NORTHGATE PLAZA
2101 NORTHGATE DR, IRVING, TX 75062 · CCN 675967
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★★☆☆ 3
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 120
- Avg residents/day
- 58.0
- Phone
- 9722554460
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-12-18 | 17 | 9.1 | 9.5 | +7.9 worse |
| 2 | 2023-11-09 | 25 | 9.4 | 9.8 | +15.6 worse |
| 3 | 2022-09-28 | 17 | 8.1 | 9.3 | +8.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 1 |
| Quality of life and care | 6 |
| Resident assessment and care planning | 2 |
| Nursing and physician services | 1 |
| Resident rights | 3 |
| Nutrition and dietary | 2 |
| Pharmacy service | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 2.99 | 85.1% |
| RN staffing (reported) | 0.45 | 85.7% |
| Total nurse staffing (adjusted) | 3.63 | — |
Fines & penalties
- Total fines
- $55,697
- Number of fines
- 2
- Number of penalties
- 2
- Payment denials
- 0
Chain
- Chain
- THE ENSIGN GROUP
- Facilities in chain
- 329
- Chain avg overall
- 3.20 / 5
Inspection citations (59)1 immediate jeopardy1 actual harm
- DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-11-25 · Health · corrected 2025-10-09
Potential for more than minimal harm
- EF0558Reasonably accommodate the needs and preferences of each resident.2025-11-25 · Health · corrected 2025-10-09
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-11-25 · Health · corrected 2025-10-09
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2025-11-25 · Health · corrected 2025-10-09
Potential for more than minimal harm
- DF0761Ensure 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.2025-11-25 · Health · corrected 2025-10-09
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-11-25 · Health · corrected 2025-10-09
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-08-07 · Health · corrected 2025-08-08
Potential for more than minimal harm
- EF0558Reasonably accommodate the needs and preferences of each resident.2025-05-14 · Health · corrected 2025-06-04
Potential for more than minimal harm
- EF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2025-05-14 · Health · corrected 2025-06-04
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-05-14 · Health · corrected 2025-06-04
Potential for more than minimal harm
- KF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-03-28 · Health · corrected 2025-04-21
Immediate jeopardy
- EF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2025-03-28 · Health · corrected 2025-04-21
Potential for more than minimal harm
- EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-03-28 · Health · corrected 2025-04-21
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-12-18 · Health · corrected 2025-01-17
Potential for more than minimal harm
- EF0727Have 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.2024-12-18 · Health · corrected 2025-01-17
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-12-18 · Health · corrected 2025-01-17
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-12-18 · Health · corrected 2025-01-17
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2024-10-31 · Health · corrected 2024-11-25
Potential for more than minimal harm
- EF0583Keep residents' personal and medical records private and confidential.2024-10-31 · Health · corrected 2024-11-25
Potential for more than minimal harm
- EF0584Honor 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.2024-10-31 · Health · corrected 2024-11-25
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-10-31 · Health · corrected 2024-11-25
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-10-31 · Health · corrected 2024-11-25
Potential for more than minimal harm
- EF0695Provide safe and appropriate respiratory care for a resident when needed.2024-10-31 · Health · corrected 2024-11-25
Potential for more than minimal harm
- DF0761Ensure 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.2024-10-31 · Health · corrected 2024-11-25
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-10-31 · Health · corrected 2024-11-25
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-10-31 · Health · corrected 2024-11-25
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-10-28 · Health · corrected 2024-11-15
Potential for more than minimal harm
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-09-19 · Health · corrected 2024-10-01
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-09-19 · Health · corrected 2024-10-01
Potential for more than minimal harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-09-19 · Health · corrected 2024-10-01
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-01-19 · Health · corrected 2024-03-04
Potential for more than minimal harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- EF0584Honor 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.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- EF0680Ensure the activities program is directed by a qualified professional.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- DF0692Provide enough food/fluids to maintain a resident's health.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- DF0693Ensure 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.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- DF0700Try 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.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2023-11-09 · Health · corrected 2023-12-09
Potential for more than minimal harm
- DF0806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.2023-09-07 · Health · corrected 2023-09-10
Potential for more than minimal harm
- DF0761Ensure 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.2023-08-22 · Health · corrected 2023-08-25
Potential for more than minimal harm
- EF0585Honor 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.2023-08-04 · Health · corrected 2023-08-10
Potential for more than minimal harm
- GF0697Provide safe, appropriate pain management for a resident who requires such services.2023-08-04 · Health · corrected 2023-08-10
Actual harm
- EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-06-16 · Health · corrected 2023-06-19
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2023-06-16 · Health · corrected 2023-06-19
Potential for more than minimal harm
- DF0584Honor 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.2023-04-13 · Health · corrected 2023-04-17
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-04-13 · Health · corrected 2023-04-17
Potential for more than minimal harm
- DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2022-09-28 · Health · corrected 2022-10-23
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2022-09-28 · Health · corrected 2022-10-22
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2022-09-28 · Health · corrected 2022-10-23
Potential for more than minimal harm
- DF0687Provide appropriate foot care.2022-09-28 · Health · corrected 2022-11-11
Potential for more than minimal harm
- DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2022-09-28 · Health · corrected 2022-10-23
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2022-09-28 · Health · corrected 2022-10-24
Potential for more than minimal harm
- EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-09-28 · Health · corrected 2022-10-03
Potential for more than minimal harm
- EF0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.2022-09-28 · Health · corrected 2022-10-24
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| HAMILTON COUNTY HOSPITAL DISTRICT | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2019-05-01 |
| SWEET BAY HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-07-01 |
| BARNES, MARCUS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-07-01 |
| BURNAM, SOON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-07-01 |
| FORREST, WILLIAM | Individual | CORPORATE DIRECTOR | — | 1992-05-20 |
| MCGREGOR, DENA | Individual | CORPORATE DIRECTOR | — | 2016-12-15 |
| MUXWORTHY, NEIL | Individual | CORPORATE DIRECTOR | — | 1996-05-20 |
| WITZSCHE, ROBERT | Individual | CORPORATE DIRECTOR | — | 1998-12-28 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | — | 2022-07-01 |
| HOOPER, GRADY | Individual | CORPORATE OFFICER | — | 2015-12-01 |
| MUXWORTHY, NEIL | Individual | CORPORATE OFFICER | — | 1996-05-20 |
| BARNES, MARCUS | Individual | W-2 MANAGING EMPLOYEE | — | 2022-07-01 |
Other facilities in IRVING
| Name | Overall | Beds |
|---|---|---|
| Avir at Irving | ★★★★☆ | 84 |
| AVANTE REHABILITATION CENTER | ★★★☆☆ | 120 |
| LAS BRISAS REHABILITATION AND WELLNESS CENTER | ★★★☆☆ | 128 |
| ASHFORD HALL | ★☆☆☆☆ | 206 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.