Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record revealed Resident #108 was admitted to the facility on [DATE]. Diagnoses included
Alzheimer's disease, chronic pain, metabolic encephalopathy, peripheral vascular disease, adult failure to
thrive, dementia, dysphagia, insomnia, hypertensive heart disease, anxiety disorder, bullous pemphigoid,
protein-calorie malnutrition, vitamin D deficiency, major depressive disorder, syncope and collapse, and
hyperlipidemia.
Residents Affected - Few
Review of the March 2025 medication administration record revealed Resident #108 had an order for the
nurse to use adhesive removal when changing the dressing to the sacrum every shift dated 01/27/25 and
was signed off as completed twice daily.
Review of the March 2025 physician orders revealed Resident #108 had an order to cleanse the sacral
wound with Hibiclens, pat dry, apply iodoform, and cover with bordered foam dressings every shift and as
needed dated 03/17/25 and a nurse to use adhesive removal when changing dressing to sacrum dated
01/27/25.
Observation of wound care on 03/26/25 at 8:00 A.M. revealed LPN #280 provided wound care to Resident
#108. LPN #280 started to remove the border foam from the sacrum of Resident #108 and the resident
voiced expressions of pain numerous times while LPN #280 removed the treatment.
On 03/26/25 at 12:30 P.M. an interview with the Director of Nursing (DON) stated she does not know why
Resident #108 still had an order for adhesive remover because she thought it was discontinued. The DON
stated at one time Resident #108 had a dressing that was irritating the skin around her sacrum so they got
an order of adhesive remover so it would be easier on her.
On 03/26/25 at 11:21 A.M. an interview with LPN #280 confirmed she did not use the adhesive remover
prior to removing the border foam dressing from the sacrum of Resident #108. LPN #280 stated she did not
know Resident #108 had an order for adhesive remover.
Review of the undated facility policy titled, Skin Care and Wound Management Overview, revealed the
facility strives to prevent resident skin impairment and to promote the healing of exiting wounds. The
interdisciplinary team works with the resident and for family to identify and implement interventions to
prevent and treat potential skin integrity issues.
This deficiency represents non-compliance investigated under Complaint Number OH00162412.
Based on observation, medical record review, resident and staff interview, review of shower sheets, and
policy review, the facility failed to ensure pressure ulcer treatments were implemented as
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
365727
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365727
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pebble Creek Healthcare Center
670 Jarvis Rd
Akron, OH 44319
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
ordered and failed to ensure pressure ulcers were properly identified and addressed in a timely manner.
This affected two (#9 and #108) of four residents reviewed for pressure ulcers. The facility census was 148.
Findings included:
1. Review of Resident #9's medical record revealed an admission date of 01/25/24. Diagnoses included
hepatic encephalopathy, type two diabetes mellitus, dysphagia, and congestive heart failure.
Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident
#9 had moderate cognitive impairment. Resident #9 was dependent for toileting hygiene, bathing, and lower
body dressing. Resident #9 required partial to moderate assistance with personal hygiene. Resident #9 was
always incontinent of urine and bowel. Resident #9 was at risk of developing a pressure ulcer but did not
have a pressure ulcer or injury. Resident #9 did not reject care during the seven-day assessment look-back
period.
Review of Resident #9's Braden scale observation tool dated 03/11/25 revealed Resident #9 was at low risk
for developing a pressure ulcer.
Review of Resident #9's progress notes dated 02/05/25 at 1:40 A.M. revealed Resident #9 was transported
to the local hospital.
Review of Resident #9's progress notes dated 02/10/25 at 4:03 P.M. revealed Resident #9 was readmitted
to the facility and had three pressure ulcers with treatments ordered. Resident #9 was placed on a low air
loss mattress and Resident #9's son was notified.
Review of Resident #9's wound assessment report dated 02/12/25 revealed Resident #9 had a stage two
pressure ulcer (partial-thickness skin loss with exposed dermis) to the sacrum present on admission with
measurements of 2.0 centimeters (cm) long by 1.0 cm wide by 0.2 cm deep. Treatment initiated to cleanse
the wound with normal saline, apply Triad cream (a zinc oxide-based paste used for managing wounds),
and a bordered foam dressing daily and as needed. Resident #9 had a stage one pressure ulcer
(non-blanchable erythema of intact skin) to the mid-back on admission with measurements of 1.0 cm long
by 1.5 cm wide with no measurable depth. Treatment was initiated to cleanse the wound with wound
cleanser, apply skin prep and a bordered foam dressing three times a week and as needed. Resident #9
also had a stage one pressure ulcer to the right lateral ankle present on admission with measurements of
1.0 cm long by 1.0 cm wide with no measurable depth. Treatment was initiated to cleanse the wound with
normal saline, apply skin prep and a bordered foam dressing three times per week and as needed.
Review of Resident #9's wound assessment report dated 02/19/25 included Resident #9's right lateral
ankle stage one pressure injury was resolved.
Review of Resident #9's wound assessment report dated 02/26/25 included Resident #9's sacral stage two
pressure ulcer was resolved.
Review of Resident #9's wound assessment report dated 03/05/25 included Resident #9's stage one
pressure ulcer to the mid-back was resolved.
Review of Resident #9's progress notes and assessments dated 03/05/25 through 03/25/25 did not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365727
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365727
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pebble Creek Healthcare Center
670 Jarvis Rd
Akron, OH 44319
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
reveal evidence Resident #9 had reddened or open areas on her back and coccyx.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #9's medication administration record and treatment administration record dated
03/05/25 through 03/26/25 did not reveal treatment orders were provided for Resident #9's back, buttocks,
or coccyx areas.
Residents Affected - Few
Review of Resident #9's nurse aide assignment sheets dated 03/20/25, 03/21/25, and 03/25/25 revealed
Certified Nurse Aide (CAN) #253 was assigned to care for Resident #9.
Review of Resident #9's shower sheet revealed the documented month was March 2025, but the specific
date was unable to be determined. Further review revealed there was an area of concern over Resident
#9's right buttock.
Review of Resident #9's shower sheet dated 03/20/25 and 03/22/25 revealed there was a mark placed over
the drawing of a back on the shower sheet indicating there was an area of concern.
Observation and interview during incontinence care on 03/26/25 at 8:30 A.M. with CNA #215 revealed
Resident #9 had three areas of injury on the skin including one to her mid-back which was red,
non-blanchable, and the size of a deck of cards; one to her coccyx which was reddened, open,
approximately 0.1 cm deep, and the size of a dime; and the third area was over slightly to the right of the
coccyx wound on the right buttock which was the size of a pencil eraser, and was reddened and
non-blanchable. Further observation by the surveyor determined the areas identified were pressurerelated. CNA #215 verified the three areas of injury on the resident's skin at the time of the observation.
Interview on 03/26/25 at 1:22 P.M. with Nurse Practitioner (NP) #412 revealed she evaluated Resident #9
today on 03/26/25 and Resident #9 had two areas of MASD on her coccyx.
Interview on 03/26/25 at 12:00 P.M. with CNA #253 revealed Resident #9 had red areas on her back and
coccyx for a while. CNA #253 stated she told the nurse a couple days ago about Resident #9's red areas
on her back and coccyx, but she did not remember what day it was or which nurse she told. CNA #253
stated the areas were reddened and were not open the last time she cared for Resident #9.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365727
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365727
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pebble Creek Healthcare Center
670 Jarvis Rd
Akron, OH 44319
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, medical record review, and review of the facility policy, the facility failed to
ensure fall interventions were in place as care planned to prevent falls. This affected one (#111) of three
residents reviewed for falls. The facility census was 148.
Findings include:
Review of Resident #111's medical record revealed an admission date of 06/02/23 and diagnoses included
hemiplegia affecting the right dominant side, acute respiratory failure with hypoxia, and vascular dementia.
Review of Resident #111's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident
#111 did not have a Brief Interview for Mental Status (BIMS) completed due to Resident #111 being rarely
or never understood. Resident #111 was dependent for toileting hygiene, bathing, personal hygiene, and
lower body dressing. Resident #111 required partial to moderate assistance for the ability to roll from lying
on her back to the left and right side and return to lying on her back on the bed. Resident #111 was always
incontinent of urine and bowel.
Review of Resident #111's fall risk observation tool dated 11/02/24 revealed Resident #111 was at risk for
falls.
Review of Resident #111's care plan revised 04/22/24 included Resident #111 was at risk for falls related to
diagnoses with a goal Resident #111 would not sustain a major injury related to falls through the review
date. Interventions included Dycem (non-slip pad) to chair as ordered; move Resident #111 closer to the
nurses station when available; and an intervention initiated 11/12/24 revealed to place Dycem between
Resident #111 and the Hoyer (mechanical lift) pad.
Review of Resident #111's progress notes dated 02/01/25 at 12:30 P.M. revealed the nurse heard Resident
#111 start yelling, when she checked on her she was found in the common area on the floor in front of her
chair. A head-to-toe assessment was completed and no injuries or pain was noted. Resident #111 was
assisted back to her chair using a mechanical lift with the assistance of three staff. Neurological checks
were started and an intervention was documented for extra Dycem in the resident's chair to prevent future
falls.
Review of Resident #111's fall risk observation tool dated 02/02/25 revealed Resident #111 was at risk for
falls.
Interview on 03/25/25 at 2:07 P.M. with Licensed Practical Nurse (LPN) #221 revealed when Resident #111
fell on [DATE] she was sitting in her padded tilt-in-space wheelchair and had recently been checked and
changed for incontinence. LPN #221 stated she did not see the fall, she heard yelling, and ran to where the
yelling was. LPN #221 stated Resident #111 slid out of her chair and she did not know how it happened.
LPN #221 stated she saw Resident #111 about five minutes before she experienced the fall and she was
fine. LPN #221 stated she could not remember the position of Resident #111's tilt-in-space wheelchair
when she had the fall. There was no evidence she had a seizure, and sometimes Resident #111 moved
around a bit in the chair.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365727
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365727
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pebble Creek Healthcare Center
670 Jarvis Rd
Akron, OH 44319
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Observation on 03/25/25 at 2:32 P.M. of Resident #111 with Unit Manager (UM) #230 revealed she was
lying in bed with her eyes open. A fall mat was observed on the floor next to her bed and the bed was in the
lowest position. Resident #111 told UM #230 she wanted to get out of bed. UM #230 instructed Certified
Nurse Aide (CNA) #292 and CNA #293 to assist Resident #111 out of her bed into her padded tilt-in-space
wheelchair. CNA #292 and CNA #293 assisted Resident #111 to her padded wheelchair using a
mechanical lift.
Observation on 03/25/25 at 4:40 P.M. of UM #230 and LPN #270 revealed they assisted Resident #111 to
her bed using a mechanical lift to check her for incontinence. Observation revealed there was Dycem
located on the wheelchair cushion, but there was no Dycem between Resident #111 and the mechanical lift
pad. The Dycem that was supposed to be between Resident #111 and the mechanical lift pad was
observed laying on Resident #111's bedside table. UM #230 and LPN #270 confirmed the Dycem was not
placed between Resident #111 and the mechanical lift pad and should have been.
Review of the undated facility policy titled, Fall Prevention and Management, revealed fall prevention and
management was the process of identifying risk factors that could minimize the potential for falls and also a
process to manage a resident's care if a fall occurred. If the resident was identified to be at risk for falls, a
care plan should be initiated that included a plan to potentially diminish the risk for falls. The care plan
should be reviewed and updated as needed with each change of condition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365727
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365727
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pebble Creek Healthcare Center
670 Jarvis Rd
Akron, OH 44319
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident and staff interview, medical record review, and review of the facility policy, the facility
failed to ensure incontinence care was completed timely. This affected one (#15) of three residents
reviewed for incontinence. The facility census was 148.
Findings include:
Review of Resident #15's medical record revealed an admission date of 11/15/24 and diagnoses included
congestive heart failure, type two diabetes mellitus with diabetic peripheral angiopathy without gangrene,
and chronic kidney disease.
Review of Resident #15's care plan revised 03/18/25 revealed Resident #15 had impaired skin integrity or
was at risk for altered skin integrity. Resident #15 would have improved or maintain current skin status
through the next review date. Interventions included to provide peri-care as needed to avoid skin
breakdown due to incontinence.
Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident
#15 was cognitively intact. Resident #15 was dependent for toileting hygiene and lower body dressing.
Resident #15 was dependent for the ability to transfer to and from a bed to a chair or wheelchair. Resident
#15 was always incontinent of urine and frequently incontinent of bowel.
Observation and interview on 03/24/25 at 2:48 P.M. of Certified Nurse Aide (CNA) #289 and CNA #417
revealed they transferred Resident #15 back to her bed. Resident #15 stated she was put in her chair
around 10:00 A.M. and she was unable to be put back to bed until now because there is no care during
meals and you might as well forget it if you need something. Resident #15 stated she had to wait until the
lunch meal was finished. Observation of Resident #15's incontinence care revealed her left and right
buttocks had large red areas on them. Resident #15's left buttock was more reddened than her right
buttock. Resident #15 stated she had a huge bowel movement that morning that was not diarrhea, and it
took at least two hours for her to be changed because it happened during the breakfast meal. CNA #289
confirmed Resident #15 had reddened areas on the right and left buttocks. CNA #289 stated she was not
working at the time of the lunch meal and just came to work. CNA #417 confirmed residents often had to
wait for care during meal times because the staff was passing out meal trays and feeding residents.
Review of the undated facility policy titled, Perineal Care Male or Female, revealed the purpose of the
procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation,
and to observe the resident's skin condition. It was the policy of the facility to provide resident care that met
the psychosocial, physical, emotional needs and concerns of the the residents. Providing personal care
services promoted a sense of well-being and met hygiene standards of care. Perineal care was performed
on residents who were unable or unwilling to maintain body cleanliness and, or who were incontinent of
bowel and bladder.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365727
If continuation sheet
Page 6 of 6
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F925 - Maintain an effective pest control program so that the facility is free of
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
FAQ · About this visit
Common questions about this visit
What happened during the March 27, 2025 survey of PEBBLE CREEK HEALTHCARE CENTER?
This was a inspection survey of PEBBLE CREEK HEALTHCARE CENTER on March 27, 2025. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PEBBLE CREEK HEALTHCARE CENTER on March 27, 2025?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.