Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mason Creek Transitional Care Of Katy during CMS and state inspections, most recent first.
Incomplete Clinical Record and MAR Documentation: A resident with a suprapubic catheter, cognitive awareness, and multiple medical diagnoses had repeated blanks on the TAR for ordered catheter care and missing MAR documentation for PRN Tylenol and a one-time dose of Tizanidine. Nursing notes and staff interviews described the pain episode and medication administration, but the MAR and charting did not consistently reflect the care provided, and staff acknowledged that blanks should not be present and that undocumented care is considered not done.
The facility failed to adhere to food safety standards, with unlabeled and improperly stored food items found during a survey. Beef tips were left in a refrigerator without a date, and syrup and chips were found on the pantry floor. Milk prepared for residents was also unlabeled. These deficiencies could lead to foodborne illnesses.
A facility failed to implement a comprehensive care plan for a resident with multiple diagnoses, including a stage 4 pressure ulcer and osteomyelitis. Despite having a midline for IV treatment, there was no care plan for its care and monitoring. Staff interviews revealed communication and procedural breakdowns, with the MDS Nurse unaware of order changes and the NP admitting to order entry errors. The DON confirmed the lack of system orders, leading to the care plan not being updated.
A resident receiving IV antibiotics via a midline catheter did not have appropriate physician orders or care plans for catheter care and monitoring. The midline dressing was not changed per facility policy, and an LVN failed to follow proper aseptic technique during a dressing change. Staff interviews revealed communication and oversight issues in updating orders and care plans, placing the resident at risk of infection.
A resident received an incorrect dosage of a nicotine patch, and the patch was not rotated as required, due to Medication Aide A's error. The resident did not refuse the rotation, contrary to the care plan. The DON was unaware of the refusal and emphasized the importance of patch rotation to prevent skin irritation.
A Medication Aide failed to sanitize blood pressure equipment between uses on two residents, one with hypotension, dementia, Alzheimer's, and hypertension, and another with fatigue, dysphagia, gastro-esophageal reflux disease, respiratory failure, and hypertension. This oversight was observed during a medication pass and confirmed by the DON, highlighting a lapse in the facility's infection prevention and control program.
The facility failed to maintain an effective pest control program, leading to the presence of a roach in the kitchen during food preparation. Staff reported previous sightings and the facility had recently switched pest control companies due to ineffectiveness. The Facility Maintenance Director noted issues with the previous company's methods and implemented procedures for inspecting personal refrigerators brought by residents.
A resident with pulmonary fibrosis experienced a significant drop in oxygen saturation during physical therapy and a shower, leading to cardiac arrest and death. Despite family instructions to increase oxygen during exertion, the facility did not adjust the resident's oxygen levels, nor did they consult the physician when his condition changed. This failure to follow the facility's policy on significant change of condition contributed to the adverse outcome.
A resident with pulmonary fibrosis and oxygen dependence experienced a critical incident due to inadequate respiratory care at a facility. Despite family warnings, staff failed to adjust the resident's oxygen during exertion, leading to severe desaturation and loss of consciousness. The facility also failed to notify the physician of oxygen drops during therapy and inaccurately documented oxygen orders, contributing to the resident's critical condition and subsequent transfer to a hospital.
A resident with severe cognitive impairment was physically abused by an LVN after bumping into the LVN's foot with her wheelchair. The LVN reacted by forcefully pushing the resident's wheelchair back and engaging in an intimidating manner. The incident was captured on security footage, leading to the LVN's termination after an investigation confirmed the abuse.
Incomplete Clinical Record and MAR Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for one resident with a suprapubic catheter and multiple diagnoses including kidney and ureter disorders, muscle spasm, UTI, severe sepsis with septic shock, benign prostatic hyperplasia with urinary tract symptoms, malignant neoplasm of the left kidney, and hypothyroidism. The resident’s quarterly MDS showed a BIMS score of 15, indicating cognitive awareness, and he was coded as having a catheter and being incontinent of bowel. A physician order dated 1/15/2026 directed suprapubic catheter care every shift, including monitoring the insertion site and securing the catheter with a leg strap or anchor each shift. Review of the treatment administration record showed multiple blanks for the catheter care order on day shift for 4/1/2026, 4/2/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/15/2026, 4/16/2026, and 4/17/2026, and on night shift for 4/5/2026. The record also showed no documentation that PRN Tylenol 325 mg was given on 4/25/2026 in the morning, and no documentation that the one-time dose of Tizanidine 2 mg was given that same morning. A physician order dated 4/25/2026 directed Tizanidine 2 mg by mouth twice daily for muscle spasm, rigidity, and pain. Nursing documentation was inconsistent with the medication record. One RN documented that Tylenol was not effective, but there was no MAR or nurse’s note documentation showing the medication was administered. In interviews, the morning LVN, the night RN, and the NP each described that Tylenol had been given and was ineffective, and that a one-time dose of Tizanidine was ordered and then changed to twice daily; however, the MAR and notes did not reflect those administrations. Staff also stated there should be no blanks on the MAR and that if medication was not documented, it was not done. The facility policy on documentation stated the clinical record should be a concise account of treatment, care, response to care, signs, symptoms, and progress, and that complete history and present illness are required.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, food items were not properly labeled and dated, which is crucial for ensuring food safety and preventing foodborne illnesses. During an inspection of the walk-in refrigerator, a metal bowl containing beef tips was found without a date or item description. The staff member present, [NAME] A, was unaware of the contents of the bowl, and [NAME] B later identified it as beef tips marinated from a leftover dinner. The Dietary Manager confirmed that the beef tips were prepared for residents and should have been discarded after three days, but they were not labeled or disposed of as required. Additionally, the facility failed to maintain proper storage conditions in the dry food area. Observations revealed a bottle of syrup and a bag of chips on the floor of the walk-in pantry, which violates the facility's policy that food items should be stored at least six inches above the floor. [NAME] A, who was overseeing the kitchen at the time, admitted to not noticing the syrup and chips on the floor and was unsure how long they had been there. The Dietary Manager was also unaware of these items being on the floor, which could lead to contamination and attract pests. Furthermore, the facility did not ensure that milk prepared for the morning meal was properly labeled. Nine glasses of milk with lids were found on a tray without any labels, and [NAME] A acknowledged that the milk should have been labeled to track its freshness and prevent serving expired milk to residents. The Dietary Manager emphasized the importance of labeling to avoid serving outdated or expired food that could make residents sick. The facility's failure to label and properly store food items poses a risk of foodborne illness to residents.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, which included the necessary services to meet her highest practicable physical, mental, and psychosocial well-being. The resident, an elderly female, was admitted with multiple diagnoses, including a stage 4 pressure ulcer, dementia, and osteomyelitis. Despite having a midline inserted for intravenous treatment of osteomyelitis, there was no care plan in place to address the care and monitoring of the midline and bandage change. This oversight was identified during a record review and observation, where it was noted that the midline dressing had not been changed since its insertion. Interviews with facility staff revealed a breakdown in communication and procedure. The MDS Nurse stated that care plans were updated based on physician order changes, which she was not aware of due to the lack of notification. The NP admitted to possibly entering the order incorrectly and failing to notify the necessary staff. The DON acknowledged that the physician orders for monitoring and care were not in the system, which led to the care plan not being updated. The facility's policy required the interdisciplinary team to develop a comprehensive care plan, but this was not adhered to, resulting in the deficiency.
Failure in Midline Catheter Care and Monitoring
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, specifically in the care and monitoring of a midline catheter. The resident, an elderly female with multiple diagnoses including stage 4 pressure ulcer, dementia, and osteomyelitis, was receiving Piperacillin-Tazobactam via a midline catheter. However, there were no physician orders or care plans addressing the care and monitoring of the midline catheter, nor were there orders for the regular changing of the midline dressing. Observations revealed that the midline dressing was not changed according to the facility's policy, which required changes every 7 days. During a dressing change, a Licensed Vocational Nurse (LVN) did not follow proper aseptic technique, failing to clean the site with alcohol before using betadine, and did not clean in the correct circular motion. The LVN was unaware of the correct procedure and had not received recent training on midline dressing changes. Interviews with facility staff, including the Director of Nursing (DON) and the Nurse Practitioner (NP), indicated a lack of communication and oversight in updating physician orders and care plans. The NP admitted to possibly entering the order incorrectly, and the DON acknowledged that the necessary orders for monitoring and care were not in the system, leading to the care plan not being updated. This oversight placed the resident at risk of infection due to improper midline care and monitoring.
Incorrect Dosage and Patch Rotation Error in Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident. Specifically, Medication Aide A administered an incorrect dosage of a nicotine transdermal patch to a resident, giving 7mg instead of the prescribed 14mg. Additionally, the aide did not rotate the patch on the resident's body, which is necessary to prevent skin irritation. The resident's medical records indicated that he was care planned for refusing the rotation of the nicotine patch, but during an interview, the resident stated he never refused the rotation. The Director of Nursing (DON) was unaware of the resident's alleged refusal to rotate the patch and stated that the patches should be rotated to avoid skin irritation. The DON also mentioned that the facility's pharmacist visits once a month to observe medication passes and check medication carts. Medication Aide A acknowledged the mistake and stated the importance of following the six rights of medication administration. The facility's policy on medication administration requires verification of the medication and dosage schedule with the resident's MAR before administration.
Infection Control Deficiency Due to Unsanitized Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Medication Aide who did not sanitize blood pressure equipment between uses on two residents. The Medication Aide took the blood pressure of a resident with hypotension, dementia, Alzheimer's disease, and hypertension, and then proceeded to use the same equipment on another resident with fatigue, dysphagia, gastro-esophageal reflux disease, respiratory failure, and hypertension, without sanitizing the equipment in between. This oversight was observed during a medication pass and was confirmed through interviews with the Medication Aide and the Director of Nursing (DON). The Medication Aide acknowledged the requirement to sanitize resident care equipment after each use to prevent cross-contamination and infection but admitted to forgetting to do so. The DON confirmed that staff are expected to sanitize all resident care equipment to prevent cross-contamination and infections. The facility's policy on Infection Control Prevention & Control Program, revised in December 2023, outlines the importance of effective disinfection of equipment as part of the facility-wide effort to prevent infections.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in the kitchen where food was being prepared for residents. During an observation, a semi-large roach was seen crossing the wall and going behind a food mixer while a staff member was preparing food. The staff member acknowledged seeing roaches in the kitchen before, although not frequently, and reported the sightings to the Dietary Manager (DM), who then informed maintenance. The DM confirmed that pest control services were conducted every two weeks, and the facility had recently switched to a new pest control company due to the ineffectiveness of the previous one. Interviews with various staff members, including the Operations Manager (OM) and Facility Maintenance Director (FMD), revealed that the facility had been experiencing issues with roaches, spiders, and ants, which were not adequately addressed by the previous pest control company. The FMD noted that the previous company only applied pest control compounds outside the facility, which were not safe for indoor use. The facility had switched back to their original pest control company about a month prior to the survey, and no further pest sightings were reported since then. The FMD also mentioned that personal mini refrigerators brought in by residents were contributing to the pest problem, and a procedure was in place to inspect these refrigerators before they were placed in rooms. Staff were trained to report pest sightings immediately, and an in-service on pest control was conducted recently.
Failure to Consult Physician Leads to Resident's Death
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant change in the resident's physical condition. The resident, a male with a history of pulmonary fibrosis, diabetes mellitus type 2, and acute and chronic respiratory failure with hypoxia, experienced a significant drop in oxygen saturation during physical therapy and later during a shower. Despite the resident's family informing the staff that his oxygen levels needed to be increased during exertion, the facility did not adjust his oxygen levels accordingly. On the day of the incident, the resident was on 5 L/min of oxygen, as per the physician's orders. However, during physical therapy, his oxygen saturation dropped to 86%, and later, after a shower, it drastically fell to 53%, leading to loss of consciousness and cardiac arrest. The staff initiated CPR, and the resident was intubated and transferred to a hospital, where he later expired on hospice care. The facility's failure to notify the physician or seek medical guidance when the resident's condition changed significantly contributed to the adverse outcome. Interviews with staff and family members revealed that there was a lack of communication and understanding regarding the resident's oxygen needs during exertion. The facility's policy on significant change of condition was not followed, as the staff did not consult the physician when the resident's oxygen saturation levels dropped during therapy. This oversight placed the resident at risk of worsening condition and ultimately led to his death.
Failure to Provide Adequate Respiratory Care Leads to Resident's Critical Condition
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required continuous oxygen therapy, leading to a critical incident. The resident, who had a history of pulmonary fibrosis and was dependent on home oxygen, was admitted to the facility with an order for 5 L/min of continuous oxygen. However, during a shower, the resident's oxygen requirements were not adjusted despite family members informing staff that his oxygen needed to be increased during exertion. The facility did not monitor the resident's oxygen levels during the shower, resulting in a drastic desaturation to 53%, loss of consciousness, and the need for CPR and intubation. Additionally, the facility failed to notify the resident's physician or seek medical guidance when the resident experienced a drop in oxygen saturation during physical therapy. The resident's medical administration record (MAR) inaccurately documented his oxygen order, listing an incorrect flow rate. This lack of accurate documentation and communication with medical professionals contributed to the resident's critical condition. Interviews with staff revealed that the resident was on a portable oxygen tank during the shower, but there was no verification of the tank's fullness or proper functioning. The CNAs involved did not check the oxygen flow during the shower, and the resident's change in condition was not immediately addressed by calling a nurse. The facility's failure to ensure proper respiratory care and monitoring placed the resident at significant risk, ultimately leading to his transfer to an acute care hospital where he later expired.
Resident Abuse by LVN
Penalty
Summary
The facility failed to protect a resident from physical abuse by an LVN. The incident occurred when the resident, who had severe cognitive impairment due to dementia, bumped into the LVN while in a wheelchair. The LVN reacted by forcefully pushing the resident's wheelchair back and engaging in an intimidating manner, which included pointing a finger at the resident and slapping the resident's hand away when the resident raised it. The resident involved had a history of major depressive disorder, dementia, and anxiety disorder, which impaired her cognitive function and required extensive assistance with activities of daily living. The resident's care plan included specific communication strategies to address her cognitive impairments, such as using simple sentences and providing necessary cues. Despite these interventions, the LVN's response to the resident's behavior was aggressive and inappropriate. The incident was captured on the facility's security camera, which showed the LVN's aggressive demeanor towards the resident. The Director of Nursing reviewed the footage and confirmed the abusive behavior. The LVN was subsequently terminated following the facility's investigation, which substantiated the abuse. The deficiency was identified as past noncompliance with Immediate Jeopardy, indicating a serious breach in the facility's duty to protect residents from abuse.
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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 Katy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakmont Healthcare And Rehabilitation Center Of Ka | 0.9 mi | ★★★★★ | 2 | 1 |
| Falcon Point Post Acute | 2.3 mi | ★★★★★ | 9 | 0 |
| Solera At West Houston | 2.5 mi | ★★★★★ | 3 | 1 |
| Ignite Medical Resort Katy, Llc | 2.9 mi | ★★★★★ | 4 | 0 |
| Sterling Oaks Rehabilitation | 3.6 mi | ★★★★★ | 13 | 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.