North Gate Health Care Facility

Inspectors wroteBased on observations, interviews and record reviews conducted during a survey, the facility failed to ensure that a resident with pressure ulcers (ulcers on the skin due to prolong pressure) received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for three (3) (Residents #14, #57, and #207) of eight (8) residents reviewed for pressure ulcers. Specifically, there was lack of initial staging, description and measurements of pressure ulcers upon admission (Resident #57), there was a delay in initiating treatment and lack of an assessment to determine the type of wound present upon admission (Resident #207), and lack of weekly monitoring, including a description and measurements of pressure ulcers (Resident #14). [...]

Inspectors wroteBased on observation, interview, and record review conducted during the survey, the facility failed to ensure residents have the right to personal privacy including accommodations for one (1) (Resident #5) of one (1) resident reviewed. Specifically, a privacy curtain in the resident's room did not fully enclose Resident #5's bed.

Inspectors wroteBased on interview and record review conducted during the survey, the facility failed to ensure that comprehensive care plans included to the extent practicable, the participation of the resident and the resident's representative(s); an explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan for one (1) (Resident #112) of one (1) reviewed for care plan participation. Specifically, Resident #112 was not invited to participate in their care plan meetings.

Inspectors wroteBased on observation, interview, and record review conducted during the survey, the facility failed to ensure that each resident received proper treatment and assistive devices to maintain vision; and if necessary, must assist the resident in making appointments for one (1) (Resident #99) of one (1) resident reviewed. Specifically, Resident #99's glasses were reported missing on 03/04/2026 to facility staff and the resident was not seen by an eye doctor until it was arranged by the family 05/05/2026. Resident #99 complained that they were unable to see well without their glasses and were unable to read without their glasses.

Inspectors wroteBased on observation, interview and record review conducted during a Complaint (#NY00338861) investigation completed on 1/30/25 the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #2) of three resident reviewed. Specifically, Resident #2 did not receive weekly and comprehensive wound assessments and received applied dressings without a physician's order for a chronic left lower leg vascular ulcer (a chronic skin wound that develops due to poor blood circulation). In addition, the Minimum Date Set (MDS, resident assessment tool) was inaccurately assessed for the chronic left lower leg vascular ulcer. The finding is: [...]

Inspectors wroteBased on interview and record review conducted during an Abbreviated survey (complaint #NY00322899) completed on 5/30/24 the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #1) of three residents reviewed. Specifically, there was lack of a provider order for the indwelling catheter (tube placed in bladder to drain urine), lack of documented urine outputs, and catheter care provided. The finding is: The policy titled Clinical Records revised 4/01 documented the medical record would be complete and accurately documented. The medical record would contain information pertinent to resident care and planning. [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (Complaint #NY00304973) completed during the Standard survey on 3/13/24, the facility did not ensure the resident's right to be free from verbal abuse for one (Resident #12) of five residents reviewed. Specifically, on 11/3/22 Licensed Practical Nurse #12 was witnessed using vulgar language towards Resident #12. The finding is: The policy and procedure titled Abuse Reporting and facility Incident Reporting revised 10/24/22, defined verbal abuse as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Standard survey completed on 3/13/2024 the facility did not ensure that all residents care plans were implemented as planned, consistent with the resident rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for one (Resident #14) of two reviewed. Specifically, Resident #14 was not care planned for the use of a positioning wedge. The resident was observed on multiple occasion lying in bed with the wedge positioned between the mattress and the bedframe. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 3/13/24, the facility did not ensure that services being provided met professional standards of quality for two (Resident #166 and #477) of four reviewed. Specifically, a medication transcription error led to Resident #166 receiving the wrong medications, causing a decrease in the resident's blood pressure which resulted in a transfer to the hospital for evaluation. Additionally, during a medication pass observation Licensed Practical Nurse #7 documented medications administered to Resident #477 using Licensed Practical Nurse #8 Unit Coordinators' employee identifier. The finding is: [...]

Inspectors wroteBased on observation, interview and record review conducted during a Complaint investigation (Complaint #NY00328436) during a Standard survey completed on 3/13/24, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary assistance to maintain grooming and personal hygiene for one (Resident #120) of six residents reviewed. Specifically, Resident #120 was not offered toileting or provided incontinent care as planned. The finding is: The policy and procedure titled Activities of Daily Living dated 11/16 documented each resident will receive and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and care plan. [...]

Inspectors wroteBased on interview and record review during a Standard survey completed on 3/13/24, the facility did not ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for one of three employees reviewed for licensure and certification. Specifically, the Associate Director of Quality and Education did not have the required license or certification and was observed providing hands on care for a resident on 3/12/24. Refer to F 677 D The finding is: Review of facility's undated Job Title: Associate Director for Quality and Education, documented they plan, organize, and directs all staff development programs and Continuous Quality Improvement Programs throughout the facility and in accordance with applicable federal, state, local and facility guidelines/regulations to ensure that the highest degree of quality is maintained at all times. [...]

Inspectors wroteBased on observation, interview, and record review completed during the Standard survey conducted from 5/11/22 through 5/17/22, the facility did not ensure that a resident with an indwelling catheter (Foley-tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTI) to the extent possible. Specifically, two (Resident's # 25, 157) of three residents reviewed for urinary catheters lacked proper infection control measures for residents with a history of UTI. The finding is: The facility policy and procedure (P&P) titled Catheter Drainage Bag Care revised 5/13 documented all nursing personnel care for urinary drainage bags. The catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder. Care should be taken to make sure the tubing does not touch or drag on the floor. 1. [...]