NORTHGATE PLAZA
2101 NORTHGATE DR, IRVING, TX 75062
Falls short of federal staffing minimum — elevated deficiency count.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
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0.45 ✗ Below federal minimum (0.55) |
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Health Deficiencies
Violations found during federal inspections over the last 3 years.
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17 |
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★☆☆ (3/5)
Staffing: ★★☆☆☆ (2/5)
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NursingHomeGrade Score
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37/100 |
Data last updated: April 12, 2026
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
Most recent inspection (May 14, 2025)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 4, 2025
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 9, 2025
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 9, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 9, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 9, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 8, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 4, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 17, 2025
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies — Deficient, Provider has no plan of correction
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 9, 2025
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 9, 2025
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 4, 2025
Inspection cycle 2 (October 28, 2024)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 15, 2024
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected November 25, 2024
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected April 21, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 25, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 25, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 1, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 21, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 25, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 25, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 25, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 1, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
Ensure the activities program is directed by a qualified professional.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
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.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 21, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 1, 2024
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 — Deficient, Provider has date of correction, corrected December 9, 2023
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 25, 2024
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 25, 2024
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 25, 2024
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 9, 2023
Inspection cycle 3 (September 28, 2022)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2022
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 19, 2023
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 10, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 3, 2022
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.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 25, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 19, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2022
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2022
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 10, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 22, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2022
Provide appropriate foot care.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 11, 2022
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 4, 2024
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 10, 2023
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 17, 2023
Quality Assurance & Integrity
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