Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garden Terrace Healthcare Center Of Fort Worth during CMS and state inspections, most recent first.
Failure to Protect Resident PHI in Email Communications: The facility sent resident medical information by email to nonresidents for three residents without an authorization for release of information on file. The SW stated she emailed welcome letters, advance directive handouts, nondiscrimination notices, current orders, and outcome prediction information, and she did not encrypt the messages because some families had trouble opening email. The MRD stated an authorization had to be completed before resident personal information could be released, and the facility policy required confidential treatment of medical records and resident approval or refusal before release to an outside individual.
Care Plans Did Not Address Inability to Use Call Light: Two residents with dementia, cognitive impairment, and significant functional dependence had care plans that only referenced keeping the call light within reach or encouraging its use. Staff stated both residents could not use the call light, and the records did not include alternative interventions such as closer monitoring, sitters, or other individualized measures in the care plans.
Two residents in an LTC facility were at risk of infection due to improper IV and chemo port care. A resident's needleless connector was not changed as ordered, and the IV dressing was undated. Another resident's chemo port dressing was undated, and an LVN accessed it without proper PPE. Staff interviews revealed a lack of awareness and training on IV and port care procedures.
The facility failed to adhere to its oxygen therapy protocols, affecting three residents who required respiratory care. The humidifier water and oxygen tubing were not changed weekly as per policy, potentially compromising the residents' oxygen support and increasing infection risk. Staff interviews revealed inconsistencies in following the policy, with the DON acknowledging the oversight.
The facility failed to maintain medication rooms according to professional principles, with observations revealing inadequate lighting and improper temperature control in refrigerators, leading to frozen medications. Staff interviews indicated confusion about responsibilities for maintaining cleanliness and functionality, and the facility's policy on medication storage was not adhered to, risking compromised medication integrity.
The facility's kitchen failed to meet food safety standards, with staff not wearing hairnets, improper storage and labeling of food items, and personal food in the kitchen area. Dented cans were found in dry storage, and a fan was improperly blowing towards the food area. The Dietary Manager acknowledged these issues, which could lead to food-borne illnesses.
The facility failed to maintain an effective Infection Prevention and Control Program, as staff did not adhere to Enhanced Barrier Precautions and hand hygiene protocols. An LVN did not wear a gown while accessing a port and performing wound care on residents requiring EBP. A CNA failed to perform hand hygiene during meal service, leading to potential cross-contamination. Despite training, these lapses indicate non-compliance with the facility's infection control policies.
The facility failed to dispose of expired medications, including TB vaccines, which were found in a medication room without a specified year. The Regional Nurse noted vaccines are effective for 30 days, and the ADON stated that all nursing staff are responsible for checking expiration dates, with monthly checks by the pharmacist. Improper storage conditions were also a concern, as they could affect medication effectiveness.
A resident with a vegetarian preference was served a meal containing meat, contrary to her dietary needs. Despite staff awareness of her preferences, the meal tray was not checked for accuracy, leading to the resident receiving an inappropriate meal. Interviews with facility staff revealed procedural lapses in ensuring meal accuracy and honoring resident preferences.
The facility failed to maintain resident dignity during meal times in the memory care unit. Two residents with dementia and other conditions were assisted by staff who stood while feeding them, contrary to the facility's policy requiring staff to sit. Staff interviews revealed awareness of the policy but cited the need for mobility as the reason for standing.
A facility failed to provide adequate supervision and proper disposal of syringes, leaving them accessible to confused residents. A resident with dementia and behavioral disturbances was involved, and syringes used for anxiety medication were found in trash cans within reach of residents. Staff interviews revealed a lack of clarity on disposal responsibilities, posing a risk to residents.
The facility failed to secure medication carts, leaving them unlocked and unattended in both the secured unit and general population hall. Staff, including an LVN and the Medical Records Director, were observed leaving carts unsecured, contrary to facility policy. Interviews confirmed that carts should be locked to prevent unauthorized access by residents.
A resident with multiple health issues was found on the floor with a head injury, later diagnosed as brain bleeding. Despite being at high risk for falls, the facility did not report the incident as required, due to a misunderstanding of what constitutes a reportable event. The DON and Administrator failed to classify the injury as reportable, potentially risking uninvestigated injuries.
The facility failed to ensure proper maintenance and documentation of respiratory care equipment for several residents, leading to undated and improperly stored oxygen and CPAP tubing. This non-compliance with facility policies and procedures was observed in multiple instances and confirmed through interviews with residents and staff.
Failure to Protect Resident PHI in Email Communications
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential for 3 of 3 residents reviewed. For Resident #1, the record showed admission with cognitive communication deficit and mild cognitive impairment of uncertain etiology, and he was his own responsible party. The record contained no authorization for release of information, yet the social worker’s email list showed a nonresident name as the recipient for Resident #1’s information. Resident #2 was admitted and readmitted, was her own responsible party, and had diagnoses including cognitive communication deficit, personal history of TIA, and cerebral infarction without residual deficits. Her record also had no authorization for release of information on file, and the social worker’s email list showed a nonresident name as the recipient for Resident #2’s information. Resident #3 was admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, was his own responsible party, had no authorization for release of information on file, and the social worker’s email list showed a nonresident name as the recipient for Resident #3’s information. During interview and record review, the social worker stated she sent a welcome letter within three days and 7-day clinical information unless a specific date was determined, and that managed care residents received an outcome prediction and current orders were sent to the email on file. She stated she did not encrypt the messages because some families had difficulty opening email, and she was not aware of a family and/or resident signing a health release form. The surveyor observed an email sample containing a welcome letter, advance directive handout, notice of nondiscrimination, your rights in a nursing facility, current orders, and a home and community care transition prediction outcome with patient evaluation information, care needs at the NF/SNF, and anticipated discharge information. The MRD stated an authorization for release of information had to be completed before resident personal information could be released, and the facility policy stated each resident has the right to confidential treatment of medical records and may approve or refuse their release to an individual outside the facility.
Care Plans Did Not Address Inability to Use Call Light
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 2 residents whose assessments showed they were unable to use a call light. Resident #1 was admitted with diagnoses including unspecified dementia, generalized muscle weakness, heart failure, schizoaffective disorder, and anxiety disorder. Her quarterly MDS reflected that she was rarely or never understood, had short-term and long-term memory problems, moderately impaired decision-making, and was dependent on staff for all self-care and mobility functional abilities except for non-applicable items. Her care plan included an intervention to encourage her to use the call light for assistance, but it did not reflect her inability to use the call light or include alternatives. Resident #2 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, acute kidney failure, lack of coordination, cognitive communication deficit, memory deficit following stroke, and unspecified dementia. Her significant change MDS showed she was rarely or never understood, had functional limitation in range of motion in one upper extremity, and required substantial to maximal assistance or total dependence for most activities of daily living and transfers. Her care plan identified her as at risk for falls and stated her call light should be within reach, but it did not reflect that she was unable to use the call light or include alternative interventions. During interviews, RN, CNA, LVN, DON, and ADM staff stated both residents could not use their call lights because of cognitive decline or mental status, and staff relied on frequent checks, sitters, open doors, or other monitoring practices. The DON and ADM stated that alternative interventions should be included in the care plan when a resident cannot use a call light, and the facility policy stated that if a resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative. The care plans reviewed did not contain those alternative interventions for either resident.
Deficiencies in IV and Chemo Port Care Lead to Infection Risks
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids and care for two residents, leading to potential infection risks. Resident #81, a female with multiple diagnoses including E. coli bacteremia and Alzheimer's disease, did not have her needleless connector changed every seven days as per physician orders. Additionally, the IV dressing was not dated, and RN G did not disinfect the midline catheter before securing a green cap, which was done without the necessary needleless connector. This oversight was observed during a survey, and RN G admitted to not being aware of the missing connector during the morning IV medication administration. Resident #15, a male with esophageal cancer and chronic kidney disease, had a chemo port with an undated dressing. LVN F accessed the port without wearing a gown, violating enhanced barrier precautions meant to prevent infection. The facility's care plan for Resident #15 did not reflect the presence of a chemo port, and there were no physician orders for dressing changes or monitoring. LVN F acknowledged forgetting to wear a gown and stated the purpose of the precautions was to protect residents from infection. Interviews with facility staff, including the ADON, LVN I, and the DON, revealed a lack of awareness and training regarding the care and management of IV lines and chemo ports. The ADON and DON both emphasized the importance of dating dressings and using needleless connectors to prevent infections. However, there was confusion about the facility's policies and procedures, particularly concerning the handling of chemo ports and the responsibilities of LVNs versus RNs. The DON admitted to not knowing when the port dressing for Resident #15 was last changed and stated that the facility was not allowed to change the port dressing without specific orders.
Failure to Adhere to Oxygen Therapy Protocols
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents who required oxygen therapy, as observed during a survey. The deficiency involved not changing the humidifier water and oxygen tubing according to the facility's policy. Specifically, the humidifier water for Residents #18, #25, and #133 was not changed weekly as required, and the oxygen tubing for Residents #18 and #25 was not replaced weekly, as per the facility's guidelines. This oversight could potentially lead to residents receiving incorrect or inadequate oxygen support and increase their risk of infection. Resident #18, a male with heart disease, heart failure, and chronic obstructive pulmonary disease, was observed with oxygen tubing dated several months prior, and humidifier water with inconsistent dates. Resident #25, a male with acute respiratory failure and COVID-19, also had outdated oxygen tubing. Resident #133, a female with respiratory failure and asthma, had humidifier water with inconsistent dates. These observations indicate a failure to adhere to the facility's policy of changing oxygen supplies weekly. Interviews with facility staff, including LVNs and the DON, revealed that the responsibility for changing the oxygen supplies fell on the nursing staff, who admitted to not consistently following the policy. The DON confirmed that the humidifier water and oxygen tubing should be changed every Sunday and that it was unacceptable to alter dates on the humidification bottles without replacing them. The facility's policy, revised in October 2024, clearly stated that oxygen supplies should be changed weekly and labeled with the date of setup or change.
Medication Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure that medication rooms A and B were maintained according to accepted professional principles, which included proper labeling, storage, and temperature control of drugs and biologicals. Observations revealed that the refrigerator in medication room A was set at 30 degrees Fahrenheit, causing medications to freeze. The Regional Nurse confirmed that the sink in the room was not used, and handwashing required going across the hallway. In medication room B, the lighting was inadequate, making it difficult to see inside the refrigerator, which also had a temperature of 30 degrees Fahrenheit. Ice particles were observed in IV medication bags, and insulin and vaccine vials were stored in standing water. Interviews with staff, including the ADON and LVN I, highlighted a lack of clarity regarding responsibilities for maintaining the cleanliness and functionality of the medication rooms. The ADON acknowledged that freezing medications could alter their effectiveness, while LVN I stated that she would not administer compromised medications and would contact the pharmacy for replacements. The DON confirmed that all nurses were responsible for ensuring the proper functioning of the medication rooms and that temperatures were checked each shift. However, there was confusion about the process for reporting and addressing maintenance issues, such as broken lighting and malfunctioning refrigerators. The facility's policy on storage and expiration of medications emphasized the importance of storing medications under appropriate conditions and monitoring for moisture and condensation. Despite this, the facility failed to adhere to these guidelines, resulting in the potential for compromised medication integrity. The report did not mention any specific corrective actions taken to address these deficiencies, focusing instead on the observations and interviews that highlighted the issues.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Several staff members, including the Dietary Manager, were found not wearing hairnets, which is a requirement to prevent hair from contaminating food. Additionally, a staff member was seen with personal food items in the kitchen area, which is against the facility's policy due to the risk of cross-contamination. The Dietary Manager admitted to not being aware of the staff food in the preparation area and acknowledged that it was not allowed. In the dry storage area, food items were not properly dated, labeled, or securely stored. A bag of nacho chips was tied with plastic wrap and had an unclear date, and two cans of food were dented, which the Dietary Manager stated should not have been accepted at delivery. In the walk-in freezer, a package of sausage had an incomplete use-by date, and a bag of hush puppies was open and undated. The Dietary Manager mentioned that the staff responsible for dating and labeling were new and had been in-serviced on the correct procedures. Other issues included a metal container of melted fat on the gas stove that was not properly covered, a mop handle leaning against clean dishes, and a fan blowing towards the food area, which could lead to contamination. The Dietary Manager acknowledged these issues, stating that the fan should not have been blowing towards the food area and that the butter should not have been stored with foil. The facility's Food Safety policy and the U.S. Public Health Service Food Code were not followed, leading to potential risks of food-borne illnesses for residents.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions and inactions of staff members, which could lead to cross-contamination and infections among residents. Specifically, LVN F did not adhere to Enhanced Barrier Precautions (EBP) by failing to wear a gown while accessing a port on a resident with a feeding tube and esophageal cancer. This resident was on EBP due to dysphagia and required tube feeding. Additionally, LVN F did not wear a gown while performing wound care on another resident with stage 3 pressure ulcers, despite being trained on EBP. CNA J also failed to follow proper infection control protocols by not performing hand hygiene during meal service. After leaving one resident's room, CNA J did not sanitize hands before handling items for another resident, including placing a straw in a drink and mixing food. This lapse in hand hygiene occurred despite the CNA's awareness of the importance of infection control and the facility's training on the matter. Interviews with the ADON and DON revealed that staff had been in-serviced on EBP and hand hygiene, yet the observed deficiencies indicated a lack of adherence to these protocols. The facility's policies on Enhanced Barrier Precautions and Standard Precautions were not followed, as evidenced by the staff's failure to use personal protective equipment and perform hand hygiene as required.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not disposing of expired medications, which could potentially compromise the therapeutic benefits intended for the residents. During an observation of medication room A, expired TB vaccines were found with dates marked as 9/27 and 10/13, but without a specified year. The Regional Nurse acknowledged that vaccines are considered effective for 30 days and expressed concern about the potency of expired vaccines. In a phone interview, the Assistant Director of Nursing (ADON) stated that all nursing staff are responsible for ensuring medications are not expired, and that the pharmacist conducts monthly checks for expired medications. The ADON also noted that improper storage, such as freezing or exposure to moisture, could alter the medication's structure and effectiveness. The facility's policy requires staff to follow manufacturer guidelines for expiration dates and to monitor storage conditions, but these procedures were not adequately followed, leading to the presence of expired medications in the facility.
Failure to Honor Resident's Vegetarian Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodates resident allergies, intolerances, and preferences for a resident who was reviewed for food preferences. The resident, a female with a history of anemia, major depressive disorder, and hypertension, was served a lunch meal containing meat, which did not align with her vegetarian preferences. This incident was observed when the resident expressed dissatisfaction with the taste of the pasta due to the presence of meat, despite her meal ticket indicating a vegetarian preference. Interviews with the facility staff, including the dietitian, CNA, and dietary manager, revealed a lack of adherence to the resident's dietary preferences. The dietitian acknowledged the importance of honoring preferences and had previously discussed meal options with the resident. However, the CNA who delivered the meal did not verify the contents of the tray, despite being aware of the resident's vegetarian preference. The dietary manager confirmed that the meal served contained meat chunks, which should not have been included in the resident's meal. Further interviews with the facility's nursing and administrative staff highlighted procedural lapses in ensuring meal accuracy. The ADON and DON emphasized the importance of checking meal trays against dietary slips to prevent such errors. The administrator acknowledged the resident's right to have their food preferences honored and recognized the potential risks of not doing so. Despite having a policy in place to monitor food quality, the facility failed to ensure that the resident's dietary preferences were consistently met.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal times, as observed in the memory care unit. Specifically, two residents were assisted with their meals by staff members who stood while feeding them, contrary to the facility's policy that requires staff to sit while assisting residents with eating. Resident #1, who has a history of central dislocation of the right hip, dementia, mood disturbance, anxiety, and Alzheimer's disease, was observed being fed by RN A who stood next to him. Similarly, Resident #2, diagnosed with metabolic encephalopathy and Alzheimer's disease with late onset, was assisted by CNA B, who also stood while feeding him. Interviews with the staff involved revealed that they were aware of the requirement to sit while assisting residents with meals but chose to stand due to the need to move around the area quickly. RN A mentioned that the residents in memory care were not calm, necessitating his standing position to be able to respond promptly if needed. CNA B stated that he stood to facilitate moving between residents for assistance. The facility's policy on feeding a resident, revised in August 2023, clearly states that staff should sit to assist residents with eating, which was not adhered to in these instances.
Inadequate Supervision and Improper Disposal of Syringes
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident prescribed medication. Specifically, the facility did not ensure that RN A and CNA B provided proper supervision after leaving syringes in the trash can of the resident's room, which were exposed and within reach of confused residents. This oversight was observed in a secure unit's common area where a resident was seated in a recliner, and syringes used to apply medication were found in trash cans accessible to residents. The resident involved was a female with a primary diagnosis of subluxation of C4/C5 cervical vertebrae and unspecified dementia with behavioral disturbances. The care plan indicated potential verbal aggression related to dementia and ineffective coping skills. During an interview, CNA B acknowledged that the syringes were used to apply gel for anxiety, and RN A admitted not knowing who was responsible for disposing of the items. The MDS Coordinator confirmed the risk of residents retrieving syringes from the trash, which should have been disposed of in a designated container according to facility policy.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to properly secure medications in locked compartments, as observed with two medication carts, one in the secured unit and another in the general population hall. Both carts were found unlocked and unattended, with the key mechanism displaying a red mark indicating they were not secured. This was observed on multiple occasions, with staff members, including LVN V, leaving the carts unattended while performing other tasks such as taking a resident's blood pressure. The Medical Records Director also found and locked an unattended cart but was unaware of the facility's medication administration policy. Interviews with various staff members, including LVN V, LVN L, and the DON, confirmed that the medication carts should always be locked to prevent unauthorized access by residents. The facility's policy, as reviewed, mandates that designated staff maintain possession of the keys and ensure the carts are locked when out of visual range. Despite this policy, the carts were left unsecured, posing a risk of residents accessing and potentially consuming medications not prescribed to them.
Failure to Report and Investigate Resident Injury
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent neglect, resulting in an incident involving a resident who sustained a serious injury. The resident, a female with multiple diagnoses including spinal stenosis, muscle weakness, and cognitive communication deficit, was found on the floor by a family member. Despite the presence of a bump on her forehead and a subsequent hospital diagnosis of bleeding on the brain, the facility did not classify the incident as reportable. The Director of Nursing (DON) and the Administrator did not report the injury to the State agency within the required timeframe. The resident's care plan indicated she was at risk for falls due to her limited physical mobility and weakness, with interventions in place to assist with transfers and ambulation. However, the facility's response to the unwitnessed fall was inadequate. The resident's fall risk evaluation had identified her as being at high risk for falls, yet the facility did not thoroughly investigate the incident or report it as an injury of unknown source, as required by their policy. Interviews with facility staff revealed a misunderstanding of what constitutes a reportable event. The DON and Administrator believed the incident did not meet the criteria for reporting because the resident did not have a visible serious injury, such as a laceration. This misinterpretation of the facility's policy on incident and reportable event management led to a failure to report the injury, potentially placing residents at risk for uninvestigated injuries.
Failure to Properly Maintain and Document Respiratory Care Equipment
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not label and date the oxygen tubing for five residents, and did not date or properly store CPAP tubing for three residents. These deficiencies were observed during multiple instances and interviews with the residents and staff, revealing a pattern of non-compliance with the facility's policies and procedures for respiratory care equipment maintenance and documentation. Resident #1, a male with chronic obstructive pulmonary disease and chronic respiratory failure, was observed with undated oxygen tubing and a nasal cannula. He reported that the tubing was changed regularly but was not dated recently. Similar observations were made for Resident #3, who had a history of stroke and required extensive assistance. His oxygen and CPAP tubing were undated and improperly stored. Resident #5, a female with pneumonia and heart disease, also had undated oxygen tubing and was unaware of when it was last changed. Resident #7, a male with chronic respiratory failure and obstructive sleep apnea, had undated and improperly stored CPAP tubing, and his nasal cannula tubing was dated inconsistently with the facility's records. Resident #9, a male with congestive heart failure and pneumonia, was observed with undated oxygen tubing. Interviews with the residents and staff, including the RN and DON, confirmed that the facility's practice of changing and dating respiratory equipment was not consistently followed, leading to potential risks of infection and inadequate respiratory care for the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cityview Nursing And Rehabilitation Center | 0.3 mi | ★★★★★ | 12 | 0 |
| Mira Vista Court | 0.9 mi | ★★★★★ | 2 | 0 |
| Ignite Medical Resort Fort Worth, Llc | 1.1 mi | ★★★★★ | 17 | 0 |
| Wedgewood Nursing Home | 1.3 mi | ★★★★★ | 16 | 0 |
| Ft. Worth Southwest Nursing Center | 1.7 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.