Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to deficiencies in respiratory care, specifically tracheostomy care and tracheal suctioning, for a resident requiring such care. The facility was evaluated for compliance with physician orders and professional standards of care.
Findings
The facility failed to provide appropriate tracheostomy care for Resident #1, including failure to change trach aerosol tubing, mask, nebulizer bottle, water trap, and trach ties as ordered, resulting in immediate jeopardy to resident health. Resident #1 was hospitalized with MRSA and brown emesis. The facility implemented a plan of correction including staff training and competency validation, and the immediate jeopardy was removed on 12/5/25, though the facility remained out of compliance at a lower severity level.
Deficiencies (1)
Failure to provide safe and appropriate respiratory care for a resident when needed, including not performing prescribed trach care such as changing trach aerosol tubing, mask, jet nebulizer bottle, water trap, and trach ties as ordered.
Report Facts
Dates of missed trach tie changes: 20
Dates of missed aerosol tubing changes: 20
Date Immediate Jeopardy identified: Dec 4, 2025
Date Immediate Jeopardy removed: Dec 5, 2025
Number of residents reviewed for tracheal care: 3
Number of additional residents with respiratory/tracheostomy care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Stated she suctioned Resident #1's trach and changed ties but did not document changing aerosol tubing |
| LVN B | Licensed Vocational Nurse | Performed trach care on Resident #1 on 11/23/25 but did not document; explained suctioning frequency |
| RN E | Registered Nurse | Demonstrated proper tracheostomy care and documentation during training on 12/5/25 |
| RT | Respiratory Therapist | Provided hands-on education, training, and competency validation for staff on tracheostomy care |
| DON | Director of Nursing | Oversaw trach care, acknowledged deficiencies, and participated in corrective action plan |
| ADM | Administrator | Notified of Immediate Jeopardy and its removal |
| FMD | Facility Medical Director | Reported on quality indicators and agreed with plan of removal |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 19, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide and document sufficient preparation and orientation of residents to ensure safe and orderly transfer or discharge, specifically for two residents reviewed for transfer, discharge rights, and discharge summary.
Complaint Details
The complaint investigation found that the facility did not complete required discharge summaries for two residents and failed to notify the ombudsman of their discharges. Interviews with staff including the Director of Nursing, LVN P, LVN M, and the Administrator confirmed these failures and acknowledged the risks posed to residents' continuity of care.
Findings
The facility failed to complete discharge summaries for two residents, CR #1 and CR #2, including missing documentation such as recapitulation of stay, physical assessment, discharge instructions, signatures, and notification to the ombudsman. This failure could place residents at risk of disruption in continuity of care.
Deficiencies (3)
Failure to complete discharge summary for resident CR #1, including missing recapitulation of stay, physical assessment, discharge instructions, and signatures.
Failure to complete discharge summary for resident CR #2, including missing recapitulation of stay and signatures.
Failure to notify the ombudsman of the residents' discharge as required by regulation.
Report Facts
Residents reviewed for transfer and discharge: 5
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN P | Licensed Vocational Nurse | Failed to complete discharge summary for CR #1 and commented on discharge summary responsibilities. |
| LVN M | Licensed Vocational Nurse | Failed to complete discharge summary for CR #2 and discussed discharge summary process. |
| Administrator | Facility Administrator | Acknowledged failure to notify ombudsman and the risks of incomplete discharge summaries. |
| DON | Director of Nursing | Explained discharge summary process and risks of non-completion. |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 39
Deficiencies: 5
Date: Jul 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in Resident #1.
Complaint Details
The investigation was triggered by a complaint regarding pressure ulcer care for Resident #1. The complaint was substantiated with findings of immediate jeopardy to resident health or safety due to failures in wound care and infection prevention.
Findings
The facility failed to ensure Resident #1 received proper wound care and implement physician's orders, resulting in the deterioration of a stage III pressure ulcer to a stage IV and subsequent hospitalization for sepsis. Staff training and communication failures contributed to inadequate wound care and monitoring.
Deficiencies (5)
Failure to minimize Resident #1's exposure to moisture and keep skin clean of fecal contamination.
Failure to implement wound care treatment orders leading to decline of wound from stage III to stage IV pressure ulcer.
Failure to ensure wound care orders were properly entered and followed by staff.
Inadequate training and supervision of wound care nurse and staff.
Failure of nursing staff to change saturated wound dressings timely.
Report Facts
Residents with wounds: 14
Skin assessments completed: 36
Direct care staff educated: 29
Resident #1 BIMS score: 7
Resident #1 Braden Scale score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Involved in wound care order management and staff supervision; last day 06/13/24. |
| WCN A | Wound Care Nurse | Received incomplete training; responsible for wound care and order implementation. |
| WCN B | Wound Care Nurse | Performed wound care prior to 06/14/24 and trained WCN A. |
| DON A | Director of Nursing | Started 06/24/24; followed up on wound care orders and staff education. |
| CNA A | Reported wound condition and resident symptoms; provided incontinent care. | |
| Nurse A | Performed skin assessments; unaware of wound deterioration. | |
| Nurse B | Performed readmission skin assessment; unaware of wound status. | |
| Nurse C | Provided wound care and education during in-service. | |
| Nurse D | Educated on wound policy and care during in-service. | |
| Nurse E | Educated on wound care and dressing changes during in-service. |
Inspection Report
Routine
Deficiencies: 2
Date: May 21, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to gastrostomy tube management and nutritional services, including menu adherence, at Garden Terrace Healthcare Center of Houston.
Findings
The facility failed to provide appropriate care for a resident with a gastrostomy tube, resulting in skin irritation and risk of infection. Additionally, the facility did not follow the posted menus for multiple meal services, potentially risking resident dissatisfaction and poor nutritional intake.
Deficiencies (2)
Failure to ensure appropriate care and services to prevent complications of enteral feeding for Resident #11, including addressing redness and dried drainage around the gastrostomy tube site.
Failure to ensure menus were followed for 3 meal services prepared for 36 residents, including lunch meals on 5/21/24 and 5/22/24 and dinner meal on 5/22/24.
Report Facts
Residents reviewed for gastrostomy tube management: 3
Residents affected by feeding tube deficiency: 1
Residents affected by menu deficiency: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Documented G-tube care and discussed dressing changes and redness around G-tube site |
| LVN A | Licensed Vocational Nurse | Administered medications via G-tube and discussed assessment and follow-up of G-tube site redness |
| RN D | Registered Nurse | Observed and assessed G-tube site redness and notified physician and wound care nurse |
| RN E | Weekend Treatment/Wound Care Nurse | Assessed G-tube site, noted hypergranulation and dried blood, and described wound care procedures |
| Medical Doctor | Physician | Evaluated G-tube site redness and cellulitis, discussed causes and need for timely notification |
| NP | Nurse Practitioner | Received calls regarding Resident #11 but not about G-tube exit site redness |
| DON | Director of Nursing | Described nursing responsibilities for G-tube care and documentation of skin changes |
| Interim Dietary Manager | Dietary Manager | Reported on menu management, staffing challenges, and efforts to improve menu adherence |
| [NAME] B | Kitchen Staff | Discussed meal preparation deviations from posted menu due to ingredient availability |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 1, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify providers of changes in condition, failure to administer medications timely and accurately, and failure to provide appropriate wound care and nursing competencies.
Complaint Details
The complaint investigation revealed failures in notification of changes in condition, medication administration errors and delays, inadequate wound care, and nursing competency issues.
Findings
The facility failed to notify the physician and resident representative of significant changes in condition for Resident #1, failed to administer medications timely and accurately including seizure and pain medications, failed to provide wound care timely for CR #1 resulting in worsening pressure ulcers, and failed to ensure nursing staff competency and proper documentation.
Deficiencies (5)
Failure to notify provider and resident representative of change in condition and medication availability for Resident #1.
Failure to provide appropriate wound care and timely orders for CR #1's surgical incision and sacral wound, resulting in worsening to a stage 3 pressure ulcer.
Failure to ensure nursing staff competency including medication reconciliation, administration, and pain assessment for Resident #1 and LVN A.
Failure to provide pharmaceutical services including timely administration of medications, accurate medication administration, and proper documentation for Resident #1 and CR #1.
Failure to maintain accurate and complete medical records for Resident #1, including inaccurate documentation of medication administration.
Report Facts
Missed or late medication administrations: 69
Wound size: 48
BIMS score: 13
BIMS score: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Admitting nurse for Resident #1, failed to reconcile medications, administer medications timely, assess pain, and document medication administration accurately. |
| NP A | Nurse Practitioner | Admitting NP for Resident #1, provided medication orders and expected nursing staff to notify her of pain and medication availability issues. |
| NP B | Nurse Practitioner | Provider for Resident #1, called in prescriptions for seizure medications after notification of unavailability, not notified timely of medication delays or resident condition changes. |
| DON | Director of Nursing | Responsible for nursing competency assessments and ensuring medication administration policies were followed; unaware of medication delays and resident condition changes prior to survey. |
| IP | Infection Preventionist | Notified of medication delays during survey, unaware of resident condition changes and medication unavailability. |
| LVN B | Licensed Vocational Nurse | Administered medications to Resident #1, did not notify providers of medication unavailability. |
| LVN C | Licensed Vocational Nurse | Admitting nurse for CR #1, did not remember wound care orders or staging wounds. |
| Wound Care MD | Wound Care Physician | Assessed CR #1's sacral wound, noted poor prognosis and inappropriate wound care orders initially. |
| Rehab Director | Rehabilitation Director | Notified late of Resident #1's decline in cognition and ADL performance. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 5, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide and document sufficient preparation and orientation to ensure a safe and orderly transfer or discharge for one resident with a stage III sacral wound.
Complaint Details
The complaint investigation found that the resident was discharged home without home health services arranged by the facility, no supplies were sent for wound care, and no teaching was provided to the resident's representative. The resident was subsequently hospitalized for a urinary tract infection. Interviews with staff and family confirmed these findings. The facility lacked documentation of an interdisciplinary discharge planning meeting.
Findings
The facility failed to arrange home health services for the resident upon discharge, did not provide necessary supplies or adequate teaching to the resident or family on wound care, and lacked documentation of discharge planning meetings. This failure placed the resident at risk for medical complications and unwanted re-hospitalization.
Deficiencies (1)
Facility failed to arrange home health services to evaluate and treat a resident with a stage III sacral wound upon discharge.
Report Facts
Residents reviewed for transfer or discharge: 8
Residents affected: 1
Date of admission: 2023
Date of discharge summary: 2023
Date of wound assessment: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Nurse on duty during resident discharge; provided teaching on wound care and medications but could not recall full details. |
| ADON | Assistant Director of Nursing | Interviewed regarding resident admission and discharge process; not present at discharge. |
| Wound Care Doctor | Physician | Provided care and assessment of resident's sacral wound; last saw resident on 08/21/2023. |
| Discharge Planner | Provided information on insurance issues and discharge planning process. | |
| Social Worker | Responsible for arranging DME and transportation; unable to recall home health agency name. | |
| DON | Director of Nursing | Interviewed about discharge process and coordination; unable to find documentation of discharge planning meeting. |
| Administrator | Administrator | Provided information on discharge policies and procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 25, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to ensure that residents requiring dialysis received appropriate dialysis care and services, specifically focusing on Resident #1 who missed scheduled dialysis treatments on 07/20/2023 and 07/22/2023.
Complaint Details
The investigation focused on Resident #1 who missed dialysis treatments on 07/20/2023 and 07/22/2023. The resident sometimes refused dialysis and had rescheduled appointments. The facility staff failed to communicate dialysis needs properly during shift changes, and the dialysis appointment was not entered into the computer system initially. Transportation was not arranged timely, and the dialysis center was not contacted effectively. Despite these issues, Resident #1 did not suffer negative health outcomes from missing treatments.
Findings
The facility failed to ensure Resident #1 received scheduled dialysis treatments, resulting in missed dialysis on two occasions. The missed treatments were due to communication and documentation failures among staff regarding dialysis scheduling and transportation arrangements. Resident #1 did not experience negative health outcomes from missing treatments, but the facility did not follow proper procedures to ensure dialysis care was provided as ordered.
Deficiencies (1)
Failure to provide safe, appropriate dialysis care/services for a resident who requires such services, resulting in missed dialysis treatments on 07/20/2023 and 07/22/2023.
Report Facts
Missed dialysis treatments: 2
Dialysis fluid removed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Admitting nurse for Resident #1 who documented dialysis information and was involved in communication failures. |
| RN B | Registered Nurse | Worked the shift after LVN A and failed to communicate dialysis needs to LVN C. |
| LVN C | Licensed Vocational Nurse | Worked the 6:00 a.m. - 2:00 p.m. shift on 07/20/2023, was unaware of dialysis needs due to lack of report and missing computer entry. |
| ADON | Assistant Director of Nursing | Interviewed regarding dialysis scheduling and staff education; responsible for notifying physician and educating staff on dialysis orders. |
| LVN D | Licensed Vocational Nurse | PRN nurse who attempted to coordinate dialysis and transportation for Resident #1 on 07/22/2023. |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 23, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on hand hygiene procedures followed by staff during dining services.
Findings
The facility failed to ensure proper hand hygiene by staff in the direct care of 2 residents during meal service, which could place residents at risk for cross contamination and infection. Observations and interviews revealed that a CNA did not sanitize or wash her hands between serving two residents' meals.
Deficiencies (1)
Failure to ensure hand hygiene procedures were followed by staff in the direct care of residents during meal service.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA/CNA 1 | Named in deficiency for failing to sanitize or wash hands between serving residents. | |
| ADON | Assistant Director of Nursing | Reported on infection prevention practices and staff education regarding hand hygiene. |
| CNA 2 | Reported on hand hygiene requirements during meal service. |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 22, 2023
Visit Reason
The inspection was conducted to assess compliance with medication storage security and infection prevention and control procedures at Garden Terrace Healthcare Center of Houston.
Findings
The facility failed to ensure that medication and treatment carts were secured when unattended, posing risks of medication loss and diversion. Additionally, staff failed to follow proper hand hygiene procedures during dining service, increasing risk of cross contamination and infection.
Deficiencies (2)
Medication and treatment carts in Hall B were left unlocked and unattended, contrary to facility policy, risking medication loss and diversion.
Staff member CMA/CNA 1 did not sanitize or wash hands between serving two residents, risking cross contamination and infection.
Report Facts
Medication carts observed: 5
Treatment carts observed: 3
Residents cared for off treatment cart: 5
Resident medication packets: 12
Residents affected by hand hygiene failure: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in finding for leaving treatment cart unlocked |
| LVN B | Licensed Vocational Nurse | Named in finding for leaving medication cart unlocked |
| DON | Director of Nursing | Provided statements on medication cart security expectations |
| Administrator | Facility Administrator | Provided statements on medication cart security and staff education |
| CMA/CNA 1 | Certified Medication Aide/Certified Nursing Assistant | Named in finding for failure to perform hand hygiene between residents |
| ADON | Assistant Director of Nursing | Provided statements on infection prevention and hand hygiene education |
| CNA 2 | Certified Nursing Assistant | Provided statements on hand hygiene requirements during meal service |
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