Edgemere Estates

Penalties

• Jul 19, 2024 — Fine ($16,801)
• Mar 14, 2024 — Payment Denial · payment denial 63 days
• Mar 14, 2024 — Fine ($16,452)
• Mar 14, 2024 — Fine ($16,039)

Inspection findings

1. Dec 16, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Dec 28, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0744 Quality of Life and Care Deficiencies

     Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

     Corrected Dec 28, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Dec 28, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0947 Nursing and Physician Services Deficiencies

     Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

     Corrected Dec 28, 2025 · CMS health inspection

2. Apr 30, 2025 Fire Safety · 18 findings
   • Not serious Scope/severity F

     E0026 Emergency Preparedness Deficiencies

     Establish roles under a Waiver declared by secretary.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected May 2, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0251 Egress Deficiencies

     Conform to length requirements for dead end corridors.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0352 Smoke Deficiencies

     Properly install and monitor supervisory attachments on automatic sprinkler systems.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0751 Miscellaneous Deficiencies

     Have restrictions on the use of flammable curtains.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Sep 10, 2025 · CMS fire safety

3. Feb 10, 2025 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Mar 11, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0660 Resident Assessment and Care Planning Deficiencies

     Plan the resident's discharge to meet the resident's goals and needs.

     Corrected Mar 11, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 11, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 11, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 11, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Mar 11, 2025 · CMS health inspection

4. Jan 31, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Feb 21, 2025 · CMS health inspection

5. Jan 2, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 24, 2025 · CMS health inspection

6. Sep 20, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 1, 2024 · CMS health inspection

7. Jul 19, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Aug 28, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 18, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jul 19, 2024 · CMS health inspection

8. May 1, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jun 14, 2024 · CMS health inspection

9. Apr 1, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected May 8, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected May 8, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected May 8, 2024 · CMS health inspection

10. Mar 14, 2024 Health · 26 findings
    • Not serious Scope/severity D Complaint

      F0559 Resident Rights Deficiencies

      Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0575 Resident Rights Deficiencies

      Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0577 Resident Rights Deficiencies

      Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0580 Resident Rights Deficiencies

      Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0585 Resident Rights Deficiencies

      Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0641 Resident Assessment and Care Planning Deficiencies

      Ensure each resident receives an accurate assessment.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Apr 18, 2024 · CMS health inspection

    • Serious Scope/severity G

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0690 Quality of Life and Care Deficiencies

      Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity C

      F0732 Nursing and Physician Services Deficiencies

      Post nurse staffing information every day.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0756 Pharmacy Service Deficiencies

      Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0758 Pharmacy Service Deficiencies

      Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Apr 5, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0814 Nutrition and Dietary Deficiencies

      Dispose of garbage and refuse properly.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0835 Administration Deficiencies

      Administer the facility in a manner that enables it to use its resources effectively and efficiently.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0868 Administration Deficiencies

      Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0908 Environmental Deficiencies

      Keep all essential equipment working safely.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0921 Environmental Deficiencies

      Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

      Corrected Apr 18, 2024 · CMS health inspection

    • Not serious Scope/severity D

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Apr 14, 2024 · CMS fire safety

    • Not serious Scope/severity D

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Apr 14, 2024 · CMS fire safety

11. Aug 31, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Sep 22, 2023 · CMS health inspection

12. Aug 8, 2023 Health · 3 findings
    • Not serious Scope/severity D Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Sep 11, 2023 · CMS health inspection

    • Not serious Scope/severity C Complaint

      F0732 Nursing and Physician Services Deficiencies

      Post nurse staffing information every day.

      Corrected Sep 11, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Aug 1, 2023 · CMS health inspection

13. Feb 10, 2023 Health · 12 findings
    • Not serious Scope/severity D

      F0578 Resident Rights Deficiencies

      Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0655 Resident Assessment and Care Planning Deficiencies

      Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0805 Nutrition and Dietary Deficiencies

      Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0808 Nutrition and Dietary Deficiencies

      Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0847 Administration Deficiencies

      Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

      Corrected Mar 31, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0848 Administration Deficiencies

      Provide a neutral and fair arbitration process and agree to arbitrator and venue.

      Corrected Mar 31, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• AMAKIRI, ONYEMA — operational/managerial control, NOT APPLICABLE, since 04/01/2025
• AMAKIRI, ONYEMA — adp of the snf, NOT APPLICABLE, since 04/01/2025
• CINTRON, ROBERT — corporate officer, NOT APPLICABLE, since 07/13/2016
• ESTRADA, ARACELY — operational/managerial control, NOT APPLICABLE, since 03/03/2025
• ESTRADA, ARACELY — adp of the snf, NOT APPLICABLE, since 03/03/2025
• HICKS, DAVID — operational/managerial control, NOT APPLICABLE, since 12/05/2024
• HICKS, DAVID — adp of the snf, NOT APPLICABLE, since 12/05/2024
• EL PASO CONTINUING CARE CENTER LTD. CO. — adp of the snf, NOT APPLICABLE, since 10/26/2025
• EL PASO CONTINUING CARE CENTER LTD. CO. — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• EL PASO COUNTY HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 04/01/2020