Cycle 1
Health 2026-01-22 · Fire 2026-01-22
4 health deficiencies
Top issue: Administration (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Dallas, TX
The Plaza At Edgemere
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
8502 Edgemere, Dallas, TX
(214) 615-7045
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-02-19
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
2,884
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.17
Composite VBP score used to determine payment impact.
Payment multiplier
1.0007
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.01
Baseline 17.88% · Performance 19.57% · Measure score 4.01 · Achievement 4.01 · Improvement 0
Healthcare-associated infections
7.18
Baseline 6.37% · Performance 5.69% · Measure score 7.18 · Achievement 7.18 · Improvement 4.46
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.96
Baseline 4.83 hours · Performance 3.92 hours · Measure score 2.96 · Achievement 2.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 375 · Observed rate 8.53% · Lower 95% interval 7.47% |
| Discharge to community | 65.38% |
50.57%
14.8 pts better
|
Better than the National Rate · Eligible stays 370 · Observed rate 61.35% · Lower 95% interval 60.89% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 266 · Denominator 266 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 2 · Denominator 266 |
| Discharge self-care score | 62.65% |
53.69%
9 pts better
|
Numerator 104 · Denominator 166 |
| Discharge mobility score | 53.01% |
50.94%
2.1 pts better
|
Numerator 88 · Denominator 166 |
| Pressure ulcers or injuries, new or worsened | 1.88% |
2.29%
0.4 pts better
|
Numerator 5 · Denominator 266 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 5.69% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 232 · Observed rate 4.31% · Lower 95% interval 3.86% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 116 |
| Staff flu vaccination coverage | 39.5% |
42%
2.5 pts worse
|
Numerator 47 · Denominator 119 |
| Discharge function score | 66.27% |
56.45%
9.8 pts better
|
Numerator 110 · Denominator 166 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 76 · Denominator 76 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 175 · Denominator 175 |
| Resident COVID-19 vaccinations up to date | 2.48% |
25.2%
22.7 pts worse
|
Numerator 4 · Denominator 161 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
97.1%
5.8 pts worse
|
93.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 91.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.3%
0.5 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
18.9%
3.5 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
10.8%
11.4 pts worse
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.7% |
16.1%
10.6 pts worse
|
14.9%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.5%
0.4 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
0.8%
2.2 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.1% |
15.0%
6.9 pts better
|
19.8%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.2%
0.4 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
89.7%
5.6 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 97.6% · Q3 95.8% · Q4 89.9% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
12.0%
4.5 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.5% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.5%
1.4 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.4% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.7% |
88.0%
8.7 pts better
|
79.7%
17 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
25.9%
0.6 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 25.9% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-03 · Fire 2024-10-03
8 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-08-23 · Fire 2023-08-23
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-22
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Not marked corrected
F · Potential for more than minimal harm
2026-01-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Not marked corrected
F · Potential for more than minimal harm
2026-01-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Not marked corrected
F · Potential for more than minimal harm
2026-01-22
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Not marked corrected
F · Potential for more than minimal harm
2026-01-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Not marked corrected
F · Potential for more than minimal harm
2026-01-22
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Not marked corrected
F · Potential for more than minimal harm
2026-01-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Not marked corrected
F · Potential for more than minimal harm
2026-01-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Not marked corrected
F · Potential for more than minimal harm
2026-01-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Not marked corrected
F · Potential for more than minimal harm
2024-10-03
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-01
D · Potential for more than minimal harm
2023-08-23
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-10-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Not marked corrected
E · Potential for more than minimal harm
2026-01-22
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
D · Potential for more than minimal harm
2025-12-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-03
F · Potential for more than minimal harm
2024-10-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-01
Penalties and ownership
What sits behind the stars
Ownership
Grenelle Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Lapis Municipal Opportunities Iv LP
5% Or Greater Indirect Ownership Interest · Organization
Certus Edgemere Management LLC
Operational/Managerial Control · Organization
Chavez, Frank
Operational/Managerial Control · Individual
Chavez, Frank
Corporate Officer · Individual
Hatch, Kjerstin
Operational/Managerial Control · Individual
Hatch, Kjerstin
Corporate Officer · Individual
Lapis- Gp LLC
General Partnership Interest · Organization
Odorizzi, Sandra
Operational/Managerial Control · Individual
Terrell, Basia
Operational/Managerial Control · Individual
Terrell, Basia
Corporate Officer · Individual
Nearby options
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1-star overall rating with 1-star inspections with $35,731 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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5-star overall rating with 5-star inspections with $27,523 in total fines with 3 recent health deficiencies
#3
Pure Health Transitional Care At Texas Health Pres
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
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