F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review the facility failed to ensure that all alleged violations involving abuse were
reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the
allegation involved abuse, to the administrator of the facility and to other officials including to the State
Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State
law through established procedures for 2 of 4 residents (Residents #1 and #2), reviewed for freedom from
abuse, neglect, and exploitation.
1. Facility failed to report incident of suspected abuse from Monday 04/12/2025 when Resident #1 stated
she had been fondled by man.
2. Facility failed to report an incident of suspected physical abuse from Monday 04/12/2025 when Resident
#2 stated he had been hit by a female resident.
These failures could put the residents at risk of abuse, allegations of abuse not being reported immediately,
and could result in physical and psychosocial harm.
The findings were:
Record review of Resident #1's face sheet, dated 06/21/2025, revealed she was admitted on [DATE] and
the latest admission being 04/02/2025 with diagnoses which included: muscle weakness (generalized),
cognitive communication deficit, and paranoid schizophrenia (subtype of schizophrenia characterized by
prominent symptoms of paranoia, including delusions and hallucinations, particularly those involving
persecution or conspiracy).
Record review of Resident #1's Quarterly MDS assessment, dated 06/05/2025, revealed the resident's
BIMS score was 15, which indicated intact cognitive impairment. The Quarterly MDS assessment further
revealed Resident #1 required substantial/maximal assistance (helper lifts or holds trunk or limbs and
provides more than half the effort) for sit to lying, chair/bed to chair transfer, was dependent (helper does all
of the effort. Resident does none of the effort to complete the activity) for toileting hygiene, upper body
dressing, and lower body dressing.
Record review of Resident #1's care plan, problem start date of 02/05/2025, revealed Resident #1 had a
problem of [Resident's name] has a hx of calling the police to report false allegations.
Resident record review of Resident #1's LVN progress notes, dated 04/12/2025, revealed Res. was heard
yelling out and crying in dayroom and res. was asked what wrong. Res. crying and mumble something
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
455804
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455804
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northgate Health and Rehabilitation Center
5757 N Knoll
San Antonio, TX 78240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
in low tone. Nurse was unable to hear and asked res. to speak up. Res. blurted out he put his hands on me
and tried to touch my breasts, he put his hands on me! Res. Was comforted and asked if she could wait
there so nurse could get help. Res. said she didn't want to leave the dayroom anyway. DON was walking
towards rosewood nurses' station when she was called and asked to come to dayroom to speak to res.
DON was made aware as she also repeated her statement about another res. to DON. Res. was asked by
DON if going to her room or nurses' station would help her feel safe. Res. agreed and went to nurses'
station then just a few min. later she asked to be taken to her room. Res. asked if I have to talk to the police,
will they come to my room? Nurse assured if needed they would be escorted to her room.
During an interview on 06/21/2025 at 12:30 PM Resident #1 stated Resident #2 put his hands on her body
and he fondled her. Resident #1 further stated he had only bothered her once.
Record review of Resident #2's face sheet, dated 06/21/2025, revealed he was admitted on [DATE] with
diagnoses which included: vascular dementia (a type of dementia caused by reduced blood flow to the
brain, often due to strokes or other conditions affecting blood vessels. This impaired blood flow damages
brain cells, leading to problems with memory, thinking, and behavior), unspecified severity, with other
behavioral disturbance, alcohol abuse, and generalized anxiety.
Record review of Resident #2's admission MDS assessment, dated 04/15/2025, revealed the resident's
BIMS score was 04, which indicated severe cognitive impairment. The Quarterly MDS assessment further
revealed Resident #2 was independent with toileting hygiene, upper body dressing, lower body dressing
and personal hygiene.
Record review of Resident #2's care plan, problem start date of 06/13/2025, revealed Resident #2 had a
problem of [Resident's name] presents with agitation and verbal behavioral symptoms and racial slurs
directed toward staff regarding smoke breaks.
Resident record review of Resident #2's progress notes, dated 04/12/2025, revealed Res. came from
dayroom and said, that lady is crazy, she just started hitting me for no reason, so I left and I'm not gonna
help her anymore. Res. said he was ok and just waiting to go smoke. DON gave instruction to have this res.
be moved to [NAME] (hall on opposite side of building) now. Res. and belongings were moved at this x.
During an interview on 06/21/2025 at 12:23 PM with Resident #2 stated he had never touched anyone, but
a lady had said he had once. Resident #2 stated she was crazy. Resident #2 did not recall having been hit
by another resident.
Record review of TULIP on 06/21/2025 revealed the facility had not made reports regarding Resident #1 or
Resident #2's allegations of abuse.
During an interview on 06/21/2025 at 3:58 PM the DON stated when she reviewed the LVN's note from
Resident #1's chart that it was the account from the LVN, but it was not the account of what she believed
happened. The DON stated she had passed the small dining room where Resident #1 was sitting and
spoke to the LVN. The DON reported after she spoke to the LVN she went to talk to Resident #1. The DON
stated Resident #1 was not distressed when they spoke Resident #1 did not report to her having been
touched and stated she was fine. The DON stated she did not think it was reportable because Resident #1
had a high BIMS and Resident #1 did not express anything to her. The DON further stated she did not feel
it should have been reported due it only being something the LVN had said and when she
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455804
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455804
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northgate Health and Rehabilitation Center
5757 N Knoll
San Antonio, TX 78240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
visited Resident #1, she did not mention it. The DON reviewed Resident #2's notes for 04/12/2025 and
stated Resident #2's allegation of being hit by another resident had not been reported to her and it was the
first time she was hearing abut it. The DON further stated she was not sure why Resident #2 was moved to
the other unit.
During an interview on 06/21/2025 at 4:30 PM the Administrator stated she was aware of the allegations
made by Resident #1. The Administrator stated if it was true, it should have been reported. The
Administrator stated according to the LVN's note there was no one in the room with Resident #1 and further
stated Resident #1 had a history of coming to her telling her that she saw things. The Administrator stated
she had not talked with Resident #1 regarding the alleged incident. The Administrator stated it had been
mentioned it was Resident #2, but it was not witnessed. The Administrator stated she did not think the LVN
had witnessed Resident #2 coming from the day room. The Administrator stated the two alleged incidents
regarding Resident #1 and Resident #2 had been related to each they would have been reported. The
Administrator stated Resident #1 had history of making allegations that were untrue and Resident #2 was
known to become upset and just say things. The Administrator stated they could have reported the alleged
incidents but there were no eyewitnesses, and Resident #2 couldn't tell if he was truly in the room. The
Administrator stated only the LVN would have been able to tell if she witnessed it. The Administrator stated
she was there the day of the alleged incidents however she did not hear any screaming. The Administrator
stated Resident #1 would sometimes sleep in the day room and would wake up startled.
During an interview on 06/21/2025 at 5:19 PM the LVN stated Resident #2 came to her while she was
standing at the medication cart and told her the woman was crazy and the woman had hit him then further
told her this would be the last time, he tried to help the woman. The LVN stated while Resident #2 was
talking to her she could hear a female yelling. The LVN stated she did go to talk to the female who was
yelling in the day room and Resident #1 told her a man had touched her all over. The LVN stated Resident
#1 was upset and had tears in her eyes. The LVN stated there was no one else in the room. The LVN stated
she had passed the day room prior to Resident #2 coming to her upset and reported both Resident #1 and
Resident #2 were in the day room with Resident #2 standing by a table and Resident #1 sitting in front of a
table like she normally did. The LVN further stated the two residents were not near each other when she
walked past the day room. The LVN stated she got the DON and stated Resident #1 told the DON the exact
thing she told the LVN and when Resident #1 would say the man touched her, she would motion to her
chest. The LVN stated Resident #1 was taken to her room and Resident #2 was moved to the other side of
the facility.
During an interview on 06/21/2025 at 5:52 PM the DON stated the residents BIMS was the determining
factor for reporting abuse allegations. The DON further stated she believed Resident #1's BIMS was a 15
and that she was not aware of Resident #2's allegation and further stated the note did not say who hit him.
During an interview on 06/21/2025 at 6:00 PM the Administrator stated she was aware of Resident #2's
allegation of being hit. The Administrator stated she did not receive report regarding Resident #2's
allegation of having been hit but she did see the nursing note. The Administrator stated when she spoke to
Resident #2, he did not remember anything regarding his having said he was hit by another resident. The
Administrator stated they could have reported the allegation Resident #2 had made and investigated it, but
it was just a statement made and there were no witnesses. The Administrator stated she guessed she could
have reported the allegations made by Resident #1 and Resident #2 with an unknown perpetrator to
HHSC. The Administrator stated regarding the facility's policy if a statement is made regarding alleged
abuse they will interview and get information to start the allegation
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455804
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455804
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northgate Health and Rehabilitation Center
5757 N Knoll
San Antonio, TX 78240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
(investigation). The Administrator stated by not reporting the alleged allegations could have led to a resident
being abused.
Review of the facility policy, Abuse/Reportable Events effective 1/10/2017, read: Policy: All residents have
the right to free from abuse, neglect, misappropriation of resident property, and exploitation .The facility will
provide and ensure the promotion and protection of resident rights. It is everyone's responsibility to
recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of
residents .that may constitute abuse or neglect in the facility. Prevention: All reports of abuse or suspicion of
abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will
be reviewed by the facility administrator and/or Abuse Preventionist with 24 hours of complaint. Appropriate
notification to state and home office will be the responsibility of the administrator. Identification: The facility
will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction
of the investigation based on a through examination of events. Opportunities to prevent abuse/neglect will
be managed accordingly. Any person having reasonable cause to believe an elderly or incapacitated adult
is suffering from abuse, neglect, exploitation must report this to the DON, administrator, and state. State law
mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly
and incapacitated persons. When suspected abuse, neglected, exploited, misappropriation of property
comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse
Preventionist or designee . Reporting: Facility employees must report all allegations of: abuse, neglect,
exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to
the facility administrator. The facility administrator or designee will report the allegation of HHSC. If the
allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the
allegation.
Event ID:
Facility ID:
455804
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455804
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northgate Health and Rehabilitation Center
5757 N Knoll
San Antonio, TX 78240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, and record reviews the facility failed to have evidence all allegations of abuse, neglect or
mistreatment were thoroughly investigated and documented for 2 of 4 residents (Resident #1 and Resident
#2) reviewed for abuse.
Residents Affected - Few
1. The Facility failed to ensure an allegation of Resident #1 being fondled by a man was thoroughly
investigated.
2. The Facility failed to ensure an allegation of Resident #2 having been hit by a female resident was
thoroughly investigated.
These failures could place residents at risk for abuse and neglect by not investigating allegations of abuse,
neglect, exploitation, or mistreatment.
The findings were:
Record review of Resident #1's face sheet, dated 06/21/2025, revealed she was admitted on [DATE] and
the latest admission being 04/02/2025 with diagnoses which included: muscle weakness (generalized),
cognitive communication deficit, and paranoid schizophrenia .( subtype of schizophrenia characterized by
prominent symptoms of paranoia, including delusions and hallucinations, particularly those involving
persecution or conspiracy.
Record review of Resident #1's Quarterly MDS assessment, dated 06/05/2025, revealed the resident's
BIMS score was 15, which indicated intact cognitive impairment. The Quarterly MDS assessment further
revealed Resident #1 required substantial/maximal assistance (helper lifts or holds trunk or limbs and
provides more than half the effort) for sit to lying, chair/bed to chair transfer, was dependent (helper does all
of the effort. Resident does none of the effort to complete the activity) for toileting hygiene, upper body
dressing, and lower body dressing.
Record review of Resident #1's care plan, problem start date of 02/05/2025, revealed Resident #1 had a
problem of [Resident's name] has a hx of calling the police to report false allegations.
Record review of Resident #1's psychiatry progress note dated 04/29/2025, revealed Resident #1's Patient
reveals: I'm alright. Appearance/behavior The patient did not appear uncomfortable. Patient was smiling.
The appearance was normal and decreased eye-to-eye contact was observed. Orientation: Orientation to
person, place, time and situation, Mood: The mood was euthymic. The affect was reactive. Affect is
appropriate. Thought Process were not impaired, and a thought disorder was not noted. The thought
content revealed no impairment.
Resident record review of Resident #1's LVN progress notes, dated 04/12/2025, revealed Res. was heard
yelling out and crying in dayroom and res. was asked what wrong. Res. crying and mumble something in
low tone. Nurse was unable to hear and asked res. to speak up. Res. blurted out he put his hands on me
and tried to touch my breasts, he put his hands on me! Res. Was comforted and asked if she could wait
there so nurse could get help. Res. said she didn't want to leave the dayroom anyway. DON was walking
towards rosewood nurses' station when she was called and asked to come to dayroom to speak to res.
DON was made aware as she also repeated her statement about another res. to DON. Res. was asked by
DON if going to her room or nurses' station would help her feel safe. Res. agreed and went
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455804
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455804
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northgate Health and Rehabilitation Center
5757 N Knoll
San Antonio, TX 78240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
to nurses' station then just a few min. later she asked to be taken to her room. Res. asked if I have to talk to
the police, will they come to my room? Nurse assured if needed they would be escorted to her room.
During an interview on 06/21/2025 at 12:30 PM Resident #1 stated Resident #2 put his hands on her body
and he fondled her. Resident #1 further stated he had only bothered her once.
Residents Affected - Few
Record review of Resident #2's face sheet, dated 06/21/2025, revealed he was admitted on [DATE] with
diagnoses which included: vascular dementia (a type of dementia caused by reduced blood flow to the
brain, often due to strokes or other conditions affecting blood vessels. This impaired blood flow damages
brain cells, leading to problems with memory, thinking, and behavior), unspecified severity, with other
behavioral disturbance, alcohol abuse, and generalized anxiety.
Record review of Resident #2's admission MDS assessment, dated 04/15/2025, revealed the resident's
BIMS score was 04, which indicated severe cognitive impairment. The Quarterly MDS assessment further
revealed Resident #2 was independent with toileting hygiene, upper body dressing, lower body dressing
and personal hygiene.
Record review of Resident #2's care plan, problem start date of 06/13/2025, revealed Resident #2 had a
problem of [Resident's name] presents with agitation and verbal behavioral symptoms and racial slurs
directed toward staff regarding smoke breaks.
Resident record review of Resident #2's LVN progress notes, dated 04/12/2025, revealed Res. came from
dayroom and said, that lady is crazy, she just started hitting me for no reason, so I left and I'm not gonna
help her anymore. Res. said he was ok and just waiting to go smoke. DON gave instruction to have this res.
be moved to [NAME] now. Res. and belongings were moved at this x.
During an interview on 06/21/2025 at 12:23 PM with Resident #2 stated he had never touched anyone, but
a lady had said he had once. Resident #2 stated she was crazy. Resident #2 did not recall having been hit
by another resident.
During an intervewi on 06/20/2025 at 10:50 PM CNA stated he remembered Resident #2 being placed on 1
to 1 observation for a few day and having been askekd to assist with the 1 to 1.
During an interview on 06/21/2025 at 3:58 PM the DON stated when she reviewed the LVN's note from
Resident #1's chart that it was the account from the LVN, but it was not the account of what she believed
happened. The DON stated she had passed the small dining room where Resident #1 was sitting and
spoke to the LVN. The DON reported after she spoke to the LVN she went to talk to Resident #1. The DON
stated Resident #1 was not distressed when they spoke Resident #1 did not report to her having been
touched and stated she was fine. The DON stated she did not think it was reportable because Resident #1
had a high BIMS and Resident #1 did not express anything to her. The DON further stated she did not feel
it should have been reported due it only being something the LVN had said and when she visited Resident
#1, she did not mention it. The DON reviewed Resident #2's notes for 04/12/2025 and stated Resident #2's
allegation of being hit by another resident had not been reported to her and it was the first time she was
hearing about it. The DON further stated she was not sure why Resident #2 was moved to the other unit.
During an interview on 06/21/2025 at 4:30 PM the Administrator stated she was aware of the allegation
made by Resident #1. The Administrator stated if it was true, it should have been reported. The
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455804
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455804
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northgate Health and Rehabilitation Center
5757 N Knoll
San Antonio, TX 78240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Administrator stated according to the LVN's note there was no one in the room with Resident #1 and further
stated Resident #1 had a history of coming to her telling her that she saw things. The Administrator stated
she had not talked with Resident #1 regarding the alleged incident. The Administrator stated it had been
mentioned it was Resident #2, but it was not witnessed. The Administrator stated she did not think the LVN
had witnessed Resident #2 coming from the day room. The Administrator stated the two alleged incidents
regarding Resident #1 and Resident #2 had been related to each they would have been reported. The
Administrator stated Resident #1 had history of making allegations that were untrue and Resident #2 was
known to become upset and just say things. The Administrator stated they could have reported the alleged
incidents but there were no eyewitnesses, and Resident #2 couldn't tell if he was truly in the room. The
Administrator stated only the LVN would have been able to tell if she witnessed it. The Administrator stated
she was there the day of the alleged incidents however she did not hear any screaming. The Administrator
stated Resident #1 would sometimes sleep in the day room and would wake up startled.
During an interview on 06/21/2025 at 5:19 PM the LVN stated Resident #2 came to her while she was
standing at the medication cart and told her the woman was crazy and the woman had hit him then further
told her this would be the last time, he tried to help the woman. The LVN stated while Resident #2 was
talking to her she could hear a female yelling. The LVN stated she did go to talk to the female who was
yelling in the day room and Resident #1 told her a man had touched her all over. The LVN stated Resident
#1 was not unclothed in anyway but upset and had tears in her eyes. The LVN stated there was no one else
in the room. The LVN stated she had passed the day room prior to Resident #2 coming to her upset and
reported both Resident #1 and Resident #2 were in the day room with Resident #2 standing by a table and
Resident #1 sitting in front of a table like she normally did. The LVN further stated the two residents were
not near each other when she walked past the day room. The LVN stated she got the DON and stated
Resident #1 told the DON the exact thing she told the LVN and when Resident #1 would say the man
touched her, she would motion to her chest. The LVN stated Resident #1 was taken to her room and
Resident #2 was moved to the other side of the facility. LVN stated she did do an assessment as much as
Resident #1 would allow with no discolorations or bruising noted. LVN further stated Resident #1 was
monitored for 72 hours for any changes.
During an interview on 06/21/2025 at 5:52 PM the DON stated the residents BIMS was the determining
factor for reporting abuse allegations. The DON further stated she believed Resident #1's BIMS was a 15
and that she was not aware of Resident #2's allegation and further stated the note did not say who hit him.
During an interview on 06/21/2025 at 6:00 PM the Administrator stated she was aware of Resident #2's
allegation of being hit. The Administrator stated she did not receive report regarding Resident #2's
allegation of having been hit but she did see the nursing note. The Administrator stated when she spoke to
Resident #2, he did not remember anything regarding his having said he was hit by another resident. The
Administrator stated they could have reported the allegation Resident #2 had made and investigated it, but
it was just a statement made and there were no witnesses. The Administrator stated she guessed she could
have reported the allegations made by Resident #1 and Resident #2 with an unknown perpetrator to
HHSC. The Administrator stated regarding the facility's policy if a statement is made regarding alleged
abuse they will interview and get information to start the allegation (investigation). The Administrator stated
by not reporting the alleged allegations could have led to a resident being abused.
Review of the facility policy, Abuse/Reportable Events effective 1/10/2017, read: Policy: All residents have
the right to free from abuse, neglect, misappropriation of resident property, and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455804
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455804
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/21/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northgate Health and Rehabilitation Center
5757 N Knoll
San Antonio, TX 78240
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
exploitation .The facility will provide and ensure the promotion and protection of resident rights. It is
everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect,
exploitation, mistreatment of residents .that may constitute abuse or neglect in the facility. Prevention: All
reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per
facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist with
24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the
administrator. Identification: The facility will identify and investigate events that may constitute
abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination
of events. Opportunities to prevent abuse/neglect will be managed accordingly. Any person having
reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, exploitation
must report this to the DON, administrator, and state. State law mandates that citizens report all suspected
cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. When suspected
abuse, neglected, exploited, misappropriation of property comes to the attention of any employee, that
employee will make an immediate verbal report to the Abuse Preventionist or designee . Investigation:
Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist.
Allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property
and injuries of unknown source will be investigated. After receipt of the allegation the Abuse Preventionist
and/or administrator will immediately evaluate the resident's situation using the criteria as stated in this
policy. Determination will be made for required reporting to HHSC reporting guidelines.
Event ID:
Facility ID:
455804
If continuation sheet
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