Pebble Creek Nursing Center: Infection Control Failures - TX
Inspectors cited the facility in September 2025 following a complaint, finding that the written procedure governing how wound care is performed at bedside creates conditions that risk cross-contamination during treatment. The deficiency was tagged under infection control, with inspectors noting it affected a small number of residents.
The policy itself describes a wax paper system meant to separate clean from dirty. Staff are told to lay wax paper on the wound care cart, open sterile supplies on top of it, and cover them with a second sheet. One end of the cart is designated clean. The other is left open for dirty items.
The problem is what the policy says to do at the end.
After treatment, the written procedure directs staff to place dirty linens, red bags, scissors, a pen, and a camera onto the open end of the same wax paper surface. These are items that have been in a resident's room, handled during wound care, or used to document wound conditions. They go back onto the cart. The cart that will be locked up and wheeled to the next resident's room.
Scissors used during wound care are not single-use items under this policy. Neither is the pen. Neither is the camera.
The policy does not describe how those items are cleaned or disinfected before the cart is used again. It describes where to put them when the treatment is done.
Wound care involves open tissue. Residents receiving treatment at a nursing facility often have compromised immune systems, reduced circulation, or underlying conditions that make infection harder to fight and easier to spread. A surface contaminated with material from one resident's wound, brought into the next resident's room on the same cart, is a direct pathway for transmission.
The facility's own written procedure, the one inspectors pulled during the inspection, is the source of the problem. Not a staff member who improvised. Not a one-time lapse. The policy, dated 2003 and apparently unchanged in the more than two decades since, tells employees to do this.
Inspectors classified the harm level as minimal or potential, meaning they did not document that a resident was injured as a direct result. The number of residents affected was listed as few. But the citation reflects something inspectors found worth flagging regardless: a facility operating wound care procedures that do not adequately separate what is clean from what is not.
The wax paper system described in the policy is not inherently wrong. Separating a clean end of a cart from a dirty end is a reasonable approach. The failure is in the final step, the one that sends contaminated items back into circulation without any described decontamination process, on the same surface, under the same cover, ready for the next treatment.
Pebble Creek Nursing Center is a licensed nursing facility in El Paso. The inspection was conducted as a complaint survey, meaning someone raised a concern that prompted investigators to come.
The facility's wound care policy is six steps long. Step seven is where the problem is.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pebble Creek Nursing Center from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 24, 2026 · Our methodology
Pebble Creek Nursing Center in El Paso, TX was cited for violations during a health inspection on September 9, 2025.
The deficiency was tagged under infection control, with inspectors noting it affected a small number of residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.