Health inspection·November 13, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Record review of a screen shot of an email addressed to HHSC Complaint and Incident Intake, provided by Administrator B as evidence previous Administrator A attempted to report the incident revealed read in part: .Sent: Monday, October 30, 2023 10:33am I am submitting an initial reportable for our long-term care resident: [CR#1]. [CR#1] complained of right hip pain xrays were ordered and resulted on 10/27/2023 with a hip fracture . The email was sent three days after the incident. Residents Affected - Few Record review of TULIP (Texas Unified Licensing Information Portal) on 11/03/23 and 11/13/23 revealed no reported alleged incidents of Abuse or Neglect, injury of unknown origin having to do with CR#1. Record review of CR#1's progress note dated 10/27/2023 at 5:02am written by LVN B revealed read in part: .Resident c/o (R)Hip pain 7/10 medicated with Tylenol 325mg 2 tabs po given for comfort. T&R, incontinent care provided. Fluids encouraged for hydration. Will continue to monitor . Record review of CR#1's progress note dated 10/27/2023 at 10:47AM written by LVN A revealed read in part: .Resident c/o right hip and knee pain, assessed resident with no noted redness or bruising to right side, noted small hematoma to left forehead, resident denies pain to forehead, no sign of distress noted. Message sent to NP, awaiting call back. VS: 135/84, 69, 18, 97.5, oxygen sat 97%. Tylenol 325 MG two tabs prn given as Ordered . Record review of CR#1's Radiology reported dated Report Date: 10/27/23 at 2:23pm revealed read in part: .Conclusion: Acute intertrochanteric RIGHT femoral fracture as noted . Electronically signed by M.D at 10/27/23 at 2:23pm Record review of CR#1's progress note dated 10/27/2023 at 3:34pm written by LVN A revealed read in part: .Spoke with resident RP and informed her of x ray results and order to send the ER, said to let her know when resident leaves for the hospital and she will meet her there . Record review of CR#1's progress note dated 10/27/2023 at 3:45pm written by LVN A revealed read in part: .X-ray was done and resulted with fracture right humorous, sent result to NP and order obtained to sent resident to RP for evaluation and treatment. RP notified, DON and ADON also notified . Record review of CR#1's progress note dated 10/27/2023 at 5:33pm written by LVN A revealed read in part: .Resident was picked up and taken to ER via stretcher, report called to Nurse . Record review of CR#1's Other Events - SBAR: Physician/NP/PA Communication Tool and Progress Note Created by LVN A revealed read in part: .When Occurred: 10/27/2023 08:40 AM. When Recorded: 10/27/2023 07:27 PM. Short Description: Reported by ongoing nurse that resident was medicated for right hip pain in am, staff reported to this writer that resident c/o pain while she was getting dress, assessed resident and noted hematoma to left forehead, no bruising to right side, informed DON and message NP . In a telephone interview on 11/03/2023 at 2:34p.m., with the complainant, she said on 10/27/23 the complainant was notified that CR#1 woke up with pain in her hip area. The facility stated that they found her in bed this way and she did not experience a fall. The facility performed x-rays and discovered the resident had a fractured right hip. Resident was transferred to the hospital. The ER performed their own x-rays of CR#1's hip and discovered the fracture. On 10/28/23, CR#1 underwent surgery on her right hip at the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676333 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Crossing Nursing and Rehabilitation Cente 10800 Flora Mae Meadows Rd Houston, TX 77089 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and attempted interview on 11/03/2023 at 3:10p.m., revealed CR #1 was resting on hospital bed receiving oxygen via nasal cannula at 2 liters per minutes. Noted hematoma to left forehead. Resident mumbled for about 5 minutes while being interviewed and could not respond appropriate to the questions asked. In an interview on 11/03/23 at 3:30p.m., with RN AA, she said CR#1 was admitted to the hospital with hip fracture. CR#1 underwent surgery and was waiting to get placement. CR#1's RP did not wanted CR#1 to return to the nursing facility. In an interview on 11/3/23 at 4:16p.m., LVN K said the Administrator was facility's abuse coordinator. She said any allegations of abuse and neglect were to be reported to the DON and Administrator immediately. She said CR#1 was often seen transferring without assistance and ambulating without wheelchair. CR#1 resided in the memory care unit and had to be reminded to use her wheelchair. In an interview on 11/03/2023 at 4:32p.m., the DON said Administrator A was the facility's abuse coordinator. She said Administrator A was out of the facility today (11/03/23). She said Administrator A reported the incident via email to HHSC Complaint and Incident Intake because TULIP was not working. The DON said CR#1 resided on the memory care unit. Resident was unable to answer questions. She had a diagnosis of dementia, fall and abnormalities of gait and mobility. CR#1 had impulsive behavior of transferring without assistance and ambulating without wheelchair. The DON said it was brought to her attention that on the morning of 10/27/28 the resident was complaining of pain to right hip. Resident was further assessed for any pain or discomfort. The DON said she asked staff if the resident had a fall and the night nurse told her that when the staff were getting resident up for the morning CR#1 complained of pain. Physician was notified of pain, and orders received for x-ray to be completed. X-ray for resident resulted in right femoral fracture. New orders were given to send resident to hospital for further evaluation and treatment. In a telephone interview on 11/13/23 at 11:54p.m., with LVN A, she said CNAs brought it to her attention that CR#1 was complaining of pain. She said during shift report the night shift nurse (LVN B) reported that CR#1 was complaining of hip pain, and she had administered Tylenol. LVN A said when she assessed CR#1 there was no noted redness or bruising to the right side. She said she noted a small hematoma to left forehead, resident denied pain to the forehead. LVN A said she notified the NP and received orders for x-ray. X-ray was done and resulted with right hip fracture and CR#1 was sent to the hospital. LVN A said resident had dementia and had to be reminded to use her wheelchair when ambulating. In a telephone interview on 11/13/23 at 12:34p.m., with LVN B, she said CR#1 slept most of the night. She said towards the end of the shift when making the last rounds CR#1 complained her leg was hurting. She said she administered pain medication and notified the oncoming nurse. She said there were two staff on the memory care unit at all times. In an interview on 11/13/23 at 1:05p.m, with CNA RR and SS. CNA SS said they worked 6am-2pm shift at the facility's memory care unit. CNA SS said CR#1 assisted with all ADLs. CNA RR said in the morning of 10/27/23 CR#1 could not stand up. CR#1 was fine the day before (10/26/23). CNA RR said they got CR#1 dressed and notified LVN A. CNA SS said CR#1 was a fall risk. CR#1 had to be reminded to use her wheelchair. In an interview on 11/13/23 at 1:54p.m., with Administrator B, she said she started working last week at this facility. She said she went through previous Administrator A email and found an email (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676333 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Crossing Nursing and Rehabilitation Cente 10800 Flora Mae Meadows Rd Houston, TX 77089 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm that was sent on 10/30/23 to the HHSC complaint and incident intake for CR#1. When asked what was the process for ensuring ANE policy was followed and how do they ensure allegations of ANE/injuries of unknown injury were reported. Administrator B said as soon as you get the results back. Injury of unknown, sent them out and should start investigating. She said the facility investigated and submitted the 3613a on 11/06/2023 under previously reported incident on a different resident. Residents Affected - Few In an interview on 11/13/23 at 2:41p.m., Surveyor reviewed email sent to HHSC Complaint and Incident intake dated 10/30/2023 with Administrator B and explained that the incident with CR#1 occurred on 10/27/23 as stated by the previous Administrator A on the email. Which was reported 3 days late and there was no follow up email/communication after the initial email sent on 10/30/23. Administrator B said TULIP had been having issue since last month. She said, but you can pick up a phone and report. Maybe the previous Administrator was a new Administrator. Record review of form 3613-A Provider Investigation Report dated 11/04/23 signed by the DON read in part: . the facility reviewed [CR #1] incident to determine contributing risk factor, evaluate continued care, and implementing interventions to include assuring bed is in lowest position, frequent reminders and rounding, fall mats at bedside. [CR#1] has been on therapy services prior to incident, OT from 8/14/23-9/18/23 and PT from 5/16/23- 7/6/23 with both disciplines showing signs of improvement. Resident to be evaluated to therapy services upon readmission. In-services for abuse and neglect, and fall prevention initiated an on-going for all staff completion . Record review of facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy (Revised September 2022) read in part: .All reports of resident abuse (including injures of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; 3. :Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676333 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Crossing Nursing and Rehabilitation Cente 10800 Flora Mae Meadows Rd Houston, TX 77089 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 4 of 4 resident's (Resident #1, #2, #3, #4) reviewed for PASRR. -The facility failed to submit authorization of PASRR Habilitative Services for Resident#1, #2, #3, #4. This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner. Findings included: Resident#1 Record review of Resident #1's face sheet, undated indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone) and anemia (a condition in which the blood doesn't have enough healthy red blood cells). Record review of Resident#1's Quarterly MDS assessment dated [DATE] revealed BIMS score of 03 out of 15 indicating severely impaired cognitively. She required extensive assistance from two-person physical assist with transfer, dressing, toilet use and personal hygiene. Record review of Resident#1's Care plan dated 03/17/2017 and revised on 12/14/2022 revealed the following: Focus: PASRR [Resident#1] is a (+) PASRR for DD. Goal: Facility will follow PASRR recommendations and monitor for any changes through next review date 11/14/2023. Interventions: Facility will follow the recommendations for the specialized services that [Resident#1] is eligible for. Follow up with Local Authority for any information on additional services that are available to [Resident#1] through PASRR. Record review of Resident#1's PASRR Comprehensive Service Plan (PCSP) Form dated 09/07/2023 revealed read in part: .A3500. LA-IDD Specialized Services and Participation Confirmation: Annual SPT was held. Individual will get new assessment for Habilitative Speech Therapy and will continue with HB Coordination only. Individual had no need for other specialized services . In a telephone interview on 11/03/2023 at 3:45p.m., with the PASRR Habilitation Coordinator (HC) (an employee of The [NAME] Center for Mental Health and IDD Authority Services), she said Resident #1 has not received authorization of PASRR habilitative speech therapy and the Resident was not receiving authorized PASRR habilitative Speech Therapy. Reisdent#1's Annual PASRR meeting was held 09/07/2023 and new assessments to restart authorization of habilitative speech therapy was requested. Facility claimed to have been providing habilitative therapy services, last previous request was for 3 months that expired on 04/15/2023. The HC said she advised the facility was not authorized to provide services and educated them that requests must be inputted into the long-term portal (SIMPLE) which the facility was not doing. The HC said she also emailed the DOR and MDS nurse HHSC resources for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676333 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Crossing Nursing and Rehabilitation Cente 10800 Flora Mae Meadows Rd Houston, TX 77089 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Nursing Facility to complete requests on how to email HHSC support for assistance. The HC said facility did not attempt to submit Specialized Services that was requested in the 09/07/2023 SPT meeting. The SPT held a update meeting on 09/21/2023 due to facility failure to meet critical date to get specialized services request submitted within 20 business days. The HC said the facility submitted request 09/21/2023 received denial of request on 09/25/2023, due to wrong submission type 'new'. The HC said the facility missed the 7 day critical response time. The facility submitted 'restart' request on 10/04/2023, and received denial on 10/17/2023 due to no signature page and HHSC notes indicated facility had until 10/25/2023 to submit corrections. The HC said facility missed another critical date. The HC said the facility was out of compliance with PASRR critical dates for getting authorization for services and failing to provide authorized PASRR Habilitative Speech Therapy services for Resident#1. Resident#2 Record review of Resident #2's face sheet, undated indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Aphasia (a language disorder that affects a person's ability to communicate), Leukemia (a cancer of blood-forming tissues, hindering the body's ability to fight infection) and Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident#2's Quarterly MDS assessment dated [DATE] revealed BIMS score of 00 out of 15 indicating severely impaired cognitively. She required extensive assistance from one-person physical assist with transfer, dressing, toilet use and personal hygiene. Record review of Resident#2's Care plan dated 11/07/2018 and revised on 12/14/2022 revealed the following: Focus: [Resident#2] has been identified as having PASRR positive status related to an developmental disability. Goal: [Resident#2] will maintain the highest level of practicable well-being through the review date 10/10/2023. Interventions: Facility will follow the recommendations for the specialized services that [Resident#2] is eligible for. Record review of Resident#2's PASRR Comprehensive Service Plan (PCSP) Form dated 9/21/23 revealed read in part: . A3300. Local Authority Comments: Update meeting held due to NF failed to get new assessments for habilitative PT completed and uploaded for services to be authorized and started . In a telephone interview on 11/03/2023 at 3:45p.m., with HC, she said Resident#2's Annual PASRR meeting was held 08/23/2023, new assessments to restart authorization of habilitative speech therapy was requested. The facility claimed to have been providing habilitative therapy services, last previous request was for 1 month that expired 04/11/2023. The HC said she advised the facility was not authorized to provide services and educated them that requests must be input into the long-term portal (SIMPLE) which the facility was not doing. The facility did not attempt to submit Specialized Services that was requested in the 08/23/2023 SPT meeting. The SPT held an update meeting on 09/21/2023 due to facility failure to meet critical date to get specialized services request submitted within 20 business days. The facility submitted request 09/21/2023 received denial of request on 09/25/2023, due to wrong submission type 'new'. The facility missed the 7 day critical response time. The facility submitted a 'restart' request on 10/04/2023 and received denial on 10/17/2023 due to invalid signature page. The HC said the facility has not submitted corrections and missed another critical date which was due by 10/27/2023. The HC said the facility was out of compliance with PASRR critical dates for getting authorization for services and failing to provide authorized PASRR Habilitative Speech (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676333 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Crossing Nursing and Rehabilitation Cente 10800 Flora Mae Meadows Rd Houston, TX 77089 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Therapy services for Resident#2. Level of Harm - Minimal harm or potential for actual harm Resident#3 Residents Affected - Some Record review of Resident #3's face sheet, undated indicated he was a [AGE] year-old male, admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included Sepsis (a life-threatening complication of an infection), Cerebral palsy (a congenital disorder of movement, muscle tone, or posture) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Record review of Resident#3's MDS assessment dated [DATE] revealed BIMS score of 03 out of 15 indicating severely impaired cognitively. He required total dependence from two-person physical assist with bed mobility, transfer, and toilet use. Record review of Resident#3's PASRR Comprehensive Service Plan (PCSP) Form dated 9/21/23 revealed read in part: .A3500. LA-IDD Specialized Services and Participation Confirmation- C. LA-IDD Specialized Services Comments-Annual SPT meeting was held. Individual will receive new assessment to establish OT services. Individual had no need for other services except Habilitation Coordination for ongoing monitoring. Individual will continue to be served in a NF setting . In a telephone interview on 11/03/2023 at 3:45p.m., with HC, she said Resident#3's Annual PASRR meeting was held 09/21/2023, new assessments to restart authorization of habilitative speech therapy was requested. Facility claimed to have been providing habilitative therapy services, last previous request was for 1 month that expired on 04/11/2023. HC said she advised facility not authorized to provide services and educated that requests must be input into long-term portal (SIMPLE) which the facility was not doing. HC said facility submitted request 09/21/2023 received, received error notice made corrections then received denial of request 09/22/2023, due to wrong submission type 'new'. Facility did not meet 7 day critical date to make corrections. Resident#3 was discharged to hospital end of September and returned on 10/18/2023. As of 11/01/23, facility failed to resubmit request for authorization as requested. HC said the facility was out of compliance with PASRR critical dates for getting authorization for services and failing to provide authorized PASRR Habilitative Speech Therapy services prior to Resident#3's hospitalization. Resident#4 Record review of Resident #3's face sheet, undated indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis(a disease in which the immune system eats away at the protective covering of nerves), schizoaffective disorder(a mental health condition including schizophrenia and mood disorder symptoms) and epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures). Record review of Resident#4's Quarterly MDS assessment dated [DATE] revealed BIMS score of 12 out of 15 indicating moderately impaired cognitively. He required total dependence from two-person physical assist with bed mobility, transfer, and toilet use. Record review of Resident#4's Care plan dated 8/17/23 revealed the following: Focus: Resident is considered PASRR positive due to a diagnosis of Mental Retardation (DD) and may require specialized services. Goal: Resident will have all identified needs met target date 11/7/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676333 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Crossing Nursing and Rehabilitation Cente 10800 Flora Mae Meadows Rd Houston, TX 77089 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Interventions: Habilitative services as indicated by PASARR meeting. Level of Harm - Minimal harm or potential for actual harm Record review of Resident#4's PASRR Comprehensive Service Plan (PCSP) Form dated 9/21/23 revealed read in part: .A3300. Local Authority Comments- Update meeting held because NF failed to get new assessments for habilitative OT services authorized and active. New Assessments are requested to get services implemented . Residents Affected - Some In a telephone interview on 11/03/2023 at 3:45p.m., with HC, she said Resident#4 has not received authorization of PASRR Habilitative Physical Therapy, and the individual is not receiving authorized PASRR habilitative Physical Therapy. The HC said Resident#4's IDT PASRR meeting was held 08/16/2023, new assessments to establish authorization of habilitative occupational therapy was requested. The facility did not submit the request from the 08/16/2023 meeting and an update meeting was held on 09/21/2023, due to facility missed the critical date for submission of 20 business days from IDT meeting. The HC said the facility submitted request 10/17/2023 and received denial on 10/27/2023 due to not submitting valid assessment with request. As of 11/01/2023 the facility has not resubmitted a request for specialized services. The HC said she had called, emailed and tried to assist this facility with getting within compliance with PASRR regulations but the facility consistently lacked follow-through measures, nor reached out to HHSC to proactively get assistance with issues or problems. The HC said this facility has a repeated cycle of lacking follow through and not taking PASRR critical dates and implementation of specialized services a priority. In an interview on 11/03/23 at 4:32 p.m., with the DON when asked whose responsible for ensuring the PASRR process was followed/completed at the facility the DON said the social worker, MDS Nurse and the Director of Rehab participated in the PASRR IDT meeting. She said she expected the PASRR process to be followed. She said the resident could decline as a result of not receiving her therapy services. Record review and interview on 11/13/23 at 11:06a.m., with RN/MDS Nurse. Surveyor reviewed Simple LTC portal (portal used to submit PASRR service requests), he said MDS in conjunction with therapy completed NFSS forms for PASRR positive residents to receive habilitative services. He said the authorization was rejected for Resident#1 because the form was submitted on the wrong side. Resident#4's was rejected because it needed more information on Section E1100. The RN/MDS nurse said it was brought to the facility's attention by PASRR HC in a meeting. RN/MDS nurse said corporate provided power point on NFSS process and created the action plan dated 10/13/23 because the NFSS PASRR forms were not being completed timely due to failure to identify rejections within the NFSS portal timely. In an interview on 11/13/23 at 1:34p.m., with Director of Rehab, she said she was responsible for the assessment portion on the NFSS form. She said Resident #1's initial submission was kicked back on 9/21/23 due to wrong submission type. She said a correction plan was initiated sometime in October 2023 that the MDS nurse was responsible for obtaining signature and uploading documents on Simple LTC portal. Record review and interview on 11/13/23 at 2:10p.m., with the RN/MDS Nurse. Surveyor reviewed Simple LTC portal (portal used to submit PASRR service requests). RN/MDS nurse said for Resident#4's authorization was submitted on 10/17/2023. He said on 10/19/23 they requested additional information on Section E1100. Facility missed the critical date for submission of 20 business days and received denial 10/27/2023 due to not submitting valid assessment with request. RN/MDS Nurse said the facility re-submitted authorization on 11/7/23 and as of today (11/13/23) authorization was on pending status. He said now the process was once the completed NFSS has been submitted, he was responsible to check (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676333 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Crossing Nursing and Rehabilitation Cente 10800 Flora Mae Meadows Rd Houston, TX 77089 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 the online portal daily for any updates and correct/provide any missing documentation as needed. Level of Harm - Minimal harm or potential for actual harm Record review of facility's admission Criteria (Revised March 2019) revealed read in part: .c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676333 If continuation sheet Page 9 of 9