Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
The Plaza at Edgemere
Dallas, TX · 72 certified beds · Last Life Safety survey January 22, 2026
CMS Certification Number 676002 · first certified February 2004
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: The Plaza at Edgemere Assisted Living (8502 Edgemere). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- Ownership changed June 13, 2023 (change of ownership)from NORTHWEST SENIOR HOUSING CORPORATION
Position within TX
19 citations — more than 93% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 11 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens March 2027 — about 5 months from now. This facility’s last Life Safety survey was January 2026. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 19 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 23, 2023 | 1 |
| October 3, 2024 | 7 |
| January 22, 2026 | 11 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 2 | 2026-01-22 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-01-22 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2026-01-22 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 1 | 2026-01-22 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-10-03 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-10-03 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2026-01-22 |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | 1 | 2026-01-22 |
What the citations cover
- Smoke Deficiencies 9
- Emergency Preparedness Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Emergency Preparedness Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 22, 2026 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (February 12, 2026) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (February 12, 2026) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (February 12, 2026) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (February 12, 2026) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (January 28, 2026) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (January 26, 2026) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (January 26, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 26, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 26, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (January 26, 2026) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (February 12, 2026) |
October 3, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0917 | Ensure electrical receptacles or cover plates have distinctive color or marking. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 1, 2024) |
August 23, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (October 13, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.