Garden Terrace Healthcare Center of Houston

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident's bedside was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 2 of 5 residents (Residents #2 and #3) reviewed for call lights. The facility failed to ensure Resident #2 and Resident #3's call lights were within reach. This failure could place residents at risk of not being able to request and receive prompt medical care and result in injury and harm.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan met professional standards of quality for 1 of 5 residents (Resident #4) reviewed for services provided. The facility failed to ensure the Dietician recommended Med Pass (a nutritional supplement to prevent weight loss) on 07/15/2026 for Resident #4 was put into place. The recommendation was not implemented until 07/21/2026. This failure could place residents at risk of delayed treatment and a decline in weight and physical health.

Inspectors wroteBased on interview and record review the facility failed to maintain, in accordance with accepted professional standards and practices, medical records on each resident that were complete and accurately documented for 1 of 5 residents (Resident #68) reviewed for accurate records. 1. LVN A failed to document Resident #5's RP's conversation and concerns about Resident #5's health and reason for the RP's chest x-ray request for Resident #5 in the progress notes on 07/08/2026. 2. LVN A and LVN B failed to document communication between the facility and the x-ray company. These failures could place residents at risk of delayed treatment due to their condition not being tracked and monitored by staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #5) reviewed for comprehensive care plans. 1. Resident #5's care plan was not followed when he was transferred from his wheelchair to his bed with one-person assist and without a gait belt present on 05/22/2026 when he was care-planned for a two-person transfer with a gait belt. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #5) reviewed for accident hazards. -Resident #5 was transferred by CNA M with a one-person transfer and without a gait belt from wheelchair to bed on 5/22/26. This failure could place residents at risk of injury from unsafe transfers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident #5) reviewed for incontinent care. -CNA M and LVN G provided incontinent care for Resident #5 without changing gloves and sanitizing their hands in-between cleaning Resident #5's penis during wiping. These failures could cause residents to be at risk of urinary tract infection, pain, injury, poor hygiene, and hospitalization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records and safeguard medical record information against loss, destruction, or unauthorized use for 1 of 5 residents (Resident #2) observed for privacy. -RN V left Resident #2's empty blister pack on the medication cart which could be observed by anyone walking by on 05/22/2026. This failure could put residents at risk of their personal health information being exposed to unauthorized personnel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Resident #5) of 5 residents observed for infection control. -There was a breakfast tray left out in an open dining area on 05/21/2026 at 1:36p.m. -CNA M and LVN G provided incontinent care for Resident #5 without changing gloves and sanitizing their hands in-between cleaning Resident #5's penis and touching Resident #5's personal and physical environment and Resident #5's skin. These failures could have placed residents at risk by exposing them to care that could have led to the spread of infections, secondary infections, or communicable diseases. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered baseline admission care plan for 1 of 3 residents (Resident #2) reviewed for baseline care plans in that:-The facility failed to develop a baseline care plan with goals, interventions, treatments, and psychosocial needs within 48 hours of admission for Resident #2. This failure could have affected new admission residents by not having their individual, medical, functional, and psychosocial needs identified and could cause a physical or psychosocial decline in health. Record review of Resident #2's face sheet dated [DATE] revealed she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, and a system of medication records that enabled periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 1 of 3 residents (Resident #1) reviewed for pharmacy services, in that:The facility failed to ensure Resident #1's control count sheet matched with the actual Lacosamide liquid medication. This failure could have placed residents at risk of not receiving their adequate dose of medication and drug diversion.

Inspectors wroteBased 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. Specifically, the facility did not change the trach aerosol tubing, mask, jet nebulizer bottle, and water trap every Sunday on nights shift or change the trach ties every night shift on 10/11/25, 10/12/25, 10/13/25, 10/18/25, 10/19/25, 10/25/25, 10/26/25, 11/2/25, 11/3/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, 11/8/25, 11/9/25, 11/16/25, 11/23/25, 11/24/25, and 11/27/25. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide and document sufficient preparation and orientation of residents to ensure safe and orderly transfer or discharge from the facility for 2 of 5 resident (CR#1 and CR # 2) reviewed for transfer, discharge rights, and discharge summary. - LVN P failed to complete a discharge summary for CR #1 - LVN M failed to complete a discharge summary for CR #2. These failures could place residents at risk of disruption in the continuity of care.

Inspectors wroteBased 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. The facility failed to implement Resident #1's wound care treatment orders to a facility acquired wound to her sacral region, which led to the decline of the wound from a stage III to a stage IV pressure ulcer. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the menus were followed for 3 meal services prepared for 36 of 36 residents. The facility failed to ensure the menu was followed for the lunch meals on 5/21/24 and 5/22/24 and the dinner meal on 5/22/24. These failures could place residents at risk for dissatisfaction, poor intake, and/or weight loss.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding for 1 (Resident #11) of 3 Residents reviewed for gastrostomy tube management. The facility failed to address the redness and dried red drainage around Resident #11's stoma (skin and entrance to the stomach) at the G tube (gastrostomy tube) site (a surgically placed device to give direct access to the stomach for feeding, hydration and medicine). This failure could place residents with G-tubes at risk of pain, infection, decline in health and hospitalization.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. The resident was transferred to the hospital on [DATE] and never returned to the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care and the facility failed to provide care which included but not limited to assessing, evaluating, planning and implementing resident care plans and responded to resident needs for 1 of 1 residents (Residents #1) and 1 of 3 nurses (LVN A) reviewed for nurse competency. 1. The facility failed to ensure LVN A was trained to admit residents, reconcile medications, administer medications, and assess pain prior to providing nursing services. This failure could place residents at risk of receiving inadequate care and harm.

Inspectors wroteBased on interview, observation and record review the facility failed to, consult with the resident's physician; and notify, consistent with his or her authority the resident representative when there was a change in condition and a need to alter treatment significantly for 1 of 5 residents (Resident #1) reviewed for notification of changes. - The facility failed to notify the provider of an observed change of condition in Resident #1's OT and ST. - The facility failed to notify the provider when Resident #1's Clobazam and Lacosamide (anticonvulsant medications) were unavailable/had not been delivered from the pharmacy - The facility failed to notify the provider when Resident #1 reported experiencing pain during admission. These failure could place residents at risk of delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 7 residents (CR #1) reviewed for quality of care. - The facility failed to accurately enter and provide wound care to CR #1 surgical incision site and sacrum after admission for surgical aftercare on 08/03/23 and 08/04/23. This failure could place residents at risk of worsening of current wounds as well as infection. Findings 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. The resident was transferred to the hospital on [DATE] and never returned to the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 6 residents (Resident #1) whose records were reviewed for accuracy and completeness. - The facility failed to document medication administration to Resident #1 accurately by documenting administration of Clobazam 5 mg film when 10 mg tablets were given. These failures could place residents at risk of having incomplete or inaccurate records and inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility for 1 (CR #1) of 8 residents reviewed for transfer or discharge in that: -Facility failed to arrange home health services to evaluate and treat for CR #1 who had a stage III sacral wound and was discharged from the NF to home on [DATE]. This failure placed CR #1 at risk for medical complications and unwanted re-hospitalization.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments for one (Medication Cart Hall B) of five medication carts and one (Treatment Cart Hall B) of three treatment carts observed for storage of medications. The facility failed to ensure the Treatment Cart and Medication Cart for Hall B were secured when unattended. These deficient practices could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure hand hygiene procedures were followed by staff in the direct care of 2 of 2 residents (Residents #2 & #3) reviewed for infection control in that: CMA/CNA 1 did not sanitize or wash her hands after serving Resident #2 lunch. She proceeded to serve Resident #3 their lunch tray without any form of sanitation. This failure affected could place residents who required dining services at risk for cross contamination and infection.