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🔎 Northgate Health And Rehabilitation Center

Inspection Results


Inspection Overview

Northgate Health And Rehabilitation Center has been cited for a total of 66 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2025-01-23
Correction Date: 2025-01-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2025-01-23
Correction Date: 2025-01-24
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-06-07
Correction Date: 2024-06-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Survey Date: 2024-06-07
Correction Date: 2024-07-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2024-06-07
Correction Date: 2024-06-27
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2024-06-07
Correction Date: 2024-07-17
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2024-06-07
Correction Date: 2024-06-28
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2024-04-14
Correction Date: 2024-04-15
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-04-14
Correction Date: 2024-04-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2024-04-14
Correction Date: 2024-04-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2024-04-14
Correction Date: 2024-04-15
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2024-04-14
Correction Date: 2024-04-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2024-04-14
Correction Date: 2024-04-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Survey Date: 2024-04-14
Correction Date: 2024-04-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Survey Date: 2024-04-14
Correction Date: 2024-04-15
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-05-11
Correction Date: 2023-05-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-05-11
Correction Date: 2023-05-25
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-05-07
Correction Date: 2023-06-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-05-07
Correction Date: 2023-05-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: J

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

Survey Date: 2023-05-07
Correction Date: 2023-05-25
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-04-28
Correction Date: 2023-04-29
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2023-04-28
Correction Date: 2023-04-29
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2023-03-09
Correction Date: 2023-03-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2023-03-09
Correction Date: 2023-03-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2022-12-08
Correction Date: 2023-01-06
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-12-08
Correction Date: 2023-01-06
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-08-25
Correction Date: 2022-09-21
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2022-07-27
Correction Date: 2022-07-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2022-03-04
Correction Date: 2022-03-25
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-03-04
Correction Date: 2022-03-25
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2022-03-04
Correction Date: 2022-03-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2022-03-04
Correction Date: 2022-03-28
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-03-04
Correction Date: 2022-03-25
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2022-02-14
Correction Date: 2022-02-21
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2021-10-30
Correction Date: 2021-11-01
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-09-10
Correction Date: 2021-10-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-05-11
Correction Date: 2021-05-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Dispose of garbage and refuse properly.

Survey Date: 2021-03-19
Correction Date: 2021-04-16
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2020-11-10
Correction Date: 2020-12-04
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Give the resident's representative the ability to exercise the resident's rights.

Survey Date: 2020-07-01
Correction Date: 2020-07-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure residents have reasonable access to and privacy in their use of communication methods.

Survey Date: 2020-06-01
Correction Date: 2020-06-16
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2020-06-01
Correction Date: 2020-06-18
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: F

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

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Dispose of garbage and refuse properly.

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: F

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2019-07-17
Correction Date: 2019-08-31
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**