility failed to notify the resident representative for a resident who experienced a fall. The resident, who had multiple diagnoses including Parkinsonism, hypertensive heart disease, repeated falls, and cognitive impairment, was found sitting on the floor in her bedroom after sliding out of bed. The nurse documented the incident and notified the physician and unit managers, but there was no documentation that the resident's Medical Power of Attorney (MPOA) was informed of the fall, as required by facility policy. A family member later raised a concern about not being notified of the fall, which was documented in the facility's Concern Log. The nurse involved stated that she did not notify the emergency contact or MPOA because the resident was listed as her own responsible party on the face sheet. However, the Director of Nursing confirmed that the nurse should have contacted the MPOA as indicated in the resident's record. The facility's policy requires notification of resident representatives for changes in condition, including accidents and incidents.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with diagnoses including epilepsy, dementia with agitation, anxiety disorder, and cognitive communication deficit. The resident reported to a police officer at the hospital that she had been assaulted within the last two weeks at the facility, stating someone placed their hands on her wrists causing injury while she was in her wheelchair. The officer did not observe visible injuries, and the resident could not identify the alleged perpetrator. The police officer followed up at the facility and spoke with the resident's case worker, who was unaware of any assault incidents and had no documentation of such events in the resident's record. The case worker recalled discussing the police visit with the DON, but the DON stated she was only informed about concerns related to money and was unaware of any abuse allegation. The DON confirmed that, had she known, she would have filed a self-reported incident and initiated an investigation. Facility policy requires immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, but this process was not followed in this case. The deficiency was identified through record review, police report review, interviews, and policy review.
Failure to Provide Appropriate Monitoring and Medication for Hepatic Encephalopathy
Penalty
Summary
A deficiency occurred when a resident with a known history of hepatic encephalopathy did not receive appropriate care and services as ordered and care planned. The resident was originally prescribed scheduled Lactulose to manage ammonia levels and prevent encephalopathy, but the order was changed to as needed after complaints of diarrhea. Despite this change, there was no evidence that the resident received Lactulose from the time the order was changed until a hospitalization occurred. Additionally, the facility failed to monitor for neurological changes and did not obtain ammonia laboratory values as ordered, which were necessary to guide further interventions. The resident's care plan included specific interventions to monitor for signs and symptoms of altered neurological status and to obtain and monitor laboratory studies as ordered. However, medical record reviews showed no documentation of monitoring for increased ammonia levels or neurological changes during the relevant period. Interviews with staff confirmed that ammonia levels were not drawn due to logistical issues with the laboratory, and there was no evidence of alternative monitoring or documentation of the resident's neurological status as required by the care plan and physician orders. The resident subsequently experienced a change in mental status and elevated ammonia levels, which led to hospitalization. Hospital records indicated that the resident was admitted for altered mental status, hyperammonemia, and other complications, and her condition improved after receiving scheduled Lactulose and other treatments. Family interviews revealed concerns about the discontinuation of Lactulose and lack of communication from the facility. The deficiency affected one resident and was substantiated through observation, interviews, and record review.
Failure to Implement Fall Prevention Interventions as Care Planned
Penalty
Summary
Staff failed to implement fall prevention interventions as outlined in the care plan for a resident with significant fall risk factors. The resident, who had diagnoses including hemiplegia, acute respiratory failure with hypoxia, and vascular dementia, was dependent on staff for most activities of daily living and was always incontinent. The care plan included specific interventions such as placing Dycem (a non-slip pad) between the resident and the mechanical lift pad during transfers and in the resident's chair. However, during an observed transfer, staff did not place the Dycem between the resident and the mechanical lift pad as required, and the Dycem was found on the bedside table instead. Both the unit manager and LPN confirmed that the intervention was not followed. The resident had previously experienced a fall from her wheelchair in a common area, after which additional Dycem was ordered for her chair. Despite being identified as at risk for falls and having a care plan in place, the required interventions were not consistently implemented. Staff interviews indicated uncertainty about the circumstances of the fall and the position of the wheelchair at the time. Observations and record reviews confirmed that the facility did not ensure fall interventions were in place as care planned to prevent falls.
Failure to Provide Timely Incontinence Care During Meal Times
Penalty
Summary
A deficiency was identified when a resident with a history of congestive heart failure, type 2 diabetes mellitus with peripheral angiopathy, and chronic kidney disease did not receive timely incontinence care. The resident was care planned for impaired skin integrity and required peri-care as needed to prevent skin breakdown due to incontinence. The resident was cognitively intact and dependent on staff for toileting hygiene, lower body dressing, and transfers. According to the resident, she was placed in her chair in the morning and was unable to return to bed or receive care for several hours, particularly during meal times when staff were occupied with meal service and feeding other residents. Observation revealed that the resident had large red areas on both buttocks, with the left side more affected, after experiencing a significant bowel movement that was not addressed for at least two hours. Certified Nurse Aides confirmed the presence of skin redness and acknowledged that residents often had to wait for care during meal periods due to staffing assignments. Review of facility policy indicated that perineal care should be provided to maintain cleanliness, comfort, and skin integrity, but this standard was not met in the resident's case.
Failure to Implement and Document Pressure Ulcer Care as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were implemented as ordered and did not properly identify or address pressure ulcers in a timely manner for two residents. One resident, with multiple comorbidities including hepatic encephalopathy, diabetes, and congestive heart failure, was readmitted to the facility with three pressure ulcers and had specific treatment orders in place. Despite documentation that these wounds resolved, subsequent observations and shower sheets indicated new or ongoing areas of concern on the resident's back, coccyx, and right buttock. Certified Nurse Aides noted and reported red areas, but there was no evidence in the medical record or treatment administration records that these areas were assessed or treated as required, and the wounds were not documented until observed by surveyors. Another resident, with a complex medical history including Alzheimer's disease, chronic pain, and malnutrition, had a physician's order for the use of adhesive remover when changing a sacral dressing. During wound care observation, an LPN did not use the adhesive remover, causing the resident to express pain. The LPN was unaware of the order, and the Director of Nursing was under the impression that the order had been discontinued, though it remained active in the records. This failure to follow the treatment order resulted in unnecessary discomfort for the resident. Facility policy required the prevention of skin impairment and the promotion of wound healing, with interdisciplinary interventions to prevent and treat skin integrity issues. However, the facility did not ensure that staff were aware of and followed current treatment orders, nor did they ensure timely identification and intervention for new or worsening pressure ulcers, as evidenced by the lack of documentation and appropriate care for the affected residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide appropriate and timely incontinence care for a resident, identified as Resident #69, who was admitted with paraplegia, neuromuscular dysfunction of the bladder, and colostomy status. The resident had a history of chronic pain, opioid abuse, and was non-compliant with preventative and protective interventions related to skin integrity. Despite being educated multiple times, the resident often refused care, including adjustments to his wheelchair for skin protection and refused to wear clothing on his lower body, opting instead to cover himself with sheets and towels. On a particular night, the resident was found in a state of altered mental status, suspected to be due to an overdose. The resident was discovered slumped over in his wheelchair, covered in feces and urine, with his colostomy bag not attached. The EMS reported a scene of neglect, with large amounts of feces and urine present, indicating more than one instance of incontinence. The resident was transferred to the hospital, where he was diagnosed with multiple decubitus ulcers and was believed to be suffering from failure to thrive secondary to neglect. Interviews with staff and EMS personnel revealed that the resident had expressed a desire to manage his own colostomy and suprapubic catheter care, often refusing assistance. However, the staff failed to ensure the resident received necessary care, as evidenced by the condition in which he was found. The facility's policies on routine resident care and perineal care were not adhered to, resulting in the resident's neglect and subsequent hospitalization.
Failure to Administer Narcan Due to Medication Retrieval Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, which affected one of the three residents reviewed for medication administration. The resident, who had a history of chronic pain and opioid abuse, was found unresponsive and slumped over in his wheelchair. The telehealth physician suspected a drug overdose and ordered Narcan to be administered. However, the medication was not available to the LPN because she attempted to retrieve it under the brand name Narcan instead of its generic name, Naloxone. Consequently, the resident was sent to the hospital by emergency medical services. The resident's medical record indicated diagnoses of paraplegia, neuromuscular dysfunction of the bladder, and colostomy status. At the time of the incident, the resident was found with urine and feces on his person and the floor, which was not initially observed by the LPN during her wellness check. The LPN was a new nurse and was later educated on how to properly retrieve Narcan from the Omnicell medication distribution center. The Director of Nursing confirmed that both nasal spray and injectable forms of Naloxone were available in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Akron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Village Skilled Nursing & Rehabilitation Ltd | 0.4 mi | ★★★★★ | 0 | 0 |
| St Luke Lutheran Community-portage Lakes | 3.1 mi | ★★★★★ | 0 | 0 |
| Pleasant View Health Care Center | 5.2 mi | ★★★★★ | 2 | 0 |
| Barberton Post Acute | 5.2 mi | ★★★★★ | 0 | 0 |
| The Colony Healthcare Center | 7.4 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.