Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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 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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 160 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for North Gate Health Care Facility.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.