Irving, TX

Northgate Plaza

1-star overall rating with 1-star inspections with $55,697 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

2101 Northgate Dr, Irving, TX

(972) 255-4460

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

2003-05-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.45

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.85

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.68

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.99

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.31

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.49

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.23

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.26

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.55

CMS adjusted RN staffing hours

Adjusted total hours

3.63

CMS adjusted total nurse staffing hours

Case-mix index

1.13

Higher values indicate more complex resident acuity

RN turnover

86%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

85%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,726

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

Composite VBP score used to determine payment impact.

Payment multiplier

0.9803

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Performance 83.02% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

Baseline 3.34 hours · Performance 2.75 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.47%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 44 · Observed rate 11.36% · Lower 95% interval 7.38%
Discharge to community	55.9%	50.57% 5.3 pts better	No Different than the National Rate · Eligible stays 27 · Observed rate 48.15% · Lower 95% interval 39.11%
Medicare spending per beneficiary	1.18	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 47 · Denominator 47
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 47
Discharge self-care score	60.71%	53.69% 7 pts better	Numerator 17 · Denominator 28
Discharge mobility score	42.86%	50.94% 8.1 pts worse	Numerator 12 · Denominator 28
Pressure ulcers or injuries, new or worsened	4.26%	2.29% 2 pts worse	Numerator 2 · Denominator 47 · Adjusted rate 3%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 1
Staff flu vaccination coverage	54.97%	42% 13 pts better	Numerator 105 · Denominator 191
Discharge function score	60.71%	56.45% 4.3 pts better	Numerator 17 · Denominator 28
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.0%	97.1% 7.1 pts worse	93.4% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 86.5% · Q4 79.2% · 4Q avg 90.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	89.1%	97.9% 8.8 pts worse	95.5% 6.4 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 89.1%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.3% 3.3 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.8%	2.7% 0.9 pts better	11.4% 9.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8%
Percentage of long-stay residents who lose too much weight	2.7%	3.3% 0.6 pts better	5.4% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 6.5% · Q4 1.9% · 4Q avg 2.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	21.7%	18.9% 2.8 pts worse	19.6% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 20.0% · Q3 19.1% · Q4 22.6% · 4Q avg 21.7%
Percentage of long-stay residents who received an antipsychotic medication	12.1%	10.8% 1.3 pts worse	16.7% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 15.0% · Q3 14.3% · Q4 9.7% · 4Q avg 12.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	22.3%	15.4% 6.9 pts worse	16.3% 6 pts worse	Long Stay · 2024Q4-2025Q3 · Q3 13.2% · Q4 35.3% · 4Q avg 22.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	39.3%	16.1% 23.2 pts worse	14.9% 24.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q3 16.2% · Q4 55.8% · 4Q avg 39.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	16.0%	15.0% 1 pts worse	19.8% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 13.9% · Q3 13.9% · Q4 14.8% · 4Q avg 16.0%
Percentage of long-stay residents with pressure ulcers	6.2%	4.2% 2 pts worse	5.1% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.6% · Q3 6.6% · Q4 7.2% · 4Q avg 6.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	60.9%	89.7% 28.8 pts worse	81.7% 20.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 67.9% · Q2 68.2% · Q3 64.3% · Q4 37.8% · 4Q avg 60.9%
Percentage of short-stay residents who had an outpatient emergency department visit	17.1%	12.0% 5.1 pts worse	12.0% 5.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 20.6% · Expected 13.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.5%	1.5% About the same	1.6% 0.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 2.8% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	59.7%	88.0% 28.3 pts worse	79.7% 20 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 59.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.8%	25.9% 0.1 pts better	23.9% 1.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 26.5% · Expected 24.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-18 · Fire 2024-12-18

17 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-11-09 · Fire 2023-11-09

25 health deficiencies

Top issue: Quality of Life and Care (10 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2022-09-28 · Fire 2022-09-28

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-18

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-01-16

E · Potential for more than minimal harm 2024-12-18

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-01-16

F · Potential for more than minimal harm 2023-11-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-11-20

E · Potential for more than minimal harm 2023-11-09

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-12-28

E · Potential for more than minimal harm 2023-11-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-11-15

E · Potential for more than minimal harm 2023-11-09

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-11-15

F · Potential for more than minimal harm 2022-09-28

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-10-07

E · Potential for more than minimal harm 2022-09-28

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2022-10-07

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-11-25

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-11-25

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-11-25

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-11-25

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-11-25

F761 · Pharmacy Service Deficiencies

Health

Ensure 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.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-11-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-09

D · Potential for more than minimal harm 2025-08-07

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-08-08

E · Potential for more than minimal harm 2025-05-14

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-06-04

E · Potential for more than minimal harm 2025-05-14

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-06-04

D · Potential for more than minimal harm 2025-05-14

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-06-04

K · Immediate jeopardy 2025-03-28

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-04-21

E · Potential for more than minimal harm 2025-03-28

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2025-04-21

E · Potential for more than minimal harm 2025-03-28

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-04-21

F · Potential for more than minimal harm 2024-12-18

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-01-17

E · Potential for more than minimal harm 2024-12-18

F727 · Nursing and Physician Services Deficiencies

Health

Have 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.

Corrected 2025-01-17

D · Potential for more than minimal harm 2024-12-18

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-01-17

D · Potential for more than minimal harm 2024-12-18

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-01-17

E · Potential for more than minimal harm 2024-10-31

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-11-25

E · Potential for more than minimal harm 2024-10-31

F584 · Resident Rights Deficiencies

Health

Honor 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.

Corrected 2024-11-25

E · Potential for more than minimal harm 2024-10-31

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-11-25

E · Potential for more than minimal harm 2024-10-31

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-11-25

D · Potential for more than minimal harm 2024-10-31

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-11-25

D · Potential for more than minimal harm 2024-10-31

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-11-25

D · Potential for more than minimal harm 2024-10-31

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-11-25

D · Potential for more than minimal harm 2024-10-31

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-11-25

D · Potential for more than minimal harm 2024-10-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-25

D · Potential for more than minimal harm 2024-10-28

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-11-15

E · Potential for more than minimal harm 2024-09-19

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-10-01

D · Potential for more than minimal harm 2024-09-19

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-10-01

D · Potential for more than minimal harm 2024-09-19

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-01

D · Potential for more than minimal harm 2024-01-19

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-03-04

E · Potential for more than minimal harm 2023-11-09

F584 · Resident Rights Deficiencies

Health

Honor 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.

Corrected 2023-12-09

E · Potential for more than minimal harm 2023-11-09

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-12-09

E · Potential for more than minimal harm 2023-11-09

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2023-12-09

E · Potential for more than minimal harm 2023-11-09

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-12-09