Health inspection·January 22, 2026

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure that only paper towels were placed in 3 of 3 handwashing sink garbage receptacles.The facility failed to ensure that 1 of 3 handwashing sinks had a garbage receptacle.The facility failed to maintain the sanitizing solution used in the manual dishwashing process at the proper chemical concentration required for effective sanitation.The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents.These failures could have placed residents at risk for food-borne illness and cross contamination. Observation of the kitchen on January 20, 2026, at 10:06 a.m., revealed the following:2 of 3 handwashing sinks had garbage receptacles that contained items other than disposable paper towels, including disposable gloves, product boxes, food, and other forms of trash.1 of 3 handwashing sinks did not have a garbage receptacle available for disposal of used disposable paper towels.On January 20, 2026, at 10:10 a.m., the Kitchen Attendant was observed testing the sanitizing water used for dishwashing; the test strip read 400 parts per million, indicating a high concentration.On January 20, 2026, at 10:33 a.m., 7 cans of green sliced olives (3 pound 7 ounces each) were observed to have large dents and compromised seals.During an interview on January 20,2026, at 10:12 a.m., with the Kitchen Attendant, she said she was unsure how to properly use the sanitizing test strip and how to interpret the results. The Director of Culinary Services provided immediate instructions and demonstrated how to properly check the chemical balance in the sanitizing water and how to read the color strip.During an interview on January 20,2026, at 10:49 a.m., the Director of Culinary Services said that all handwashing sinks were required to have a garbage receptacle, and he immediately retrieved a garbage can being used in another area of the kitchen and placed it by the sink that did not have one.During an interview on January 20, 2026, at 10:55 a.m., with the Director of Culinary Services and the Dietary Manager revealed cooks were responsible for unloading delivery trucks, and if dented cans were found, they were placed in a separate area and returned.Record review of the facility's 3 Compartment Sinks policy, with no date, revealed Procedure: .5. Check sanitation sink frequently using a test strip to assure the level of sanitizing solution is appropriate. Follow chemical manufacturers guidelines to prepare sanitizing solutions.Sink Setup.3. Sanitizing Compartment.Verify concentration using appropriate test strips before and during use.Step 4 - Sanitize. verify sanitizer concentration using test strips regularly.Record review of facility's food storage policy with no date, revealed nothing in the policy relating to dented cans.There was no policy on garbage receptacles in the kitchen.Review of the U.S. FDA Food Code 2022 reflected: .6-301.20 Disposable Towels, Waste Receptacle. Waste receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or Page 1 of 6 676002 676002 01/22/2026 The Plaza at Edgemere 8502 Edgemere Dallas, TX 75225

F 0812 Level of Harm - Minimal harm or potential for actual harm rodents.Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Residents Affected - Some 676002 Page 2 of 6 676002 01/22/2026 The Plaza at Edgemere 8502 Edgemere Dallas, TX 75225

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the fourth quarter (July 1, 2025, to September 30, 2025). The facility failed to submit complete PBJ staffing information to CMS for July 1, 2025, to September 30, 2025. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included:Record review of the CASPER3 PBJ report reflected the facility failed to submit data for the FY quarter 4 (July 1, 2025- September 30, 2025). No other quarter triggered. An interview with the Administrator on 01/20/2026 at 9:30 am, revealed she was not employed by this facility during that reporting period. She stated that she was unaware of the failure to report data for that reporting period.An interview with the Executive Director on 01/20/2026 at 9:31 am revealed the facility simply did not get the data entered in the system in on time. She stated that they just missed the data entry due date. She stated there were no issues with data input or connecting to the website. She stated that they have not had any problems entering the information since then.The facility provided a policy for payroll Based Journal dated 10/31/2025 which reflected the following: .It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.Definitions: Direct Care Staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being.Policy Explanation and Compliance Guidelines:The facility will electronically submit timely to CMS complete and accurate direct care staffing information including the following:The category of work for each person on direct care staff (including, but not limited to, whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS);Resident census data; andInformation on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day (including, but not limited to, start date, end date (as applicable), and hours worked for each individual).When reporting information about direct care staff, the facility will specify whether the individual is an employee of the facility or is engaged by the facility under contract or through an agency.The facility will submit direct care staffing information in the uniform format specified by CMS.The facility will submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly. The facility shall submit information (specify frequency), and no later than the deadline specified for the specific quarter in which the data is to be reported.Reporting deadlines:Fiscal Quarter 1 (October 1 - December 31): February 14Fiscal Quarter 2 (January 1 - March 31): May 15Fiscal Quarter 3 (April 1 - June 30): August 14Fiscal Quarter 4 (July 1 - September 30): November 14The facility will ensure all staffing data entered in the Payroll-Based Journal (PBJ) system is auditable and able to be verified through either payroll, invoices, and/or tied back to a contract.The facility will utilize the current submission guidelines as described in the CMS Electronic Staffing Data Submission Payroll-Based Journal Policy Manual.Responsibilities for data submission:The Administrator, HR Director, and Director of Nursing are responsible for verifying accuracy of the staffing data that is submitted to CMS using various facility audit forms and/or payroll vendor reports.The Business Office Manager is responsible for verifying the accuracy of census data and collaborating with MDS 676002 Page 3 of 6 676002 01/22/2026 The Plaza at Edgemere 8502 Edgemere Dallas, TX 75225

F 0851 Level of Harm - Minimal harm or potential for actual harm Coordinator for any needed corrections. Reports available through CASPER may be utilized to assist with verifying data.(Designated individual or vendor) is responsible for submitting data and obtaining validation reports.The Administrator is responsible for reviewing validation reports and ensuring that any needed corrections are made before the quarterly deadline Residents Affected - Some 676002 Page 4 of 6 676002 01/22/2026 The Plaza at Edgemere 8502 Edgemere Dallas, TX 75225

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #14, and #71) of four residents observed for infection control in that: LVN A failed to disinfect the blood pressure cuff (used to take blood pressure), and the thermometer in between vital sign checks for Resident #14, and Resident #71. This failure could place residents at risk for spread of infection through cross-contamination. Findings included:Review of Resident #14's 5-day MDS assessment, dated 01/10/2026, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), diabetes (increase of blood sugar), and anxiety disorder (anxious and nervous). Resident #14's BIMs score of 15 indicated the resident was alert and oriented with no cognitive impairment. The MDS revealed Resident #14 required assistance from one staff for activities of daily living.Review of Resident #14's the consolidated physician orders dated January 2026 reflected: order dated 01/05/2026, metoprolol succinate ER (high blood pressure) tablet 25mg one tab by mouth one time a day. Further review revealed physician orders to check blood pressure, every shift.Review of Resident #71's 5-day MDS assessment, dated 12/31/2025, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: hip fracture (broken hip) and depression (sadness). Resident #71's had moderate cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #71 consolidated physician orders dated January 2026 reflected: order dated 01/05/2026, check vital signs every shift or for condition change.Observation on 01/22/2026 at 9:20 a.m. revealed LVN A, during medication pass, went to the medication cart and started preparing to perform medication administration for Resident #14. LVN A took the blood pressure cuff to check her blood pressure, then administered Resident #14's medications. LVN A did not clean the machine prior to or after using it on Resident 14, with Sani Wipes. LVN A did use hand gel on her hands prior to collecting supplies. LVN A left the room went back to the cart, used hand sanitizer documented on the resident's clinical record and began to prepare for the next medication pass.Observation on 01/22/2026 at 9:40 a.m. revealed LVN A, during medication pass, went to the medication cart and started preparing to perform medication administration for Resident #71. LVN A entered the room as the CNA informed LVN A Resident #71 had loose stools and vomiting. LVN A took the blood pressure cuff and thermometer (to measure temperature) to check her blood pressure and the electronic thermometer to check her temperature. LVN A did not clean the machines prior to or after using on Resident #71. LVN A did use hand gel on her hands prior to collecting supplies. LVN A left the room, went back to the cart, used hand sanitizer documented on the resident's clinical record and began to prepare the medications Resident #71 had for her symptoms. In an interview on 01/20/2026 at 9:45 a.m., LVN A stated she was to clean all equipment that was used before and after use on each resident, to prevent the spread of infection. LVN A stated she had been in-serviced concerning the spread of infection, including cleaning of equipment in the past six months. LVN A stated with both of these residents she had just forgotten.In an interview on 01/22/2026 at 10:45 a.m. with interim DON revealed all direct care staff must clean equipment, including blood pressure cuffs, and thermometers. The interim DON stated they have Sani wipes available on all medication and treatment carts. The interim DON stated if the staff was not cleaning the equipment appropriately this could spread germs to themselves and the residents.Review of the in-services given in the past six months reflected an in-service dated August 10th, 2025, for infection control and cleaning of equipment. LVN A attended the meeting. Residents Affected - Few 676002 Page 5 of 6 676002 01/22/2026 The Plaza at Edgemere 8502 Edgemere Dallas, TX 75225

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy Medical Equipment Cleaning Procedure Policy dated June 2023, reflected, 1. Purpose: The purpose of this policy is to ensure all medical and resident care equipment is properly cleaned, disinfected, and maintained to prevent the spread of infections . This policy establishes consistent procedures for cleaning, handling, and storing medical equipment. 2. Scope: This policy applies to all employees responsible for handling or cleaning non-critical, semi critical, and shared medical equipment within the community, including but not limited to: . blood pressure cuff,. thermometer (non-disposable) . Responsibilities: . nursing staff . Ensure shared patient -care devices are disinfected between residents. 7. Frequency of cleaning. blood pressure cuffs . between each resident. reusable thermometers after each usage . 676002 Page 6 of 6