Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Gate Health Care Facility during CMS and state inspections, most recent first.
Pressure ulcer care was not consistently assessed, monitored, or documented for multiple residents. One resident had buttock wounds on admission without initial staging, measurements, or descriptions, and treatment documentation was incomplete. Another resident had heel pressure injuries with missing weekly wound monitoring and delayed implementation of a wound consultant’s Santyl recommendation, while staff also failed to sign off some ordered treatments. A third resident had buttock redness/open areas noted on admission without a documented RN follow-up assessment or ongoing wound measurements.
A resident with depression, PTSD, osteomyelitis, and cognitive impairment was found in a room where the privacy curtain did not fully close, leaving a gap of about three to four feet. The resident said the lack of privacy bothered them because the roommate could see them during care. Staff, including a CNA, an LPN, and maintenance, confirmed the curtain was too short and did not fully enclose the bed, and no maintenance request records were available for the room.
Resident not invited to care plan meetings. A cognitively intact resident with COPD, OA, and MDD was documented as independent with decision making and included on a care plan that called for resident participation, yet the resident stated they were never invited and never received a letter. Staff interviews showed the receptionist mailed care plan notices to the listed responsible party and the SW did not specifically invite residents, even though the resident should have been included as their own decision maker.
A resident with stroke, CHF, and MDD had glasses reported missing and was documented as needing them for reading and daily vision. Staff placed the resident on the optometrist list, but the resident was not seen at the scheduled visit and there was no documented follow-up for weeks. The family ultimately arranged an outside eye appointment themselves after receiving little communication from the facility, and the resident stated they could not read without the glasses and that it caused eye discomfort.
A resident with a chronic left lower leg vascular ulcer did not receive proper wound assessments or physician-ordered treatments. The facility failed to document necessary wound details and apply dressings with a physician's order. Staff interviews revealed inconsistencies in following treatment protocols and communication gaps regarding the resident's wound care.
A facility failed to provide appropriate care and documentation for a resident with an indwelling catheter, leading to inconsistent records and a subsequent hospital admission for sepsis secondary to a urinary tract infection.
Pressure Ulcer Assessment, Monitoring, and Treatment Documentation Failures
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. Surveyors identified deficiencies involving three residents: one resident with pressure ulcers present on admission, one resident with heel pressure injuries that were not monitored weekly as required, and one resident with skin redness/open areas on the buttocks that were not fully assessed or tracked with measurements and descriptions after admission. For one resident with kidney transplant failure, dialysis dependence, and chronic kidney disease, the admission nursing evaluation documented open areas on the right and left buttocks, but it did not include the type, stage, measurements, or descriptions of the wounds. The record also did not show an evaluation of those areas in progress notes or medical visit notes for several days after admission. Weekly skin documentation later identified multiple stage II pressure ulcers with measurements, and treatment orders were entered, but the treatment administration record did not show completion initials for several days of ordered calcium alginate and Calmoseptine treatments. The resident stated the buttocks areas were washed daily and that staff applied cream from an orange tube during care. For another resident with hypertension, heart failure, and chronic kidney disease, weekly skin documentation initially recorded suspected deep tissue injuries to both heels, but there was no weekly monitoring with ongoing descriptions and measurements for the heel wounds for an extended period. The record also showed that a wound consultant later assessed the right heel as a stage III pressure ulcer and recommended Santyl with a dry dressing, but the facility did not change the treatment order until several days later. Treatment records also showed missing or delayed documentation of ordered heel treatments, and staff interviews indicated that some treatments were not signed off when completed or were not completed because staff believed they did not have time. For a third resident who was cognitively intact and dependent for bed mobility and transfers, admission documentation noted redness to the right groin and bilateral buttocks, but there was no documented follow-up assessment with type, description, or measurements after admission. The record did not show additional weekly skin status documentation for the area, and there was no documented evidence of ordered preventive treatment for the buttocks redness until later in the stay. Staff interviews reflected uncertainty about whether the redness was blanchable, pressure-related, or moisture-related, and the wound was not clearly assessed by a registered nurse at the time it was first identified.
Privacy Curtain Did Not Fully Enclose Resident Bed
Penalty
Summary
The facility failed to ensure resident privacy and confidentiality for one resident when a privacy curtain in the resident's room did not fully enclose the bed. The resident had diagnoses including major depressive disorder, post-traumatic stress disorder, and osteomyelitis, and the MDS documented moderate cognitive impairment. The comprehensive care plan noted an alteration in bladder function related to incontinence, with incontinent care as needed, and also documented the resident as alert and oriented to identity, location, and time with mild cognitive impairment. During observation, the resident stated the room did not feel very private because the curtain needed another panel and did not close all the way. When the curtain was pulled, it left an open gap of approximately four feet, and the resident stated that if the roommate left the room during care, the roommate could see them. The resident said this bothered them and that staff had commented the curtain was not big enough. Maintenance request records for the room for the prior 30 days could not be provided. Staff interviews confirmed the curtain did not fully close. A CNA stated the curtain did not go around the bed during morning care and that staff were aware of the issue but too busy to fix it. An LPN unit coordinator stated the curtain was short, should have extended the full length of the track, and that staff should have notified them or submitted a maintenance request. Other staff and maintenance also observed a gap of at least three feet and stated the curtains should have been wide enough to enclose the resident for privacy. The DON and Administrator stated the curtain should fully close to provide privacy and dignity, and maintenance was responsible for hanging privacy curtains.
Resident Not Invited to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that comprehensive care plans included, to the extent practicable, the participation of the resident and the resident's representative, and failed to document an explanation in the medical record when such participation was not practicable. Resident #112, who had diagnoses including COPD, osteoarthritis, and major depressive disorder, was assessed as cognitively intact, able to understand and be understood by others, independent with decision making, and without alteration in psychosocial well-being. The resident's comprehensive care plan included interventions to remain involved in daily decisions and care, receive information to make safe and independent decisions, respect choices, and be invited to attend comprehensive care plan meetings, along with inviting the responsible party to attend. During interview, Resident #112 stated they had never been invited to attend a care plan meeting and had never received an invitation or letter. Staff interviews showed the receptionist sent care plan letters to the responsible party listed in the electronic medical record, and the social worker stated residents were not specifically invited to attend their care plan meetings. The receptionist confirmed Resident #112's letters were mailed to a family member rather than to the resident, and the social worker later stated Resident #112 should have been invited because they were their own decision maker. The administrator stated social workers were responsible for inviting residents to their care plan meetings.
Failure to Ensure Access to Vision Services and Replacement Glasses
Penalty
Summary
The facility failed to ensure that Resident #99 received proper treatment and assistive devices to maintain vision and, when necessary, assistance with making appointments for vision services. Resident #99 had diagnoses including cerebral infarction, congestive heart failure, and major depressive disorder, and the MDS documented moderate cognitive impairment, that the resident understood and was understood by others, and that vision was adequate with corrective lenses. The care plan and Kardex indicated the resident used glasses, enjoyed reading, and was to have optometry and ophthalmology consults as ordered. Resident #99's glasses were reported missing on 03/04/2026, and progress notes reviewed through 04/29/2026 did not document evidence of the missing glasses. The resident was placed on the in-house optometrist schedule, but the appointment on 04/03/2026 did not occur because the resident was marked not available. Emails between staff showed concern that the family was waiting for the appointment and that the resident would have to wait another month if rescheduled. A later note documented an appointment for 05/05/2026 with an outside eyecare center, with the family member taking the resident. During interviews, Resident #99 stated they could not read without their glasses and that it bothered them because it made seeing harder and caused their eyes to hurt. The family member stated the glasses had been missing for over six weeks, that the facility only told them there was an optometrist, and that they received no follow-up from the facility before arranging an outside appointment themselves. Staff interviews confirmed awareness that the glasses were missing, that the resident had been placed on the optometrist list, and that the resident was not seen on the scheduled visit. The DON stated glasses should be replaced as soon as possible for quality of life and did not believe it should take two months, while the CNO stated there was no policy and procedure specific to vision or eye care.
Deficiency in Wound Care Management
Penalty
Summary
The facility failed to ensure that Resident #2 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #2, who has a chronic left lower leg vascular ulcer, did not receive weekly and comprehensive wound assessments as required. Additionally, dressings were applied to the wound without a physician's order. The facility's policy mandates weekly skin assessments for chronic wounds, but these were not consistently documented with necessary details such as measurements and wound characteristics. Resident #2 has a medical history that includes diabetes mellitus, schizophrenia, and a right above-the-knee amputation. The Minimum Data Set inaccurately assessed the resident's chronic ulcer, indicating only one unstageable pressure ulcer and no other skin issues. Observations revealed that the resident had a dressing on the left lower leg, which was not dated or signed, and the resident occasionally refused dressing changes. Despite the chronic nature of the wound, there was no specific physician's order for the daily wound dressings, and the wound was not consistently evaluated by the facility's wound consultant. Interviews with facility staff, including nurses and the Director of Nursing, highlighted a lack of adherence to proper documentation and treatment protocols. The wound was not assessed with the required detail, and there was confusion regarding the need for physician orders for dressings. The Adult Nurse Practitioner, serving as a wound consultant, was not aware of the resident's vascular wound, indicating a communication gap within the facility. The Medical Doctor emphasized the necessity of documenting all wound characteristics and obtaining physician orders for treatments, which was not followed in this case.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility did not ensure that a resident with an indwelling catheter received appropriate care and services. Specifically, there was no provider order for the catheter, no documented urine outputs, and no evidence of catheter care being provided. The resident had diagnoses including post laminectomy syndrome, depression, and colitis, and was documented as occasionally incontinent of urine. However, the resident's medical records and care plans did not consistently reflect the presence of a foley catheter, and there were discrepancies in staff documentation regarding the catheter's existence and care provided. The Nursing Admission Evaluation and Kardex did not document the presence of a foley catheter, and there were no provider orders addressing the use or discontinuation of the catheter. Nursing progress notes and the 24-hour Nursing Services Supervisor Report contained inconsistent documentation about the catheter, with some entries noting its presence and others not. There was also no documentation of urine outputs or catheter care in the Treatment Administration Record, and the facility could not provide certified nurse aide task documentation related to these aspects of care. Interviews with various staff members, including LPNs, an occupational therapist, and the Director of Nursing, revealed a lack of clarity and consistency regarding the resident's catheter status and care. The Director of Nursing admitted that the medical record should have clearly indicated whether the resident had a catheter and whether catheter care was provided. The resident was later admitted to the hospital with sepsis secondary to a urinary tract infection, indicating a serious lapse in care and documentation at the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Tonawanda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Wheatfield | 2.5 mi | ★★★★★ | 0 | 0 |
| Degraff Memorial Hospital-skilled Nursing Facility | 3.1 mi | ★★★★★ | 1 | 0 |
| Rosa Coplon Jewish Home And Infirmary | 5.5 mi | — | 0 | 0 |
| Schofield Residence | 5.7 mi | ★★★★★ | 0 | 0 |
| Elderwood At Grand Island | 6.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.