Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Edgewood Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions, who was care-planned as dependent on staff for ADLs and grooming, was observed with long, dirty fingernails and reported wanting them cleaned and trimmed. Staff, including a CNA, an LVN, and the DON, acknowledged that CNAs were responsible for nail care during showers and that nurses were responsible for oversight, and facility policy required providing necessary ADL care for grooming and hygiene, but the resident’s fingernails had not been cleaned or trimmed as required.
A resident with advanced dementia and total care needs was found by a family member sitting in urine and feces with soiled bedding. The facility did not conduct a thorough investigation, as required by policy, by failing to interview all staff with firsthand knowledge of the incident, including the aide who changed the resident after the report.
A resident with a G-tube experienced inadequate care when their dressing was not changed after becoming wet during a shower, leading to pain and potential infection risk. The nurse did not notice or report green discharge from the site, and the CNA failed to inform the nurse about the wet dressing. The DON was unaware of the situation, and the facility's G-tube policy was not relevant to the care needed.
The facility failed to implement enhanced barrier precautions for residents with indwelling medical devices and wounds, as required for infection control. Observations showed that staff did not use gowns and gloves during high-contact care activities, and there was no signage or PPE outside residents' rooms. Interviews revealed a lack of awareness among staff about which residents required these precautions, placing residents at risk of infection.
A facility failed to develop a comprehensive care plan for a resident, omitting critical details about the resident's diabetes and use of a foley catheter. Despite being prescribed insulin and having an order for a catheter, these were not included in the care plan. The resident, who was cognitively intact, confirmed receiving insulin and having a catheter. The MDS Coordinator acknowledged the oversight, which was contrary to the facility's policy requiring comprehensive care plans.
The facility did not employ a qualified full-time social worker since the previous one resigned without notice, leaving essential social work responsibilities unmet. The administrator confirmed the position was posted, and interim staff were assisting with social work tasks, but no hiring date was set.
A resident with multiple diagnoses, including a hip fracture and cognitive deficits, fell and sustained injuries after being left unsupervised by a CNA during care. The CNA left the resident to fetch an LVN, despite the resident's warning about falling. The facility's policies for fall management and resident supervision were not adequately followed, contributing to the incident.
The facility failed to ensure accurate dental assessments in the MDS for three residents, leading to unaddressed dental issues. One resident had no teeth and used dentures, another had several broken and missing teeth, and the third had multiple missing and broken teeth. The MDS Coordinator and other staff failed to document these issues accurately.
The facility failed to maintain an infection prevention and control program, as staff did not properly disinfect reusable equipment like blood pressure cuffs and glucometers between uses, putting residents at risk of cross-contamination and infection.
The facility failed to provide or obtain routine dental services for two residents, leading to a deficiency. One resident with moderate cognitive impairment did not receive a dental referral despite having dentures that he did not wear due to discomfort. Another resident with severe cognitive impairment had missing and broken teeth, but no dental consults were arranged. The facility's policies and procedures for dental care were not followed, resulting in the residents not receiving the necessary dental assessments and consults.
The facility failed to update the care plans for two residents after they experienced falls, despite the facility's policy requiring such updates. Interviews revealed that the DON and ADON were unaware if the care plans had been updated, and the Administrator acknowledged ongoing issues with care plan updates identified in a recent mock survey.
Failure to Provide Required ADL Grooming and Nail Care
Penalty
Summary
Surveyors identified that the facility failed to provide necessary assistance with activities of daily living, specifically grooming and personal hygiene, for a resident who was dependent on staff for these needs. The resident was an elderly male with hypertension, non-Alzheimer's dementia, and respiratory failure, and had a BIMS score of 2/15 indicating severely impaired cognition. His comprehensive care plan documented that he required assistance with ADLs and that he was to be appropriately dressed and groomed, with an intervention indicating he required assistance with grooming. During an observation on 04/28/26 at 8:15 a.m., the resident was seen lying in bed watching TV with fingernails on both hands approximately 0.4 cm beyond the fingertips and visibly dirty. The resident stated he would like to have his fingernails cleaned and trimmed. Further observations and interviews showed that staff recognized the resident’s nails were long and dirty and needed cleaning and trimming, but this care had not been provided. CNA A stated that CNAs were responsible for cleaning and trimming residents’ nails during showers, and that only nurses cut nails for diabetic residents. LVN B similarly stated that CNAs were responsible for nail care during showers and that charge nurses were responsible for ensuring residents received appropriate care. The DON stated that CNAs were responsible for checking residents and providing appropriate care and grooming every shift and as needed, and that nurses in charge of the halls were also responsible for ensuring residents’ needs were met. The facility’s ADL policy stated that the facility provides necessary care to all residents unable to carry out ADLs to ensure they maintain proper grooming and hygiene, but this was not followed for this resident’s fingernail care on the observed date.
Failure to Thoroughly Investigate Allegation of Neglect
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of neglect involving a female resident with Alzheimer's disease, a gastrostomy tube, and adult failure to thrive. The resident was dependent on staff for all activities of daily living and was always incontinent of bladder and bowel. A family member found the resident sitting in urine and feces with dirty bedding and reported this to staff. The nurse on duty was unable to locate the assigned aide, who was later found to be on break, and another aide was called to change the resident. The facility administrator was notified of the allegation via email and initiated an investigation, which included checking on the resident and having clinical staff perform a skin assessment. The administrator reported the incident to the state and attempted to contact the agency and the assigned CNA, but was unsuccessful. The administrator did not contact the nurse who was on shift or the aide who changed the resident. The DON also attempted to contact the nurse and CNA involved but was unsuccessful and did not contact the aide who changed the resident. The investigation did not include interviews with all individuals who had firsthand knowledge of the incident, specifically the aide who changed the resident after the family member's report. Facility policy required comprehensive investigations, including written summaries of interviews with witnesses, but this was not completed. The failure to conduct a thorough investigation was confirmed by both the administrator and DON, who acknowledged that key staff were not interviewed.
Failure to Provide Appropriate G-Tube Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a gastrostomy tube (G-tube). The resident, who was cognitively intact and had multiple diagnoses including malnutrition and dysphasia, was observed with a G-tube dressing that was not changed after it became wet during a shower. The resident reported pain and discomfort from the G-tube site, with a pain level of 8 out of 10, and had to request pain medication. Upon observation, the dressing was found to contain blood and a greenish substance, indicating potential infection risk. The nurse responsible for the resident's care did not initially notice the green discharge and failed to document or notify the physician about it. The CNA who assisted with the resident's shower did not inform the nurse about the wet dressing, which was against her training. The Director of Nursing (DON) was unaware of the green discharge and the initiation of antibiotics for the resident. The facility's policy on G-tube care was not relevant to the specific care needed for the G-tube site, contributing to the oversight in care.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of enhanced barrier precautions for five residents observed for infection control. These residents, who had conditions such as feeding tubes, pressure ulcers, and Foley catheters, were not placed on enhanced barrier precautions, which are necessary to prevent healthcare-associated cross-contamination and infections. Observations revealed that staff did not use gowns and gloves as required for high-contact resident care activities, and there was no signage or personal protective equipment (PPE) outside the residents' doors to indicate the need for such precautions. Resident #1, a female with a Stage IV pressure ulcer, feeding tube, and Foley catheter, was not on enhanced barrier precautions despite showing signs of infection. Staff members, including RN E and LPN A, were observed entering her room and performing care activities with gloves only, without donning gowns or following proper infection control protocols. Similar observations were made for Residents #2, #3, #4, and #5, who also had indwelling medical devices or wounds but lacked care plans and physician orders for enhanced barrier precautions. Interviews with staff, including RN E, LVN B, LVN C, and the Director of Nursing (DON), revealed a lack of awareness and implementation of enhanced barrier precautions. The DON acknowledged that staff should have known which residents required these precautions and that PPE should have been available. The Assistant Director of Nursing (ADON), who served as the infection preventionist, confirmed that enhanced barrier precautions were necessary for residents with wounds and indwelling devices, yet there was no signage or PPE provided. The facility's failure to implement these precautions placed residents at risk of infection.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical needs. Specifically, the care plan did not address the resident's diagnosis of diabetes and the use of an indwelling foley catheter. This oversight was identified during a review of the resident's records, which showed that the resident was prescribed insulin and had an order for a foley catheter, yet these were not reflected in the care plan. The resident, who was cognitively intact with a BIMS score of 15, was observed to have a foley catheter and confirmed receiving insulin for diabetes. The MDS Coordinator acknowledged the resident's conditions and the responsibility to update the care plan but admitted that the care plan was not revised to include the resident's diabetes and catheter use. The facility's policy mandates the development of a comprehensive care plan to provide effective and person-centered care, which was not adhered to in this case.
Failure to Employ Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker for a facility with more than 120 beds, which is a requirement to meet the social services and psychosocial needs of the residents. The deficiency was identified during an observation from October 19 to October 21, 2024, which revealed the absence of a full-time social worker. The facility had not employed a full-time, qualified social worker since September 26, 2024, when the previous social worker resigned without notice. This left the facility without a dedicated professional to handle essential social work responsibilities, such as referrals, discharge assistance, and coordination with auxiliary providers like podiatry, audiology, optometry, and dental services. The facility's administrator confirmed in an interview that the social worker position was posted on the internal facility website, and the interviewing process had begun. However, there was no anticipated date for hiring a new social worker. In the interim, the Admissions Coordinator, MDS, ADON, and DON were assisting with social work tasks to ensure residents received necessary social services. The facility's job description for the Social Services Director outlined responsibilities that include planning, organizing, implementing, evaluating, and directing the social services department to meet the medically-related emotional and social needs of residents, which were not being fully met due to the vacancy.
Failure to Provide Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident. The resident, who had multiple diagnoses including a displaced intertrochanteric fracture of the left femur, neuropathy, and cognitive communication deficit, was left unsupervised by a CNA while being positioned on her side. Despite the resident's warning that she might fall, the CNA left the room, resulting in the resident falling to the floor and sustaining a bruise on her arm and increased back pain. The incident was unwitnessed, and the resident was found on the floor by another staff member shortly after the fall occurred. Interviews with staff revealed that the CNA had left the resident to fetch an LVN to check a saturated bandage, despite the resident's expressed concern about falling. The CNA claimed to have positioned the resident's leg to prevent a fall, but the resident still fell when left unattended. The facility's policies and procedures for fall management and resident supervision were not adequately followed, as the resident did not have necessary assistive devices like bed rails or a fall mat, and there was no second staff member present during the care. The facility's incident report and progress notes documented the fall and the immediate response, including assessments and notifications to the DON and the resident's family. However, the failure to provide adequate supervision and necessary assistive devices directly contributed to the resident's fall and subsequent injury. Staff interviews indicated a lack of adherence to the facility's protocols for preventing falls and ensuring resident safety.
Inaccurate Dental Assessments in MDS
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the residents' dental status for three residents. Resident #17's Admission MDS assessment indicated no dental problems, despite the resident having no teeth and using dentures that he left at home. The resident expressed a need for a dental checkup and was observed to have no teeth during an interview. The MDS Coordinator acknowledged that the former Social Worker should have documented the resident's use of dentures in the MDS assessment but did not do so. Resident #37's Admission MDS assessment also indicated no dental problems, although the resident had severely impaired vision and several broken and missing teeth. During an interview, the resident expressed a desire to see a dentist and revealed the poor condition of his teeth. The MDS Coordinator admitted that she did not make another attempt to assess the resident's teeth after he initially refused to open his mouth and incorrectly coded the MDS assessment. Resident #60's Admission and Quarterly MDS assessments indicated no dental problems, despite the resident having several missing and broken teeth. The resident expressed a need to see a dentist and was observed to have poor dental condition during an interview. The MDS Coordinator acknowledged that she did not assess the resident's teeth upon admission and relied on the nurses' and Social Worker's documentation, which was inaccurate. The Director of Nursing and the Administrator were unaware of the inaccuracies in the MDS assessments and stated that it was the responsibility of the MDS Coordinator to ensure the assessments were accurate.
Infection Control Lapses in Equipment Sanitization
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to potential cross-contamination and infection risks for residents. Specifically, LVN A did not disinfect the blood pressure cuff between uses on multiple residents, including Resident #10 and Resident #34. LVN A admitted to being unaware of the need to sanitize the blood pressure cuff, despite having attended in-service training on infection control and cleaning equipment. Observations confirmed that the blood pressure cuff was not sanitized before or after use on these residents. Additionally, LVN B and RN C failed to properly disinfect the glucometer between uses on Resident #1. LVN B used an alcohol swab instead of the appropriate EPA-registered disinfectant wipes, which is against the facility's policy. Both LVN B and RN C acknowledged knowing the correct procedure but did not follow it during the observed incident. This lapse in protocol was also noted during an interview with the Director of Nursing (DON), who emphasized the importance of sanitizing all reusable equipment between each resident use. The facility's policies and procedures clearly state the need for using EPA-registered disinfectant wipes for cleaning and disinfecting reusable equipment like blood pressure cuffs and glucometers. Despite recent in-service training on infection control, the staff failed to adhere to these guidelines, putting residents at risk of cross-contamination and infection. The DON confirmed that there were adequate supplies of disinfectant wipes available and reiterated the expectation for staff to follow proper sanitization protocols.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide or obtain routine dental services for two residents, leading to a deficiency. Resident #17, a male with moderate cognitive impairment, was admitted without a dental referral despite having dentures that he did not wear due to discomfort. He expressed the need for a dental checkup multiple times, but no action was taken by the staff. His admission and quarterly assessments did not accurately reflect his dental needs, and there were no documented dental consults for him. Resident #60, a female with severe cognitive impairment, also did not receive a dental referral upon admission. Her dental condition, which included missing and broken teeth, was not properly documented in her assessments. Despite her poor dental condition being noted in a nurse's note, no follow-up dental consults were arranged. The facility was without a social worker for several months, and the responsibility for dental referrals fell to the Director of Nursing, who did not ensure that these residents received the necessary dental care. Interviews with staff revealed a lack of awareness and communication regarding the dental needs of these residents. The new social worker was not informed about any dental issues, and the MDS Coordinator admitted to not following up on dental referrals. The Administrator was also unaware of the dental referral issues. The facility's policies and procedures for dental care were not followed, resulting in the residents not receiving the necessary dental assessments and consults.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to review and revise the person-centered comprehensive care plan to reflect the current status of two residents who experienced falls. Resident #33, a male with severe cognitive impairment and multiple diagnoses including Huntington Chorea and dementia, had a fall resulting in a head laceration that required emergency room treatment. Despite this incident, his care plan was not updated to include goals and interventions specific to this fall. Similarly, Resident #58, a male with moderate cognitive impairment and diagnoses including traumatic subdural hemorrhage and prostate cancer, experienced a non-injury fall, but his care plan was also not updated to reflect this event. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the MDS/care plan nurse is responsible for updating care plans and that falls and changes in residents' conditions are discussed in morning meetings. However, both the DON and ADON were unaware if the care plans for Resident #33 and Resident #58 had been updated following their falls. The DON admitted that she does not follow up on care plans, assuming it was under regional oversight, and acknowledged that without proper updates, staff would not know the goals for preventing further falls. The Administrator confirmed awareness of the issue, noting that a recent mock survey by the corporation had identified deficiencies in care plan updates, which were still being addressed. Attempts to contact the MDS/care plan nurse on the day of the survey were unsuccessful. The facility's policy mandates that care plans be reviewed and revised after each assessment and when there is a change in the resident's clinical status, such as falls, but this was not adhered to in these cases.
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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 Mesquite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesquite Village Wellness & Rehabilitation | 0.9 mi | ★★★★★ | 6 | 0 |
| Willowbend Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 19 | 0 |
| Palomino Place | 2.1 mi | ★★★★★ | 13 | 1 |
| Mesquite Tree Nursing Center | 2.4 mi | ★★★★★ | 12 | 0 |
| Town East Rehabilitation And Healthcare Center | 2.7 mi | ★★★★★ | 18 | 2 |
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