Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Magnolia Crossing Nursing And Rehabilitation Cente during CMS and state inspections, most recent first.
Surveyors found that a CMA left multiple medications, including Aspirin, Zyrtec, Iron, Vitamin B-12, Cyanocobalamin, Eliquis, Metformin HCl, Hydroxyzine, Lisinopril, and Protonix, on top of a medication cart while the cart was unattended in a resident care area. The CMA reported being in a resident’s room at the time and acknowledged that medications should have been placed back inside the locked cart. Other staff, including another CMA, the ADM, the DON, and the NP, confirmed that facility policy requires all medications to remain secured in a locked cart when not in immediate use and that the cart must not be left unlocked or unattended.
A resident with severe cognitive impairment, Parkinson’s disease, epilepsy, and ID/DD was identified as receiving PASRR services, including a customized wheelchair and planned habilitation coordination, but the facility failed to submit the required NFSS request after an IDT meeting where OT for self-feeding and seating was recommended. The resident’s PCSP indicated specialized OT was not needed, while an OT evaluation documented skilled OT services focused on restoration and compensation, billed to Managed Care Part B rather than PASRR. An OT discharge summary noted the resident was not on PASRR as originally thought and that OT was held after benefits were exhausted. Interviews with the MDS nurse, DON, Regional MDS nurse, and administrator confirmed there was no evidence of an NFSS submission, and leadership acknowledged relying on non-PASRR-funded OT instead of requesting PASRR NFSS, contrary to regulatory requirements.
A resident with dementia, severe cognitive impairment, a history of falls, gait abnormalities, muscle weakness, and poor coordination required substantial/maximal assistance and one-person assist for transfers per the MDS and care plan. Video evidence showed a CNA repeatedly transferring the resident between bed and wheelchair without a gait belt, pulling the resident up by the hand without back support, failing to lock the bed, and abruptly seating the resident while the resident screamed, cried, and appeared to grimace. During one transfer from the restroom, the resident’s private area was exposed and the CNA again transferred the resident without a gait belt. The DON and therapy director stated gait belts should be used for transfers and that not using them could result in falls or injury, and facility policy required compliance with safe handling/transfer practices.
A resident with severe cognitive impairment and multiple medical diagnoses reported difficulty breathing to staff. Despite care plan requirements, an LVN failed to assess the resident's respiratory status or check vital signs when the concern was first raised, instead instructing staff to leave the room. The deficiency was confirmed through interviews, record review, and video evidence, showing a lack of immediate clinical assessment in response to the resident's reported symptoms.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it report the results of its investigation to the appropriate authorities as required.
Staff failed to follow infection control and hand hygiene procedures during care for two residents, including not washing hands after handling soiled linen and using gloves that had fallen on the floor. These actions were not consistent with facility policy and were confirmed by staff and leadership interviews.
A resident who was fully dependent on staff for care had soiled linens with dried fecal matter and food crumbs that were not changed for 8 days, despite repeated requests to CNAs. Staff interviews confirmed that linen changes were expected on shower or bed bath days, but this was not consistently performed, and observations confirmed the ongoing issue. Nursing and administrative staff acknowledged the requirement for clean linens and the facility's policy on resident rights to a clean environment.
A resident with severe cognitive impairment and total dependence for ADLs did not consistently receive scheduled bed baths as required by her care plan. Documentation showed missed bed baths on multiple scheduled days, and staff interviews revealed confusion about responsibilities and documentation procedures. The resident’s family reported that hygiene care was often only provided after their requests, and facility leadership confirmed that care was not consistently delivered or documented according to policy.
A CNA was observed sleeping while assisting a resident with severe cognitive impairment and dysphagia risk during a meal. The resident began coughing and signaled distress, but the CNA did not respond or provide supervision as required by the care plan. Other staff and a roommate confirmed the CNA's inattention, and video evidence showed the CNA repeatedly asleep during the feeding process.
Unsecured Medications Left Unattended on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to medication security and storage involving Medication Cart #1 on Hall A. During a complaint and incident investigation, observation of the cart at 9:38 a.m. showed four medication bottles and five blister packs left on top of the cart unsupervised, rather than secured inside the locked cart as required. The medications observed included Aspirin 81 mg chewable tablets, Zyrtec 10 mg tablets, Iron 325 mg tablets, Vitamin B-12 1,000 mg, Cyanocobalamin 500 mcg tablets, Eliquis 2.5 mg tablets, Metformin HCl 1,000 mg tablets, Hydroxyzine 25 mg tablets, Lisinopril 10 mg tablets, and Protonix 20 mg delayed-release tablets. These medications were not under direct supervision and were not stored in locked compartments as required by facility policy and professional standards. In an interview, CMA B acknowledged that she had been informed a picture was taken of her medication cart and, upon viewing it, stated she had been "moving too fast" and confirmed that medications should be placed inside the cart and locked before leaving it unattended. She reported that she had been in a resident’s room while the cart, with medications on top, was left unattended. Additional interviews with another CMA, the ADM, the DON, and the NP confirmed that medications are expected to be kept inside a locked cart when not in immediate use and that leaving medications on top of the cart unsupervised is contrary to facility policy dated 10/01/19, which states that the mobile medication cart is to ensure appropriate control and surveillance of medications and must not be left unlocked or unattended in resident care areas.
Failure to Submit NFSS and Implement PASRR-Recommended OT Services
Penalty
Summary
The deficiency involves the facility’s failure to coordinate PASRR-recommended services and to submit a Nursing Facility Specialized Services (NFSS) request within the required timeframe for a resident with significant cognitive and neurological impairments. The resident, an older female with Parkinson’s disease, epilepsy, cognitive communication deficit, and unspecified intellectual disabilities, had a BIMS score of 6 indicating severe cognitive impairment and was identified as receiving PASRR services related to ID/DD. Her care plan noted that a customized manual wheelchair was acquired through PASRR and that she would participate in habilitation coordination to establish a PASRR plan. A PASRR program spreadsheet showed that an IDT meeting occurred for this resident, but the PASRR department did not receive an NFSS service request for an OT assessment and OT services, despite the PASRR meeting resulting in a request for OT to address self-feeding and seating. The resident’s PCSP form indicated that specialized OT was not needed, while an OT evaluation and plan of treatment documented that she was receiving skilled OT services with a focus on restoration and compensation, paid by Managed Care Part B rather than PASRR funds. An OT discharge summary stated that the resident was not on PASRR as originally thought, so OT would be held, and listed the reason for discharge as exhausted benefits. Interviews with the MDS nurse, DON, Regional MDS nurse, and administrator revealed that no documentation of an NFSS submission could be produced, and the Regional MDS nurse acknowledged that OT services were provided under another payor source and that he did not see an NFSS request in the record. The DON stated the NFSS was not filed because the resident was already receiving OT services, which she believed were through PASRR. This failure to submit a complete and accurate NFSS request within 20 business days after the IDT meeting, as required by 26 TAC §554.2704(i)(7), and to incorporate PASRR recommendations into the assessment, care plan, and transition of care, constituted the cited deficiency.
Improper Transfer Techniques and Lack of Gait Belt Use During Resident Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide safe transfers and adequate supervision for a cognitively impaired resident with a history of falls, gait abnormalities, muscle weakness, and lack of coordination. The resident’s MDS dated 01/25/2026 documented severe cognitive impairment with a BIMS score of 4/15 and a need for substantial/maximal assistance for bed mobility, sit-to-stand, and transfers to a wheelchair. The care plan dated 03/29/2025 indicated the resident required one-person assistance for transfers. Video and photo evidence from 02/14/2026 showed CNA A transferring the resident without a gait belt on multiple occasions. At approximately 5:01 p.m., CNA A placed the wheelchair at the bedside, pulled back the covers, and used her right hand to grab the resident’s left hand to pull her up to a sitting position without supporting the resident’s back, during which the resident screamed and appeared to grimace. The bed was not locked and rolled slightly during this process. The same video sequence showed CNA A grasping the resident’s upper right arm by the bicep area, adjusting the resident’s blouse, and then transferring the resident from the bed to the wheelchair without a gait belt, with both appearing to struggle and the resident being assisted into the wheelchair abruptly and appearing to cry. Later, around 5:12 p.m., the video showed CNA A returning the resident from the restroom to the bedside with the resident’s upper body covered but without a brief, leaving the resident’s private area exposed. CNA A then transferred the resident from the wheelchair back to the bed without using a gait belt. Interviews with the Director of Therapy and the DON confirmed that staff were expected to use gait belts for transfers and that failure to do so could result in falls or injury. The facility’s “Safe Resident Handling/Transfers” policy dated 02/19/2025 stated that all residents require safe handling when transferred and that handling aids may include gait belts, and that staff are expected to maintain compliance with safe handling/transfer practices, which was not followed in this case.
Failure to Assess Resident Reporting Shortness of Breath
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including a history of stroke, heart failure, and severe cognitive impairment, reported difficulty breathing to staff. The resident's care plan specifically required monitoring and documentation of changes in breathing patterns and prompt reporting of abnormalities to a physician. On the evening in question, the resident verbally expressed to a Restorative Aide that she could not breathe. The aide notified an LVN, who, along with other staff, entered the room. The LVN questioned the resident about her symptoms and medication but did not perform an assessment or check vital signs, including oxygen saturation, as required by the care plan and professional standards of practice. The LVN then instructed staff to leave the room, and no immediate clinical assessment was performed at that time. Subsequently, a family member, observing the situation remotely, called the facility to express concern about the resident's breathing. Another nurse responded to the call, assessed the resident, and documented normal oxygen saturation levels and no signs of distress. The hospice nurse was also called and confirmed the resident was stable upon her arrival. However, the initial failure to assess the resident when she first reported difficulty breathing was corroborated by interviews with staff, the family member, and review of video footage. The Director of Nursing and the Administrator both acknowledged that the LVN did not follow protocol by failing to assess the resident's respiratory status when the concern was first raised. The facility's policy required staff to assess, evaluate, and respond to residents' needs, including performing necessary clinical assessments when a resident reports symptoms such as shortness of breath. The deficiency was identified based on the lack of immediate assessment and documentation when the resident expressed respiratory distress, despite clear care plan interventions and facility policy. This lapse was confirmed through interviews, record reviews, and video evidence.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly documents the failure to follow required reporting protocols.
Failure to Follow Infection Control and Hand Hygiene Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not following proper hand hygiene and infection control procedures during resident care. In one instance, a CNA entered a resident's room carrying soiled linen and trash from another room, removed her gloves, and did not wash her hands before providing care. The CNA acknowledged that she should have discarded the soiled items and gloves before entering another room and should have performed hand hygiene before and after resident contact. Facility leadership and the CNA both confirmed that these actions were not in line with facility policy and posed a risk of cross-contamination. In another case, an LVN was observed entering a resident's room, picking up gloves that had fallen on the floor, and then donning them to provide care, including administering water and checking blood sugar. The LVN did not discard the contaminated gloves or perform hand hygiene before or after providing care. The LVN later stated that the correct procedure would have been to discard gloves that fell on the floor and to wash hands before and after resident contact. The resident involved had multiple diagnoses, including dementia, diabetes, and mobility issues, and required regular blood sugar checks and assistance with care. Interviews with staff and facility leadership confirmed that the expectation was for all staff to follow hand hygiene protocols and not to use contaminated PPE. Facility policy required hand hygiene before and after resident contact and proper handling of soiled linen. The observed failures by both the CNA and LVN to adhere to these protocols resulted in a deficiency related to infection prevention and control for the residents involved.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
A facility failed to provide a safe, clean, and homelike environment for a resident who was dependent on staff for all activities of daily living due to severe cognitive impairment and functional quadriplegia. The resident's linens had not been changed for 8 days, and observations revealed dried fecal matter and food crumbs on the bedding. The resident reported having requested multiple CNAs to change his sheets, but staff did not return to complete the task after stating they needed assistance. The resident received bed baths on scheduled days, during which linen changes were supposed to occur, but this was not consistently done. Interviews with the resident's family member confirmed ongoing complaints about unchanged linens and unmet care needs. Staff interviews revealed that CNAs were responsible for changing linens, typically on shower or bed bath days, and were expected to document any refusals of care. However, there was a lack of follow-through, and the linen remained soiled despite the resident's requests and scheduled care routines. Observations on consecutive days confirmed that the condition of the linens did not improve. Nursing and administrative staff, including the interim DON and the administrator, acknowledged that linens should be changed on shower days and as needed, and that failure to do so could result in dignity issues and potential health concerns. The facility's resident rights policy emphasized the right to live in safe, decent, and clean conditions, which was not upheld in this instance.
Failure to Provide Scheduled Bed Baths for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with severe mental impairment and a need for assistance with personal care received scheduled bed baths as required. Record review showed that the resident, diagnosed with Alzheimer’s disease and always incontinent, was care planned to receive bed baths three times per week on specific days and shifts. Documentation revealed that bed baths were not provided or recorded on several scheduled dates over a 30-day period, despite the resident’s inability to perform activities of daily living independently. Interviews with staff indicated a lack of clarity and communication regarding which staff were responsible for providing and documenting bed baths for the resident. Certified Nursing Assistants (CNAs) expressed uncertainty about why the resident had missed scheduled bed baths, with some staff unaware of the resident’s care needs or relying on outdated shower sheets instead of the electronic Plan of Care (POC) system. The resident’s representative and family members also reported that bed baths were often only provided after they requested them, and they monitored care through a camera in the resident’s room. Facility leadership, including the Clinical Specialist, Interim DON, and Administrator, acknowledged that showers and bed baths should be provided and documented according to the POC. However, discrepancies in documentation and staff communication led to missed care. The facility’s policy required that care and services for activities of daily living, including bathing, be provided based on comprehensive assessment and resident needs, but this was not consistently followed for the resident in question.
CNA Fell Asleep During Feeding, Failing to Supervise Resident with Dysphagia Risk
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) fell asleep while providing feeding assistance to a resident with severe cognitive impairment and multiple medical conditions, including dementia, malnutrition, atrial fibrillation, osteoporosis, diabetes, and hypertension. The resident required supervision or touching assistance for eating and had recently been evaluated for dysphagia, with recommendations for close supervision during oral intake. Despite these needs, the CNA was observed on video footage sleeping in a chair next to the resident during lunch, with her eyes closed and head nodding, while the resident was left unattended. During the incident, the resident began coughing while the CNA remained asleep and did not respond to the resident's distress. The video showed the resident covering her mouth and waving her hand to indicate she did not want more food, but the CNA did not wake up or check on her. Another resident in the room attempted to alert the CNA by calling out, but the CNA only briefly woke up, smiled, and then resumed sleeping. The CNA's inattention persisted throughout the meal period, and she attempted to feed the resident again after waking, despite the resident's refusal. Interviews with staff and residents confirmed that the CNA fell asleep multiple times while assisting with feeding and failed to respond when the resident coughed. The resident's care plan required close supervision during meals, and the facility's policies emphasized the need for necessary services to maintain good nutrition and health. The failure to provide adequate supervision during feeding placed the resident at risk, as documented by the survey findings.
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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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Manor Of South Belt | 0.8 mi | ★★★★★ | 2 | 0 |
| Oasis At Pearland | 3.9 mi | ★★★★★ | 4 | 0 |
| The Suites Pasadena | 4.9 mi | ★★★★★ | 24 | 2 |
| Hca Houston Healthcare Southeast | 5 mi | — | 0 | 0 |
| Pasadena Post Acute | 5.4 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.