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The Plaza at Edgemere
8502 Edgemere, Dallas, TX 75225 · CMS Certification Number (CCN) 676002
At a glance
- CMS overall rating
- ★★★★☆ 4 of 5
- Health inspection citations
- 13 in the last 3 inspection cycles (0 immediate jeopardy, 1 actual harm, 10 from complaints)
- Fire safety citations
- 19
- Fines (last 3 years)
- 1 fine, total $8,278
- Payment denials
- 0
- Most recent standard inspection
- January 22, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★★☆ 4 of 5 | 2.7 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.8 | 2.8 |
| Staffing | ★★★☆☆ 3 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | January 22, 2026 | 5 | 3 | 2 |
| Cycle 2 | October 3, 2024 | 8 | 8 | 8 |
CMS weighted health inspection score: 47 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
13 health citations across 4 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
March 27, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| G | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/01/2026 |
January 22, 2026: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/29/2026 |
| E | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/29/2026 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/29/2026 |
December 2, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/03/2025 |
October 3, 2024: 8 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/01/2024 |
| E | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/01/2024 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/01/2024 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/01/2024 |
| E | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/01/2024 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/01/2024 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/01/2024 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 11/01/2024 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
19 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 01/22/2026 | F | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 02/12/2026 |
| 01/22/2026 | F | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/26/2026 |
| 01/22/2026 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/26/2026 |
| 01/22/2026 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/26/2026 |
| 01/22/2026 | F | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/26/2026 |
| 01/22/2026 | D | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 01/26/2026 |
| 01/22/2026 | F | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies | Deficient, Provider has date of correction Corrected 01/28/2026 |
| 01/22/2026 | F | E-0037 | Establish staff and initial training requirements. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 02/12/2026 |
| 01/22/2026 | F | E-0026 | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 02/12/2026 |
| 01/22/2026 | F | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 02/12/2026 |
| 01/22/2026 | F | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 02/12/2026 |
| 10/03/2024 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 11/01/2024 |
| 10/03/2024 | E | K-0917 | Ensure electrical receptacles or cover plates have distinctive color or marking. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 11/01/2024 |
| 10/03/2024 | E | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/01/2024 |
| 10/03/2024 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/01/2024 |
| 10/03/2024 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/01/2024 |
| 10/03/2024 | F | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 11/01/2024 |
| 10/03/2024 | F | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 11/01/2024 |
| 08/23/2023 | D | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 10/13/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| March 27, 2026 | Fine | $8,278 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 4.29 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.76 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.37 | Not published | Not published |
| Nurse aide hours per resident per day | 2.16 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 4.01 | Not published | Not published |
| RN hours per resident per day, weekends | 0.6 | Not published | Not published |
| Total nursing staff turnover (%) | Staffing data not submitted or invalid for calculating turnover. | 55.3 | 45.8 |
| Registered nurse turnover (%) | Staffing data not submitted or invalid for calculating turnover. | Not published | Not published |
| Administrators who have left | Staffing data not submitted or invalid for calculating turnover. | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Bay 9 Holdings LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Not published
- Ownership changed in last 12 months
- No
- Certified beds
- 72
- Average residents per day
- 60
- Participates in
- Medicare
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- February 19, 2004
- County/parish
- Dallas
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
12 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| GRENELLE HOLDINGS LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| LAPIS MUNICIPAL OPPORTUNITIES IV LP | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| CHAVEZ, FRANK | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HATCH, KJERSTIN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TERRELL, BASIA | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CERTUS EDGEMERE MANAGEMENT LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CHAVEZ, FRANK | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HATCH, KJERSTIN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ODORIZZI, SANDRA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| TERRELL, BASIA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LAPIS- GP LLC | GENERAL PARTNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ODORIZZI, SANDRA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: The Plaza at Edgemere. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.