Garden Terrace Healthcare Center of Houston

In the surveyor’s words

From the most serious findings on record at Garden Terrace Healthcare Center of Houston, in the surveyor’s own words.

• Immediate jeopardy, patternF695Dec 9, 2025

  Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preference for 1 (Resident #1) of 3 residents reviewed for tracheal care. The facility failed to follow physician orders for Resident #1 by not performing the prescribed trach care as ordered. […]

• Immediate jeopardy, patternF686Jul 10, 2024

  Based on interview and record review, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #1) of 5 residents whose records were reviewed for pressure ulcer care. 1. The facility failed to minimize Resident #1's exposure to moisture and keep the skin clean of fecal contamination, after the resident was discovered to have moisture associated skin damage to her sacral region. 2. […]

• Actual harm, patternF755Nov 1, 2023

  Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 2 of 6 residents (CR #1 and Resident #1) reviewed for pharmacy services in that: - The facility failed to administer pain medications to Resident #1 as ordered upon admission after the resident reported pain at 10 out of 10. - The facility failed to acquire and administer medications to Resident #1 as ordered upon admission, with some seizure meds not administered until 2 days after admission. […]

• Actual harm, isolatedF686Nov 1, 2023

  Based on interview and record review, the facility failed to provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 7 residents (CR#1) reviewed for pressure sores. -The facility failed to enter orders and provide wound care for CR #1's sacrum upon admission resulting in the resident going from shearing/redness to a stage 3 pressure ulcer. This failure could place residents at risk of worsening of current sores or the development of new pressure sores. Finding Included: Record review of CR #1's Face Sheet dated 10/25/23 at 11:42 AM revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: femur fracture and an encounter for orthopedic aftercare. […]

• Actual harm, isolatedF600Jun 25, 2021

  Based on record review and interviews, the facility failed to ensure one (Resident (R) 16) of seven residents reviewed for abuse was free of abuse in the facility. This failure caused R16 to experience fear and anxiety related to the incident that resulted in her seeking alternate placement, as well as severe pain that required hospitalization . Findings include: Record review of R16's 06/07/21 Admission Record, found in the Reports section of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with healing fractures of the left tibia (shinbone)left humerus (long bone of the arm), and left rib and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of R16's admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD)… […]