Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 1
Dec 2, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with care plan requirements, specifically focusing on the development and implementation of comprehensive person-centered care plans for residents.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #2, including measurable objectives and timely updates after falls on 06/17/2025 and 06/22/2025. This failure could affect all residents by contributing to inadequate care and fall prevention.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plan: 4
BIMS score: 3
Falls: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Responsible for acute care plans and acknowledged failure to add new intervention after falls |
| ADON | Assistant Director of Nursing | Responsible for acute care plans and stated care plans should be updated after each fall |
| MDS Coordinator | Responsible for comprehensive care plans and noted no new intervention was added after falls |
Inspection Report
Routine
Deficiencies: 8
Oct 3, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident dignity, assessment accuracy, care planning, respiratory care, pharmaceutical services, food safety, staffing data submission, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by not properly covering catheter bags, inaccurate resident assessments, incomplete care plans, improper respiratory care equipment storage, leaving medications unattended with residents, inadequate food storage and sanitation practices, failure to submit timely staffing data to CMS, and lapses in infection control practices such as improper glove use and hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to treat Resident #29 with dignity by not placing catheter bag away from door and not using a privacy bag. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident #32's MDS assessment accurately reflected CPAP use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive care plan including hospice care for Resident #19. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care by not properly storing nasal cannula and CPAP masks for Residents #6, #15, and #32. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were not left unattended with Resident #148. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards including improper sealing of foods and unclean ice machines. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to electronically submit complete and accurate direct care staffing data to CMS for FY Quarter 3 2024. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection prevention and control program by improper glove use and hand hygiene during incontinent care for Residents #18 and #198. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
BIMS score: 13
BIMS score: 7
BIMS score: 0
BIMS score: 9
BIMS score: 14
BIMS score: 11
BIMS score: 14
Oxygen flow rate: 3
CPAP pressure setting: 16
Medication count: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Mentioned in relation to catheter bag privacy and respiratory care deficiencies |
| ADON | Assistant Director of Nursing | Provided statements on catheter bag privacy, respiratory care, care planning, medication administration, and infection control |
| DON | Director of Nursing | Provided statements on catheter bag privacy, respiratory care, care planning, medication administration, and infection control |
| Administrator | Provided statements on catheter bag privacy, respiratory care, medication administration, food safety, staffing data submission, and infection control | |
| HN | Health Nurse | Interviewed regarding Resident #19 hospice care |
| LVN C | Licensed Vocational Nurse | Mentioned in relation to respiratory care and medication administration deficiencies |
| MDS Nurse | Mentioned in relation to assessment accuracy, care planning, respiratory care, and infection control | |
| CNA A | Certified Nursing Assistant | Observed and interviewed regarding infection control lapses during incontinent care |
| CNA B | Certified Nursing Assistant | Observed and interviewed regarding infection control lapses during incontinent care |
| Dietary Manager | Interviewed regarding food safety and kitchen sanitation |
Inspection Report
Routine
Deficiencies: 8
Oct 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, accuracy of assessments, care planning, respiratory care, pharmaceutical services, food safety, staffing data submission, and infection prevention and control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by not properly covering catheter bags, inaccurate resident assessments, incomplete care plans, improper respiratory care equipment storage, leaving medications unattended with residents, inadequate food storage and sanitation, failure to submit staffing data timely, and lapses in infection control practices such as improper glove use and hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to treat Resident #29 with dignity by not placing the catheter bag away from the door and not using a privacy bag. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident #32's MDS assessment accurately reflected CPAP use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive care plan for Resident #19 including hospice care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care for Residents #6, #15, and #32 by not properly storing nasal cannula and CPAP masks. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were not left unattended with Resident #148. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards including improper sealing of foods and unclean ice machines. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to electronically submit complete and accurate direct care staffing information for FY Quarter 3 2024. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection prevention and control program by not ensuring proper glove changes and hand hygiene during incontinent care for Residents #18 and #198. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
BIMS score: 13
BIMS score: 7
BIMS score: 0
BIMS score: 9
BIMS score: 14
BIMS score: 11
BIMS score: 14
Oxygen flow rate: 3
CMS PBJ Staffing Data Report Quarter: 3
Ice Machine Cleaning Log months: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Mentioned in relation to catheter bag privacy and respiratory care findings |
| ADON | Assistant Director of Nursing | Provided statements on catheter bag privacy, respiratory care, care planning, medication administration, and infection control |
| DON | Director of Nursing | Provided statements on catheter bag privacy, respiratory care, care planning, medication administration, infection control, and staffing |
| Administrator | Provided statements on catheter bag privacy, respiratory care, medication administration, food safety, staffing data submission, and infection control | |
| LVN C | Licensed Vocational Nurse | Mentioned in relation to respiratory care and medication administration findings |
| HN | Health Nurse | Mentioned in relation to hospice care assessment |
| MDS Nurse | Mentioned in relation to assessment accuracy, care planning, respiratory care, and infection control | |
| CNA A | Certified Nursing Assistant | Observed and interviewed regarding infection control during incontinent care |
| CNA B | Certified Nursing Assistant | Observed and interviewed regarding infection control during incontinent care |
| Dietary Manager | Provided statements regarding kitchen sanitation and food safety |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 23, 2023
Visit Reason
The inspection was conducted as a routine annual survey of The Plaza at Edgemere nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 1
Jul 14, 2022
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitary standards in the facility's kitchen, specifically regarding the use of hair and beard restraints by dietary staff during food preparation and service.
Findings
The facility failed to ensure that dietary staff wore hair restraints covering beards while preparing and serving food, which could place residents at risk of foodborne illness. Multiple observations and interviews confirmed that a staff member (DA-A) repeatedly did not wear a beard restraint despite facility policy and repeated requests, leading to unsanitary conditions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to wear a hair restraint covering beard in Kitchen A during food preparation and service. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: Some
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DA-A | Dietary Aide | Observed multiple times not wearing beard restraint while preparing and serving food |
| DA-B | Dietary Aide | Interviewed regarding facility policy on hair and beard restraints |
| DA-C | Dietary Aide | Interviewed about hair restraint requirements and denied observations of non-compliance |
| DC-D | Dietary Coach | Interviewed about hair net availability and policy enforcement |
| DM | Dietary Manager | Reported that DA-A was suspended for not following hair restraint guidelines |
| DD | Dietary Director | Interviewed about hair restraint policies and standards |
| DC-E | Dietary Coach | Interviewed about hair restraint requirements and leadership responsibilities |
| DA-F | Dietary Aide | Interviewed about hair restraint requirements and observed DA-A non-compliance |
| DON | Director of Nursing | Interviewed about expectations for dietary staff hair restraint compliance |
| Administrator | Interviewed about expectations for dietary staff compliance with sanitation and food service policies |
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