Northgate Plaza

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the new privacy bag on hand. She said the privacy bag was to maintain the resident's integrity and dignity.

In an interview on 09/30/2025 at 12:23 PM, the ADON stated a catheter bag must have a privacy bag to avoid incidents that could lead to embarrassment. She said some visitors might enter the resident's room and would see the catheter bag and its content. She said the purpose of the privacy bag was to provide dignity for residents with urinary catheters. She said the expectation was for the staff to make sure the catheter bags had privacy bags when the residents were inside their rooms or outside their rooms. She said

an in-service was already going around and she would coordinate with the DON to closely monitor the adherence of the staff in providing dignity. In an interview on 09/30/2025 at 12:47 PM, the Administrator stated a catheter bag should be inside a privacy bag to prevent any dignity issue. She said all the staff were responsible in providing dignity to all residents. She said staff must do their due diligence in ensuring the residents have a dignified existence while in the facility. The Administrator said she would coordinate with

the DON to re-educate the staff with regards to dignity and to monitor that the catheter bags were not exposed. She said the facility did not have a policy specific in putting a catheter bag in a privacy bag but in essence, there should be a privacy bag to ensure dignified existence.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northgate Plaza

2101 Northgate Dr Irving, TX 75062

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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

they used to call the staff in case they needed something. She went to Resident #2's room and checked the resident's call light. She then went inside Resident #3's room and saw Resident #3's call light was inside

the drawer of the resident's side table. She took the call light from the drawer and placed it where Resident #3 could reach it when needed. She said she would also check on Resident #4's room and make sure the call light was within Resident #4's reach. She said if the call lights were not within the reach of the residents, the residents might fall or might get mad when they could not get hold of the staff. In an interview

on 09/30/2025 at 10:03 AM, the DON stated call lights were safety measures wherein the residents could call the staff if they needed something or needed to do something that needed assistance. She said residents might try to go to the bathroom by themselves because she had no way to call the staff that might result in a fall and injuries. The DON said all the staff were responsible for the call lights, including her. She said the call lights were for dependent and independent residents. The DON said the expectation was for

the staff to scan the resident's room when they do their rounds and ensure the call lights were within reach of the residents before they leave the room. She said she would remind the department heads to check the call lights when they do their rounds in the morning. The DON said an in-service was already on-going as soon as CNA C told her about the call light not within reach. In an interview on 09/30/2025 at 11:00 AM, LVN B stated, to be honest, she did not check if the call lights were with the residents on her hall. She said

the call lights should be with the residents at all times so the residents could call the staff if they needed help. She said staff should make sure that the call lights were with the residents when they leave the residents' rooms. In an interview on 09/30/2025 at 12:23 PM, the ADON stated call light should be with the residents at all times because the call light was the only way they could reach out to the staff if they were in distress or just needed water. She said the call light were for all the residents, whether independent or dependent. She said an independent resident might be having a heart attack and could not call anybody because the call light was not with the resident. She said she was one of the responsible in checking if the call lights were with the residents. She said an in-service was already going around and that she would coordinate with the DON to randomly check if the call lights were with the residents. In an interview on 09/30/2025 at 12:47 PM, the Administrator stated the staff should make sure that the call lights were with

the residents before they leave the room because for some resident, call lights were their sense of security.

She said call lights were for all residents and all the staff were responsible in making sure the call lights were within reach. The Administrator said she would coordinate with the DON to re-educate the staff with regards to call lights. Record review of the facility's policy entitled Call Light/Bell Policy/Procedure - Nursing Clinical revised 05/2020 reflected POLICY: It is the policy of this facility to provide the resident a means of communication with nursing staff . PROCEDURES . 5. Leave the resident comfortable. Place the call device within resident's reach before leaving room.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northgate Plaza

2101 Northgate Dr Irving, TX 75062

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

in-service was already going around. In an interview on 09/30/2025 at 12:47 PM, the Administrator stated

she was not a clinician and would let the ADON and the DON to make sure the said issue would be addressed. Record review of the facility's policy entitled Physician Orders Policy/ Procedure - Nursing Clinical revised 05/2007 reflected POLICY: It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments . PROCEDURES . 1. No drugs or biologicals shall be administered except upon the order of

a person lawfully authorized to prescribe for and treat human illnesses . recorded immediately in the resident's chart by the person receiving the order and must include the date and time of the order.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northgate Plaza

2101 Northgate Dr Irving, TX 75062

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 0695

PROCEDURES . 5. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northgate Plaza

2101 Northgate Dr Irving, TX 75062

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 0761 Level of Harm - Minimal harm or potential for actual harm

skin protectant inside the rooms. Record review of the facility's policy entitled, Medication Access and Storage/Drug Destruction Policy/Procedure - Nursing Clinical revised 07/2023 reflected POLICY: It is the policy of this facility to store all drugs and biological in locked compartments . The medication supply is accessible only to licensed nursing personnel.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northgate Plaza

2101 Northgate Dr Irving, TX 75062

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 - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

EBP and monitor closely their adherence to the policy of infection control. Record review of the facility's policy entitled Infection Control IPCP Standard and Transmission-Based Precautions revised 03/2024 reflected Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions . Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident . a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with . Indwelling medical devices . urinary catheters.

Event ID:

Facility ID:

If continuation sheet