Northgate Care Center

In the surveyor’s words

From the most serious findings on record at Northgate Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF760Mar 4, 2026

  Based on observation, record review, and staff, doctor, pharmacist interview, and policy review the facility failed to have 4 of 7 nurses administer medications following the 6 rights of medication administration. The 6 rights are a process of verifying the right resident, right drug, right dose, right route, right time, and right documentation performed to systematically minimize medication errors, ensure patient safety, and maintain the efficacy of treatment. By verifying these key factors, healthcare providers prevent adverse events, protect residents, and adhere to safety protocols. […]

• Actual harm, isolatedF684Nov 14, 2025

  Based on clinical record review, staff interview, facility video, and facility policy review the facility failed to properly assess and intervene for 2 of 3 residents reviewed, (Residents #3 and #8). The facility identified a census of 45 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 7/24/25 indicated Resident #3 had diagnosis that included Non-Traumatic Brain Dysfunction, Alzheimer's Disease, Non-Alzheimer's Dementia and a Retinal Vascular Occlusion. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (cognitively impaired), with delusions, ambulated with a walker, required supervision to touch assistance with transfers and ambulation and with two (2) falls since reentry to the facility on 2/25/25. […]

• No harm, potential for more than minimal, widespreadF761Mar 4, 2026

  Based on observation, staff, and pharmacist interviews, and policy review the facility failed to store medications in the pharmacy labeled package for all residents on 2 of 8 days of the survey. The facility also failed to keep insulin pens in a locked container/cart/room and keep narcotic in a double locked container/cart/room. The facility reported a census of 44 residents. Findings include: An observation on 2/22/26 at 7:17 AM revealed the facility had two (2) medication carts (South cart and North cart) in the building that contained all residents oral daily medications. The South cart had 21 plastic cups with pill medications inside them and white paper cups with names written on them, in the top drawer of the cart. […]

• No harm, potential for more than minimal, widespreadF865Mar 4, 2026

  Based on record review, staff interview, and policy review the facility failed to make a good faith attempt and ensure effective quality assurance processes regarding significant medication errors when a deficient practice with F760, Residents are Free of Significant Medication Errors, was cited at the facility for 3 of 4 onsite surveys, which included the current survey, since 9/1/2024. The facility reported a census of 44 residents.Findings include: 1.Review of Form CMS-2567 (the official document produced after a state or federal inspection (survey) that included survey results) for the survey ending on 9/22/2024 documented the facility was cited for F760 relating to 1 of 3 residents received 6 medications that were not prescribed for him and was hospitalized overnight for observation. […]

• No harm, potential for more than minimal, patternF880Mar 4, 2026

  Based on observation, staff interviews, and policy review the facility failed to implement infection control measures when 6 of 6 morning insulins were stored together in a container (Resident #30, #14, #43, #19, #2, and #4). The facility also failed to provide Enhanced Barrier Precautions (EBP) as the Centers for Disease Control and Prevention (CDC) (an infection control strategy for nursing homes and long-term care facilities to reduce the spread of multidrug-resistant organisms, It involves using gowns and gloves during high-contact care for residents with wounds, indwelling devices, or known multi-drug resistant organism colonization) directs during wound care (Resident #37). […]