Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 The Plaza At Edgemere during CMS and state inspections, most recent first.
Two residents developed non-pressure wounds after being provided briefs that were too small, and one resident’s wound was also linked by the WCN to a mechanical lift sling that was too small. Both residents were incontinent and had care plans addressing incontinence and skin breakdown, but one resident later had a wound to the left posterior thigh and the other had a wound to the right ischium. The DON and WCN both acknowledged the briefs were tight or too small, and the WCN identified the sling as a factor in one resident’s wound.
Food Storage and Kitchen Sanitation Deficiencies: The facility failed to keep handwashing sink waste receptacles limited to disposable paper towels, failed to provide a garbage receptacle at 1 handwashing sink, failed to maintain the manual dishwashing sanitizer at the proper ppm, and had 7 dented cans with compromised seals in storage. The Kitchen Attendant said she was unsure how to use the sanitizer test strip, and the DCS and DM stated that cooks unloaded deliveries and dented cans were separated and returned.
Failure to Submit PBJ Staffing Data: The facility failed to electronically submit complete and accurate PBJ staffing data to CMS for a quarterly reporting period. CASPER3 showed no submission for the quarter, and the Administrator said she was unaware of the missed report because she was not employed there at the time. The ED stated the data was simply not entered by the deadline, with no website or input issues reported. The facility’s PBJ policy required timely submission of auditable staffing, census, turnover, tenure, and hours-worked data.
Failure to disinfect shared vital sign equipment: An LVN used a BP cuff and thermometer on two residents without cleaning the devices between uses. One resident had HTN, DM, and anxiety and was alert and oriented; the other had a hip fracture, depression, moderate cognitive impairment, and loose stools with vomiting. The LVN stated she knew equipment should be cleaned before and after each resident but forgot.
A resident with dementia and a history of falls experienced two separate falls, but the care plan was not updated to include new interventions after each incident. Staff assessments and monitoring were documented, but no additional fall prevention strategies were implemented, and the care plan continued unchanged despite facility policy requiring updates after status changes.
The facility failed to maintain food safety and sanitation standards, with improperly sealed and unlabeled food items in storage, and unsanitary conditions in ice machines. Observations revealed exposed food items in the main kitchen and unsanitary ice machines in the secondary kitchen. The Dietary Manager and Administrator acknowledged these issues, highlighting the risk of food contamination.
The facility failed to properly store respiratory equipment for three residents, leading to deficiencies in care. A resident's nasal cannula was left hanging without a bag, while two other residents' CPAP masks were not bagged when not in use. These actions were inconsistent with the care plans and increased the risk of cross-contamination and respiratory infections.
The facility failed to submit complete and accurate direct care staffing information to CMS for FY Quarter 3 of 2024. The administrator, responsible for the submission, did not send the data on time, mistakenly believing it was completed. This oversight was discovered during a survey, revealing a lack of timely submission as required by the facility's policy manual.
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper hand hygiene and glove use during incontinent care for two residents. A CNA did not change gloves after touching the trash can and after cleaning a resident's bottom before handling a new brief. Similarly, another CNA and an MDS Nurse failed to change gloves and perform hand hygiene at critical points during care. Interviews confirmed that the facility's expectations for hand hygiene and glove changes were not met, posing a risk of cross-contamination and infection.
A resident with paraplegia and a neurogenic bladder had a catheter bag that was not placed according to the care plan, compromising dignity. The bag was visible upon entering the room and lacked a privacy cover, contrary to facility policy. Staff interviews confirmed the expectation for privacy bags to maintain resident dignity.
A facility failed to accurately document a resident's use of a CPAP machine in their MDS Assessment, despite the resident's care plan and physician orders indicating its use. The oversight was confirmed through staff interviews and record reviews, highlighting the need for synchronized documentation to ensure effective resident care.
A facility failed to develop a comprehensive care plan for a resident receiving hospice care. The resident, with severe cognitive impairment and dementia, was admitted to hospice care, but her care plan lacked this crucial component. Staff interviews confirmed the oversight, acknowledging the importance of care plans in ensuring residents receive necessary care and services.
A resident with moderate cognitive impairment was left with medications in their room by an LVN, contrary to facility policy. The resident, who was not assessed for self-administration, had a history of encephalopathy and depression. Interviews with staff confirmed that medications should not be left with residents, highlighting a failure in following proper medication administration procedures.
Improperly Sized Briefs and Lift Sling Contributed to Resident Skin Wounds
Penalty
Summary
The facility failed to ensure two residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices. Resident #1 was a female with moderately impaired cognitive skills, always incontinent of urine and frequently incontinent of stool, and diagnosed with heart failure, diabetes, and end-stage kidney disease. Her care plan addressed incontinence and skin breakdown, and she later had a non-pressure wound to the left posterior upper thigh that was treated with daily wound care. During observation, the wound care nurse stated Resident #1’s wound developed because the brief was too small and the mechanical lift sling was too small. The Director of Nursing also stated the resident had briefs that were tight and had areas that were really red, and that staff were responsible for ensuring the resident had the right sized brief. Resident #2 was a male with intact cognitive skills, always incontinent of urine and stool, and diagnosed with heart failure and diabetes. His care plan addressed incontinence and brief use, and he later developed a non-pressure wound to the right ischium that required daily wound care. During interview, Resident #2 stated he developed the wound because he was wearing a brief that was too small and said his briefs were now the correct size. The wound care nurse stated Resident #2 had a wound due to him having a very small brief and that it developed on 03/03/26. The facility’s wound treatment policy stated it was the policy to provide evidence-based treatments in accordance with current standards of practice and physician orders, and the resident rights policy stated residents have a right to a safe environment, including receiving treatment and supports for daily living safely.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen reviewed for food safety. During observation of the kitchen, 2 of 3 handwashing sink garbage receptacles contained items other than disposable paper towels, including disposable gloves, product boxes, food, and other trash, and 1 of 3 handwashing sinks did not have a garbage receptacle available for used disposable paper towels. The facility also failed to maintain the sanitizing solution used in the manual dishwashing process at the proper chemical concentration, as the Kitchen Attendant tested the solution and the strip read 400 parts per million. In addition, 7 cans of green sliced olives were observed with large dents and compromised seals. During interview, the Kitchen Attendant stated she was unsure how to properly use the sanitizing test strip and how to interpret the results. The Director of Culinary Services stated that all handwashing sinks were required to have a garbage receptacle, and the Dietary Manager and Director of Culinary Services stated that cooks were responsible for unloading delivery trucks and that dented cans found during unloading were placed in a separate area and returned. Record review showed the facility's 3 Compartment Sinks policy required checking the sanitation sink frequently with a test strip and following chemical manufacturer guidelines, while the food storage policy did not address dented cans. The U.S. FDA Food Code 2022 was also referenced regarding disposable towels and waste receptacles at handwashing sinks.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the fourth quarter covering July 1, 2025 through September 30, 2025. Record review of the CASPER3 PBJ report showed that the facility did not submit data for that quarter, and no other quarter was triggered. During an interview on 01/20/2026 at 9:30 a.m., the Administrator stated she was not employed by the facility during that reporting period and was unaware of the failure to report the data. During an interview on 01/20/2026 at 9:31 a.m., the Executive Director stated the facility simply did not get the data entered into the system on time and had missed the data entry due date. She stated there were no issues with data input or connecting to the website and that the facility had not had any problems entering the information since then. The facility’s PBJ policy, dated 10/31/2025, stated that the facility is to electronically submit timely, complete, and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data, including agency and contract staff, resident census data, turnover and tenure, and hours of care provided by each category of staff per resident per day.
Failure to Disinfect Shared Vital Sign Equipment
Penalty
Summary
The facility failed to maintain its Infection Prevention and Control Program when LVN A did not disinfect shared equipment between residents. During medication pass, LVN A used a blood pressure cuff to check Resident #14’s blood pressure and then administered medications without cleaning the cuff or the machine before or after use. Resident #14’s record showed diagnoses of hypertension, diabetes, and anxiety disorder, and she was alert and oriented with no cognitive impairment and required assistance from one staff member for activities of daily living. Later the same morning, LVN A entered Resident #71’s room during medication pass after the CNA reported that the resident had loose stools and vomiting. LVN A used the blood pressure cuff and an electronic thermometer to obtain vital signs for Resident #71 without cleaning either device before or after use. Resident #71’s record showed diagnoses of hip fracture and depression, moderate cognitive impairment, and a need for assistance from one staff member with activities of daily living. LVN A stated she was supposed to clean all equipment used before and after each resident and said she had been in-serviced on infection control and cleaning equipment within the past six months, but she had forgotten in both instances.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for a resident with dementia and a history of falls. Despite the resident experiencing two separate falls, the care plan was not updated to include new interventions after each incident. Documentation showed that after both falls, staff performed assessments and monitoring, but no additional fall prevention strategies were added to the care plan. The care plan continued with existing interventions without revision, even though the resident's risk for falls was clearly identified. Interviews with facility staff, including the MDS Coordinator, DON, and ADON, confirmed that the care plan was not revised following the falls, contrary to facility policy and expectations. The staff acknowledged that care plans should be updated after such events to ensure appropriate interventions are in place. Facility policies reviewed indicated that care plans should be revised upon a change in resident status, such as a fall, but this was not done for the resident in question.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations in the main kitchen revealed that food items in the refrigerator and freezer, such as sandwich buns, breads, celery, hamburger meat, tomato sauce, and grapes, were not properly sealed and were exposed to air contaminants. Additionally, these items were not labeled or dated, which is a requirement for food safety. The dry food storage area had food storage bins with stains on the lids, indicating a lack of proper sanitation. Further observations in the secondary kitchen showed that the ice machine had a brownish sticky substance on its surface, and the ice scooper holder contained a brownish substance. The facility's Ice Machine Cleaning Log indicated that cleaning was not consistently documented, with a gap noted in September. Interviews with the Dietary Manager and the Administrator confirmed awareness of these issues, with the Dietary Manager acknowledging responsibility for ensuring compliance with food storage and sanitation guidelines. The Administrator recognized the potential risk of food contamination and the importance of resolving these issues to prevent foodborne illnesses.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in the storage of respiratory equipment. Resident #6, a female with hypoxemia and anemia, was observed with a nasal cannula hanging on a portable oxygen tank without being bagged. This was contrary to the physician's order and care plan, which required oxygen therapy via nasal cannula. The improper storage of the nasal cannula could lead to cross-contamination and respiratory infections. Resident #15, diagnosed with acute and chronic respiratory failure with hypercapnia, was found with a CPAP mask stored in a drawer without a protective bag. The resident was cognitively intact and mentioned that the CPAP was not used due to recent surgery. The lack of proper storage for the CPAP mask was not in line with the care plan, which required CPAP use as ordered. The staff member, LVN C, acknowledged the oversight and the risk of cross-contamination. Resident #32, with severe cognitive impairment and diagnosed with acute and chronic respiratory failure with hypoxia, had a CPAP mask connected to a machine on a table without being bagged. The resident was unaware of the need to bag the mask, and LVN D did not initially notice the improper storage. The facility's policy on oxygen administration was not followed, as the nasal cannula and CPAP masks were not bagged when not in use, increasing the risk of respiratory infections.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the fiscal year Quarter 3 of 2024, covering the period from April 1 to June 30. This deficiency was identified through a review of the CMS PBJ Staffing Data Report, which indicated that no data was submitted for the specified quarter. The facility's administrator acknowledged responsibility for the submission of the PBJ data and was aware of the reporting regulations. However, the administrator did not submit the data on time, believing it had been completed, and only realized the oversight when informed by the surveyors. During interviews, the administrator explained that the failure to submit the PBJ data was due to not hitting the send button on the document to CMS. The administrator was under the impression that the submission had been completed early and did not receive any notices or warnings indicating otherwise. The facility's policy manual requires that direct care staffing and census data be collected quarterly and submitted by the end of the 45th calendar day after the last day of each fiscal quarter to be considered timely. The failure to submit this data could potentially impact the facility's ability to demonstrate accurate staffing levels in relation to the resident census.
Infection Control Deficiencies in Incontinent Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper hand hygiene and glove use during incontinent care for two residents. For Resident #18, a cognitively intact female with bowel incontinence, CNA A did not change gloves after touching the trash can and after cleaning the resident's bottom before handling a new brief. This lapse in protocol occurred despite CNA A's acknowledgment of the importance of hand hygiene and glove changes to prevent germ transfer. Similarly, for Resident #198, a cognitively intact female with chronic kidney disease and bowel incontinence, both CNA B and the MDS Nurse failed to change gloves and perform hand hygiene at critical points during incontinent care. The MDS Nurse did not change gloves after handling a soiled brief, and CNA B did not change gloves before applying cream to the resident's skin. Additionally, CNA B did not sanitize her hands before donning a new pair of gloves. Both staff members recognized the importance of these practices in preventing cross-contamination and infection. Interviews with the ADON, DON, and Administrator confirmed that the facility's expectations for hand hygiene and glove changes were not met. The facility's policies on hand hygiene and perineal care were reviewed, highlighting the requirement for proper hand hygiene and glove changes to prevent infection. The staff's failure to adhere to these policies during resident care posed a risk of cross-contamination and infection development.
Failure to Maintain Resident Dignity with Catheter Bag Placement
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not adhering to the care plan regarding the placement of the resident's catheter bag. The resident, a cognitively intact male with paraplegia and a neurogenic bladder, had a suprapubic catheter. The care plan specified that the catheter bag should be placed away from the door to maintain the resident's dignity. However, during an observation, the catheter bag was found hanging at the railings below the bed, visible upon entering the room, and not placed inside a privacy bag. Interviews with staff, including an LVN, the ADON, and the DON, revealed that the facility's expectation was for catheter bags to be placed inside privacy bags to prevent embarrassment and maintain dignity. The staff acknowledged the oversight, noting that the catheter bag was exposed and visible to others, which could lead to embarrassment for the resident. The facility's policy emphasized the importance of protecting and promoting resident rights and treating each resident with respect and dignity.
Inaccurate Assessment of CPAP Use
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status for one resident reviewed for accuracy of assessments. Specifically, the facility did not accurately document the use of a CPAP machine for a resident diagnosed with acute and chronic respiratory failure with hypoxia. The resident's Comprehensive MDS Assessment did not indicate the use of a CPAP, despite the resident's care plan and physician orders reflecting its use at night and in the morning. This discrepancy was confirmed through observations, interviews, and record reviews. Interviews with facility staff, including the MDS Nurse, ADON, and DON, revealed that the oversight was acknowledged, and it was emphasized that the medical diagnosis, physician orders, MDS, and care plan should be synchronized to provide a clear overview of the resident's condition. The MDS Nurse admitted the oversight and recognized the need for an audit to ensure the MDS accurately reflects residents' current conditions. The ADON and DON highlighted the importance of accurate assessments for effective resident care, noting that inaccuracies could lead to misunderstandings about the care needed by the resident.
Failure to Implement Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving hospice care. The resident, an elderly female with dementia and severe cognitive impairment, was admitted to hospice care earlier in the year. Despite this, her comprehensive care plan did not include hospice care, which was a significant oversight. The absence of a hospice care plan was confirmed by the MDS Nurse, who acknowledged the oversight and began creating the necessary care plan after it was brought to her attention. Interviews with facility staff, including the MDS Nurse, ADON, DON, and Administrator, revealed a consensus that a care plan for hospice care should have been in place. The staff recognized the importance of care plans in ensuring that residents receive the necessary care and services. The lack of a hospice care plan for the resident was attributed to an oversight, and the staff acknowledged that without such a plan, the resident's needs might not be adequately addressed, and staff might not be aligned in providing care.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was provided with medications and pharmaceutical services to meet their needs. Specifically, a Licensed Vocational Nurse (LVN) left the resident's medications inside the resident's room, which could result in the resident not receiving medications as ordered by the physician. The resident, who had moderate cognitive impairment and was not assessed for self-administration of medications, was found with a cup containing nine pills on their overbed table. The resident stated that the nurse left the medications with them and that it was not the first time this had occurred. The resident's medical history included encephalopathy, depression, and cognitive communication deficit, with a BIMS score indicating moderate cognitive impairment. The resident's care plan did not include self-administration of medications, and there was no assessment indicating the resident was competent to manage their own medications. The medications prescribed included folic acid, gabapentin, loperamide, multivitamins, potassium chloride, sertraline, thiamine, and vitamin D, all of which were to be administered by mouth at specified times. Interviews with the LVN, Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator revealed that the facility's policy was not to leave medications with residents. The LVN admitted to leaving the medications due to being called away and acknowledged the risk of the resident not taking them or choking. The ADON and DON emphasized the importance of ensuring residents take their medications in the presence of staff to prevent potential risks, such as hoarding or overdose. The facility's policy stated that residents could only self-administer medications if deemed competent by the care planning team.
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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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walnut Place | 2.2 mi | — | 0 | 0 |
| The Meadows Health And Rehabilitation Center | 2.5 mi | ★★★★★ | 8 | 0 |
| The Legacy Midtown Park | 2.6 mi | ★★★★★ | 3 | 0 |
| Pure Health Transitional Care At Texas Health Pres | 2.7 mi | ★★★★★ | 0 | 0 |
| Traymore Nursing Center | 2.7 mi | ★★★★★ | 2 | 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.