Garden Terrace Healthcare Center of Fort Worth
7500 Oakmont Blvd, Fort Worth, TX 76132 · Tarrant County · 120 certified beds · avg 41 residents/day · certified since Dec 6, 1996
Part of chain: LIFE CARE CENTERS OF AMERICA (194 facilities, chain avg rating 3.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Dec 15, 2023 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 5, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 15, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 5, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 15, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 5, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (22)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 4, 2026 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Feb 12, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Jul 18, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jul 18, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 1, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Apr 1, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Feb 1, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Dec 15, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Dec 15, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 15, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 15, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Oct 12, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 12, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Oct 12, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 3 | J ▲ |
| 2024 | 12 | 0 | E |
| 2026 | 2 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $34,405.
| Date | Type | Amount / length |
|---|---|---|
| Dec 15, 2023 | Fine | $34,405 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.00 | 3.46 | 3.95 | top 15% in Texas; top 39% in the U.S. |
| Registered Nurse hours | 0.56 | 0.44 | 0.69 | top 20% in Texas; bottom 46% in the U.S. |
| Weekend total nurse staffing | 3.60 | 3.04 | 3.50 | top 14% in Texas; top 38% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.42 | 0.34 | 0.48 | top 23% in Texas; top 45% in the U.S. |
| Total nursing staff turnover (%) | 45.5 | 55.3 | 45.8 | top 35% in Texas; bottom 49% in the U.S. |
| RN turnover (%) | 33.3 | 54.6 | 42.9 | top 20% in Texas; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.26, RN 0.59, weekend 3.83. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Developers Investment Company INC | Organization | Direct Ownership Interest | NOT APPLICABLE | 03/10/1994 |
| Preston, Forrest | Individual | Direct Ownership Interest | NOT APPLICABLE | 03/10/1994 |
| Preston, Forrest | Individual | Indirect Ownership Interest | NOT APPLICABLE | 03/10/1994 |
| Abubakar, Barira | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/02/2023 |
| Abubakar, Barira | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/02/2023 |
| Butner, Nancy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/16/2018 |
| Butner, Nancy | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/16/2018 |
| Cross, Cindy | Individual | Corporate Officer | NOT APPLICABLE | 01/01/1997 |
| Davidson, Sarah | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/24/2025 |
| Davidson, Sarah | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/24/2025 |
| Davidson, Sarah | Individual | ADP of the SNF | NOT APPLICABLE | 03/24/2025 |
| Developers Investment Company INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/14/2006 |
| Fletcher, Todd | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/13/2024 |
| Henry, Terry | Individual | Corporate Officer | NOT APPLICABLE | 08/16/1999 |
| Lay, Lisa | Individual | Corporate Director | NOT APPLICABLE | 04/24/2017 |
| Lay, Lisa | Individual | Corporate Officer | NOT APPLICABLE | 02/09/2018 |
| Le, Quang | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2010 |
| Le, Quang | Individual | ADP of the SNF | NOT APPLICABLE | 03/24/2025 |
| Life Care Centers of America, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/1997 |
| Life Care Centers of America, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 02/27/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who on your staff manages IV therapy, and what training and monitoring is in place?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Cityview Nursing and Rehabilitation Center | 0.3 mi | Fort Worth, TX | ★★☆☆☆ | 1/5 | |
| Mira Vista Court | 0.9 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | |
| Ignite Medical Resort Fort Worth, LLC | 1.1 mi | Fort Worth, TX | ★★☆☆☆ | 1/5 | |
| Wedgewood Nursing Home | 1.3 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | |
| Ft. Worth Southwest Nursing Center | 1.7 mi | Fort Worth, TX | ★★★☆☆ | 2/5 | |
| Avir at Fort Worth | 2.0 mi | Fort Worth, TX | ★★☆☆☆ | 1/5 | abuse |
| Renaissance Park Multi Care Center | 2.2 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | |
| Benbrook Nursing & Rehabilitation Center | 2.5 mi | Benbrook, TX | ★☆☆☆☆ | 1/5 | abuse |
| Stonegate Nursing and Rehabilitation | 4.1 mi | Fort Worth, TX | ★★★★★ | 4/5 | |
| Arlington Heights Health and Rehabilitation Center | 4.7 mi | Fort Worth, TX | ★☆☆☆☆ | 2/5 | abuse |
| Ridgmar Medical Lodge | 5.2 mi | Fort Worth, TX | ★★☆☆☆ | 2/5 | |
| Willow Ridge Wellness & Rehabilitation | 5.7 mi | Fort Worth, TX | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 675650.