Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to develop and implement a comprehensive
person-centered care plan for each resident that included measurable objectives and time frames to meet
residents' medical needs for one (Resident #1) of five residents reviewed for care plans.
The facility failed to develop a care plan with measurable objectives and timeframes to address Resident
#1's diagnosis of diabetes and use of an indwelling foley catheter.
This failure could place residents at risk of receiving inadequate individualized care and services.
Findings included:
Record review of Resident #1's admission MDS assessment, dated 08/13/24, revealed she was an [AGE]
year-old female who admitted to the facility on [DATE]. Her diagnoses included hypertension,
gastroesophageal reflux disease, diabetes mellitus, hyperlipidemia, other fracture, cerebrovascular
accident, malnutrition, dysphasia. Her BIMS score was 15 of 15, which indicated she was cognitively intact.
Her medication section reflected she received insulin injections. Her bowel and bladder section reflected
she did not use any appliances such as an indwelling catheter.
Record review of Resident #1's Comprehensive Care Plan, undated, reflected the care plan did not address
the resident's diagnosis of diabetes and use of a foley catheter.
Record review of Resident #1's Physician order report dated 09/21/24 - 10/21/24 reflected she was
prescribed Lantus Solostar U-100 Insulin (dated 08/12/24) and Insulin Lispro (dated 08/12/24). She was
ordered an indwelling foley catheter on 08/14/24.
Record review of Resident #1's MAR dated 10/01/24 - 10/21/2024, reflected she was administered Insulin
Lispro and Lantus Solostar U-100 Insulin per physician's order.
An observation and interview with Resident #1 on 09/27/24 at 3:10 PM, revealed she had a foley catheter.
She stated she was diabetic and received insulin.
An interview on 10/21/24 at 12:19 PM, with the MDS Coordinator revealed Resident #1 received insulin and
was diabetic. She stated Resident # 1 had a foley catheter. She stated she was responsible for updating
Resident #1's care plan. She stated the purpose of a comprehensive care plan was for staff to know how to
care for Resident #1. She stated Resident #1's care plan should include her
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
676326
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676326
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgewood Rehabilitation and Care Center
1101 Windbell Dr
Mesquite, TX 75149
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
diagnosis of diabetes and urinary catheter. She stated Resident #1's care plan was revised on 09/19/24.
She stated she did not know any risk associated with Resident #1's care plan not included diabetes or foley
catheter.
Record review of the facility policy, Nursing Policy and Procedures: Care Plan Process, Person-Centered
Care, dated 05/05/23, reflected The facility will develop and implement a baseline and comprehensive care
plan for each resident that includes the instructions needed to provide effective and person-centered care
of the resident that meet professional standards of quality of care.
Event ID:
Facility ID:
676326
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676326
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgewood Rehabilitation and Care Center
1101 Windbell Dr
Mesquite, TX 75149
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide appropriate treatment and services to
prevent complications of enteral feeding for one (Resident #1) of four residents reviewed for feeding tube.
The facility failed to ensure Resident #1's gastrostomy tube (G-tube) dressing was changed.
This failure could place residents with G-tubes were at risk of infection.
Findings included:
Record review of Resident #1's admission MDS assessment, dated 08/13/24, revealed she was an [AGE]
year-old female who admitted to the facility on [DATE]. Her diagnoses included hypertension,
gastroesophageal reflux disease, diabetes mellitus, hyperlipidemia, other fracture, cerebrovascular
accident, malnutrition, dysphasia. Her BIMS score was 15 of 15, which indicated she was cognitively intact.
Her swallowing/nutritional status section revealed her nutritional approach was a feeding tube.
Record review of Resident #1's Physician order report dated 09/21/24 - 10/21/24 reflected:
Enteral feeding: tube site care. Once a day; 7:00 PM - 7:00 AM (dated 08/20/24)
Doxycycline Hyclate capsule; 100 mg; amt 1 cap; oral. Special instructions: for 7 days. Twice a day; 8:00 AM
and 4:00 PM (start date 10/20/24 and end date 10/26/24).
Record review of Resident #1's TAR dated 10/01/24 - 10/21/24 reflected she received tube site care and
Doxycycline Hyclate capsule as ordered.
Record review of Resident #1's nursing notes reflected, Nurse noted light yellowish drainage in the PEG
tube site during medication administration. Changed dressing immediately and notified physician (dated
10/19/24 at 7:25 PM). New order for Doxycycline 100mg BID for 7 days due to greenish/yellowish discharge
around PEG tube site (dated 10/20/24at 4:20 am). The physician was notified and an order for Doxycycline
was entered after the surveyor observed the concerns regarding Resident #1's g tube.
Interview with Resident #1 on 10/19/24 at 3:10 p.m., revealed her g-tube dressing got wet during her
shower (10/19/24). She stated the nurse did not change her wet g-tube dressing. She stated she was
experiencing pain and discomfort from her g-tube site. She stated her pain level was an 8 out of 10 (pain
scale 0 - 10). She stated she had to request pain medication from the nurse.
Observation of Resident #1's g-tube site on 10/19/24 at 3:15 p.m., revealed there was a bandage dated
10/19/24 on the site area. There appeared to be blood and a greenish substance on the bandage. The
nurse and resident adjusted the tubing to the g-tube and green discharge emerged from underneath the
bandage located on the site area. Resident #1 informed RN E that her g-tube bandage got wet in the
shower. RN E left the room and did not return.
Interview with RN E on 10/19/24 at 3:28 PM, revealed the night nurse would change Resident #1's g-tube
dressing sometime between 7:00 PM - 7:00 AM. She stated she did not hear Resident #1 request a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676326
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676326
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgewood Rehabilitation and Care Center
1101 Windbell Dr
Mesquite, TX 75149
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
g-tube dressing change due to bandage getting wet in the shower. RN E stated she would return to
Resident #1's room to change her g-tube dressing.
Observation of Resident #1 on 10/19/24 at 3:40 PM, revealed RN E was providing g-tube site care. The
dressing contained blood and green drainage. The resident did not complain of pain during the dressing
change. Her skin around the tube appeared to be reddish.
Interview with RN E on 10/19/24 at 5:47 PM, revealed there was green discharge coming from Resident
#1's g-tube site. She stated she had not noticed the green discharge prior to Surveyor observation of
Resident #1's g-tube. She stated green discharge from Resident #1's g-tube site was not normal. She
stated she was supposed to document and notify the physician regarding the green discharge coming from
Resident #1's g-tube. RN E stated, Resident #1 was at risk of an infection due to having green discharge
coming from her g-tube site.
Interview with CNA F on 10/19/24 at 5:58 PM, revealed she provided a shower to Resident #1 during her
shift on 10/19/24 (did not remember the time). She stated Resident #1's g-tube dressing got wet during her
shower. She stated she was trained to inform the nurse when a dressing gets wet during showers. She
stated she forgot to inform RN E about Resident #1's wet g-tube dressing. CNA F stated she was supposed
to inform the nurse about Resident #1's wet g-tube dressing. She stated she was unaware Resident #1's
g-tube site had green discharge. She stated Resident #1 was at risk of an infection because RN E was not
informed of the wet g-tube site dressing.
Interview with the DON on 10/21/24 at 3:19 p.m., revealed she was unaware there was green discharge
coming from Resident #1's g-tube site area. She stated green discharge was not normal. She stated she
was unaware Resident #1 had started an antibiotic. She stated she did not know if Resident #1 had an
infection. She stated RN E was responsible for changing Resident #1's dressing. The DON stated she
ensured the nurses were completing g-tube site care by periodically checking residents' MARs and TARs.
She stated her expectation for CNA F was to notify RN E about Resident #1's wet g-tube dressing. She
stated her expectation for RN E was to immediately change Resident #1's g-tube dressing. The DON stated
Resident #1 was at risk of maceration due to g-tube dressing being wet.
A policy regarding g-tubes was requested from the Administrator and DON on 10/19/24 at 6:03 PM. The
g-tube policy provided was not relevant to g-tube site care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676326
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676326
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgewood Rehabilitation and Care Center
1101 Windbell Dr
Mesquite, TX 75149
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0850
Hire a qualified full-time social worker in a facility with more than 120 beds.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to employ a qualified social worker on a full-time
basis for one of one social worker positions reviewed for qualified social worker, in that:
Residents Affected - Few
The facility had not employed a full-time, qualified social worker since 09/26/2024.
This failure placed residents at risk for unmet social services and psychosocial needs.
Findings included:
Observation of the facility from 10/19/24 at 2:00 PM to 10/21/24 at 4:30 PM, revealed the facility did not
have a fulltime social worker.
Record review of the facility's Social Worker's requisition dated 09/27/24 reflected the facility posted a
social worker position.
In an interview with the Administrator on 10/21/24 at 4:10 PM, revealed the previous Social Worker's last
day was 09/26/24. He stated the Social Worker resigned without notice. He stated he did not have enough
time to find a candidate for the social worker position. He stated the job was posted on the internal facility
website. He stated he had started the interviewing process to hire a social worker. He stated the social
worker was responsible for referrals, discharge assistance, axially providers (podiatry, audio, optometry,
and dental). He stated Admissions Coordinator, MDS, ADON, and DON were assisting with social work
tasks. He stated the purpose of having a social worker was to combat social work services. He stated the
residents were provided social services even though the facility did not have a social worker. He stated he
did not have an anticipated date of hiring a social worker but was actively seeking.
Review of the facility's social services' job description, titled, Social Services Director, reflected, The Social
Services Director was responsible for assisting in the planning, organizing, implementing, evaluating and
directing of the social services department in accordance with current exiting federal, state, and local
standards, as well as established facility policies and procedures, to ensure that the medically-related
emotional and social needs of the patient/resident are met/maintained on an individual basis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676326
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676326
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgewood Rehabilitation and Care Center
1101 Windbell Dr
Mesquite, TX 75149
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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
observations, interviews, and record review the facility failed to establish and 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 five (Resident
#1, Resident #2, Resident #3, Resident #4, and Resident #5) of five residents observed for infection
control.
Residents Affected - Some
1.
The facility failed to ensure Residents #1, #2, #3, #4, and #5 were placed on enhanced barrier precautions.
These failures place residents at risk for healthcare associated cross contamination and infections.
Findings included:
1.
Record review of Resident #1's admission MDS assessment, dated 08/13/24, reflected she was an [AGE]
year-old female admitted to the facility on [DATE]. Her BIMs score was 15 indicating her cognitive status
was intact. Her diagnoses included stroke and diabetes. The resident had a feeding tube and a Stage IV
pressure ulcer.
Record review of Resident #1's care plan, dated 08/20/24, reflected the resident had a Stage IV pressure
ulcer, a feeding tube, and a Foley catheter. There was not a care plan for enhanced barrier precautions.
Record review of Resident #1's Physician orders revealed there were no orders for enhanced barrier
precautions.
Observation on 10/19/24 at 3:40 PM with RN E revealed they donned gloves to administer medication
through Resident #1's feeding tube. RN E did not put on a gown. There was no signage or PPE outside of
the resident's door for enhanced barrier precautions. RN E changed the dressing to the feeding tube site.
An observation and interview on 10/21/24 at 10:20 AM, with LPN A revealed Resident #1 was in her room,
lying in bed. There was no signage or PPE outside of the resident's door for enhanced barrier precautions.
LPN A entered the room and put on gloves only. LPN A showed the Surveyor the g-tube site and foley
catheter site. The WCN entered the room and put on gloves only. Resident #1 was assisted to roll to her left
side. The resident had a loose dressing on her pressure ulcer on her sacrum. The wound appeared to be
healing. The resident was repositioned for comfort. LPN A and the WCN removed their gloves and
performed hand hygiene.
An interview on 10/21/24 at 11:57 am, with RN E revealed a gown and gloves were to be worn when a
resident was on enhanced barrier precautions. RN E said she used the facility infection control guidelines
while administering medications and changing the dressing to Resident #1's feeding tube. She
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676326
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676326
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgewood Rehabilitation and Care Center
1101 Windbell Dr
Mesquite, TX 75149
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
stated she performed hand hygiene prior to providing the resident with assistance. She stated she perform
hand hygiene and wore gloves to reduce the chances of the resident contracting an infection. She stated
she did not wear a gown while providing services to the resident because there were no droplet or other
precautions. She stated when a resident was on precautions there was supposed to be a sign on the door
and PPE was to be worn before entering the room. She stated the resident was at risk of contracting an
infection if precautions were not followed. She stated she informed the physician the resident had yellowish
drainage from around the feeding tube and was started on an antibiotic. She stated Resident #1 was
showing signs of an infection.
2. Record review of Resident #2's quarterly MDS assessment, dated 09/11/24, reflected he was a [AGE]
year-old male admitted to the facility on [DATE]. His BIMs score was 3 indicating his cognitive status was
severely impaired. His diagnoses included stroke and non-Alzheimer's dementia. The resident had a foley
catheter.
Record review of Resident #2's care plan, dated 06/19/21, reflected the resident had a suprapubic foley
catheter.
There was not a care plan for enhanced barrier precautions.
Record review of Resident #2's Physician orders revealed there were no orders for enhanced barrier
precautions.
An observation and interview on 10/21/24 at 10:40 AM, with LVN B revealed Resident #2 was lying in bed.
He was awake and alert. There was no signage or PPE outside of the resident's door for enhanced barrier
precautions. LVN B entered the room and put on gloves only. The resident said he had a suprapubic
catheter. Site observed between lower abdominal folds of skin with no issues.
3. Record review of Resident #3's quarterly MDS assessment, dated 09/03/24, reflected she was a [AGE]
year-old female admitted to the facility on [DATE]. Her BIMs score was not filled out. The resident's cognitive
skills for daily decision making were severely impaired. Her diagnoses included stroke and malnutrition. The
resident had a feeding tube.
Record review of Resident #3's care plan, dated 02/15/22, reflected the resident had a feeding tube.
There was not a care plan for enhanced barrier precautions.
Record review of Resident #3's Physician orders revealed there were no orders for enhanced barrier
precautions.
An observation and interview on 10/21/24 at 10:45 AM, with LVN B revealed Resident #3 was in her room,
sitting in her wheelchair. There was no signage or PPE outside of the resident's door for enhanced barrier
precautions. LVN B entered the room and put on gloves only. LVN B raised the resident's shirt. The feeding
tube site was intact with no issues. The resident was non-verbal. She gave a thumbs up when asked about
her feeding tube.
4. Record review of Resident #4's quarterly MDS assessment, dated 08/20/24, reflected he was a [AGE]
year-old male admitted to the facility on [DATE]. His BIMs score was a 9. The resident's cognitive skills were
moderately impaired. His diagnoses included stroke, end-stage renal disease, and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676326
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676326
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgewood Rehabilitation and Care Center
1101 Windbell Dr
Mesquite, TX 75149
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Alzheimer's disease. The resident had a feeding tube.
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #4's care plan, dated 05/20/21, reflected the resident had a feeding tube and a
perma-catheter site in his chest for dialysis.
Residents Affected - Some
There was not a care plan for enhanced barrier precautions.
Record review of Resident #4's Physician orders revealed there were no orders for enhanced barrier
precautions.
An observation and interview on 10/21/24 at 10:50 AM, revealed LVN C entered Resident #4's room and
put on gloves. There was no signage or PPE for enhanced barrier precautions outside of the door. The
resident was awake, alert, and oriented. The resident lifted his shirt and revealed his feeding tube site had
no issues.
5. Record review of Resident #5's quarterly MDS assessment, dated 09/12/24, reflected she was a [AGE]
year-old female admitted to the facility on [DATE]. Her BIMs score was an 8. The resident's cognitive skills
were moderately impaired. Her diagnoses included diabetes and seizure disorder. The resident had a foley
catheter.
Record review of Resident #5's care plan, dated 03/15/22, reflected the resident had a supra-pubic
catheter.
There was not a care plan for enhanced barrier precautions.
An observation and interview on 10/21/24 at 10:55 AM, revealed Resident #5 was in her room. There was
no signage or PPE outside of the resident's door for enhanced barrier precautions. LVN D entered the room
and put on gloves only. The resident's suprapubic catheter site was visualized. The resident said she did not
have any issues with it.
An interview on 10/21/24 at 11:00 AM, with LVN C revealed she did not know which residents were on
enhanced barrier precautions.
An interview on 10/21/24 at 11:05 AM, with LVN B and LVN C revealed they did not know which residents
were on enhanced barrier precautions and said the residents should have signs on their doors indicating if
they were on barrier precautions.
An observation and interview on 10/21/24 at 11:10 AM, with LPN A and the WCN revealed there was no
signage or PPE outside of any resident's door for enhanced barrier precautions. Neither nurse knew what
enhanced barrier precautions were. They said they thought the PPE required for enhanced barrier
precautions would be a gown, gloves, and mask to be worn for high contact resident care.
An interview on 10/21/24 at 11:50 AM, with the DON revealed staff knew which residents were on
enhanced barrier precautions because it was listed on the 24-hour report. She said the PPE for enhanced
barrier precautions should have been inside the door of each resident's room. The DON said there was no
signage on the doors because Corporate staff had not notified them to put it up.
An interview on 10/21/24 at 12:15 PM, with the ADON revealed she was the infection preventionist of the
facility and had been since 12/01/22. She said enhanced barrier precautions were used for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676326
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676326
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgewood Rehabilitation and Care Center
1101 Windbell Dr
Mesquite, TX 75149
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
residents who had feeding tubes, wounds, and foley catheters. She said the purpose of enhanced barrier
precautions was to protect the resident from increased risk of infection. She said following Surveyor
questioning she was putting signage on the resident doors and PPE outside of their doors. She said she
was currently in-servicing the staff and updated the 24-hour report to include the information. The ADON
said there were no residents in the building who had a MDRO (multidrug-resistant organisms) or infection
that required isolation precautions.
Review of the CDC website: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html
reflected:
Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of
multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and
glove use during high-contact resident care activities for residents known to be colonized or infected with a
MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling
medical devices).
.Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid
exposures. They focus on use of gown and gloves during high-contact resident care activities that have
been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if
blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for
residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO
acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply
while using Enhanced Barrier Precautions.
.Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care
activities (unless otherwise indicated as part of Standard Precautions). Residents are not restricted to their
rooms and do not require placement in a private room. Enhanced Barrier Precautions also allow residents
to participate in group activities. Because Enhanced Barrier Precautions do not impose the same activity
and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of
a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical
device that placed them at higher risk.
Review of the facility in-service, Infection Control, dated 07/26/24, reflected:
Enhanced Barrier Precautions
Enhanced-based precautions: Additional measures to protect residents and staff from multidrug-resistant
Organisms (MDROs) with the expansion of the use of PPE (gowns and gloves) face mask if sprays are
expected during high-contact activities.
Implement EBP: .
o All residents with chronic wounds and/or indwelling medical devices regardless of MDRO status.
Wound Clarification-Chronic Wounds:
o Pressure Ulcers, Diabetic foot ulcers, Unhealed surgical wounds, Venous stasis ulcers
o Does not include skin tears, skin breaks
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676326
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676326
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edgewood Rehabilitation and Care Center
1101 Windbell Dr
Mesquite, TX 75149
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Indwelling Medical Devices Clarification
Level of Harm - Minimal harm
or potential for actual harm
o Central lines, Urinary catheters, Feeding tubes, Tracheostomies, Peripherally inserted central catheter
o Does not include peripherally intravenous lines, ostomy, continuous glucose monitors, or insulin pumps
Residents Affected - Some
PPE Required:
o Gloves, Gown, Face protection-if spray or splash is at risk
o [NAME] and doff all PPE with hand hygiene-remove and replace when visibly soiled
o Removal of PPE and hand hygiene must be completed when providing care for another resident
High Contact Care Activities:
o Dressing, Bathing/showering, Transferring, providing hygiene, changing linens, changing briefs, Assisting
to toilet, Device care, Wound care .
Review of the facility policy, Infection Control, dated 09/29/22, reflected:
Purpose: To establish a facility wide program that incorporates a system for preventing, identifying
reporting, investigating and controlling infections and communicable diseases. The program covers all
residents, staff, consultants, students in the facility's nurse aide training program or from affiliated academic
institutions, volunteers, visitors, and other individuals providing services under a contractual agreement and
is based on the individual facility assessment following accepted national standards.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676326
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F850 - Social worker
Hire a qualified full-time social worker in a facility with more than 120 beds.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the October 21, 2024 survey of EDGEWOOD REHABILITATION AND CARE CENTER?
This was a inspection survey of EDGEWOOD REHABILITATION AND CARE CENTER on October 21, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EDGEWOOD REHABILITATION AND CARE CENTER on October 21, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.