Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

EDGEWOOD REHABILITATION AND CARE CENTER

MESQUITE, TX · 142 certified beds · Last Life Safety survey May 15, 2025

CMS Certification Number 676326 · first certified October 2012

Ownership

Operated by FUNDAMENTAL HEALTHCARE · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

6
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
0
Tags cited more than once
Across separate surveys
3
Inspection & testing records
Of the citations on file

Position within TX

6 citations — more than 35% 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

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 0 citations; the earlier surveys in the window averaged 3. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (June 2026 to July 2026), and past the point by which nine in ten TX facilities have been surveyed. This facility’s last Life Safety survey was May 2025. 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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Which alerts

Emergency preparedness

1 of the 6 citations on file is 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)

6 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 6 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.

This facility6TX median7National median11
Citations on file over three years, compared
MeasureCitations
This facility6
Median facility in TX7
Median facility nationally11

Survey history

Citations at each Life Safety survey
12023-0252024-0402025-05
Citations at each Life Safety survey
Survey dateCitations
February 16, 20231
April 12, 20245
May 15, 20250

Most-cited tags

Most-cited tags at this facility
E-00061K-03451K-03611K-03631K-03211K-03721
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
E-0006Conduct risk assessment and an All-Hazards approach.12024-04-12
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12024-04-12
K-0361Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.12024-04-12
K-0363Install corridor and hallway doors that block smoke.12024-04-12
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.12024-04-12
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.12023-02-16

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 5
  • Emergency Preparedness Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies5
Emergency Preparedness Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 12, 2024 — 5 citations

Citations issued on April 12, 2024
TagWhat the surveyor checksStatus
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (May 10, 2024)
K-0321Ensure 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 (May 10, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (May 10, 2024)
K-0361Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.Deficient, Provider has date of correction (May 10, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (May 10, 2024)

February 16, 2023 — 1 citation

Citations issued on February 16, 2023
TagWhat the surveyor checksStatus
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (March 17, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.