Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a resident received treatment and care in
accordance with professional standards of practice, the comprehensive person-centered care plan, and the
residents' choices for 1 (CR #1) of 5 residents reviewed for quality of care. The facility failed to perform an
assessment on CR #1 when she reported to have trouble breathing.This failure could place residents at risk
for a delay in treatment or diagnosis, a decline in the resident's condition and/or the need for hospitalization
and prolonged treatment.Findings included: Record review of CR #1's face sheet dated 10/28/25, revealed
an [AGE] year-old female admitted to the facility with an initial admission date of 2/4/25 and readmitted on
[DATE]. Diagnoses included: nontraumatic intracerebral hemorrhage in brain stem (a stroke that occurs
when blood vessels in the brain rupture without any external trauma), dysphagia (difficulty swallowing),
shortness of breath, other specified symptoms and signs involving the circulatory and respiratory systems,
Stage 4 pressure ulcer, anemia (low levels of healthy red blood cells to carry oxygen throughout your body),
Type 2 diabetes, hypertension, atherosclerotic heart disease (the buildup of fats, cholesterol and other
substances in and on the artery walls), chronic combined systolic and diastolic heart failure, hemiplegia
and hemiparesis following cerebral infarction affecting left non-dominant side, and peripheral vascular
disease. Record review of the comprehensive MDS dated [DATE] indicated CR #1 had a BIMS score of 6
reflecting severe cognitive impairment. Record review of CR #1's care plan dated 8/22/25 indicated CR #1
had shortness of breath r/t perception or cognitive impairment. Interventions included: monitor/document
changes in orientation, increased restlessness, anxiety, and air hunger; monitor/document breathing
patterns, report abnormalities to MD: nasal flaring, respiratory depth changes, altered chest excursion, use
of accessory muscles, pursed-lip breathing or prolonged expiratory phase, increased anteroposterior chest
diameter; monitor/document/report breathing abnormalities to MD: bradypnea (abnormally slow breathing),
tachypnea (abnormally rapid breathing), hyperventilation, Kussmaul's respirations (deep and labored
breathing pattern), Cheyne-Stokes (alternating periods of rapid deep breathing followed by pauses in
breathing), apneusis (prolonged, gasping inhalations followed by short, inadequate exhalations), Biot's
respirations (alternating periods of rapid, shallow breaths and pauses in breathing); position resident with
proper body alignment for optimal breathing pattern. Review of video dated 8/21/25 at 8:56 pm, CR #1 was
lying in bed, bed was at 45-degree angle, the Restorative Aide entered the room and asked CR #1 what's
going on? CR #1 stated I can't hardly breathe. LVN A walked in the room and the Restorative Aide told LVN
A, CR #1 can't hardly breathe. MA D walked in the room followed by RN C. LVN A told CR #1 You have to
take your medicine. What's going on with you? Your family member just left. LVN A asked CR #1 Can you
take your medicine? CR #1 responded I will take my medicine. LVN A said, So what is the problem now, so
we can figure out what we need to do for you? CR #1 responded I do not know. LVN A then stated, Ok we
can talk later, you can bring the medicine. LVN A told
Residents Affected - Few
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
676333
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
12/01/2025
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
everyone in the room When she calms down, we can come back, let's go. Everyone exited the room. CR #1
was moaning. MA D came back in the room and brought CR #1 some water. MA D said to CR #1 I'm going
to sit you up a little bit. MA D then raised the head of the bed. CR #1 started moaning again. MA D then
lowered the bed. Record review of progress note dated 8/21/25 at 11:25 pm written by LVN B read in part
.CR #1's family member called facility with concerns about CR #1's breathing. LVN B went to CR #1's room
and checked the resident. O2 saturation was checked- O2 saturation 96% and 97% on room air. LVN B
repositioned resident and raised her head. This nurse asked CR #1 is that better and CR #1 stated yes
while shaking her head. CR #1 is not showing any s/s of distress at this time . Interview with the family
member on 10/30/25 at 10:10 am, she said CR #1 started having trouble breathing on the evening of
8/21/25. She said CR #1 told the Restorative Aide I can't breathe, so the Restorative Aide got the nurse.
The family member said MA D was trying to give CR #1 her medicine. The family member said LVN A went
into CR #1's room and started yelling at CR #1 to take her medication. LVN A said to CR #1 What is wrong
with you?. The family member said LVN A ordered everyone out of the room and did not take CR #1's vitals.
The family member said CR #1 was cognitive and was able to tell staff her needs. Interview with the
Hospice Nurse on 10/28/25 at 11:40 am, she said the family member called her on 8/21/25 at
approximately 10:41 pm. The Hospice Nurse said she did a PRN visit on 8/21/25 and was at the facility
around 11:20 pm. She said CR #1 was stable at the time of her visit. She said CR #1 was resting and her
O2 saturation was 98% on RA. The Hospice Nurse said she did not see any signs of distress from the
resident. The Hospice Nurse said she received a portion of the video from CR #1's family member because
the family member was upset. She said the video she received did not show what happened prior to the
incident or after the incident. The Hospice Nurse said CR #1's base line was intermittently confused.
Interview with MA D on 10/28/25 at 1:48 pm, she said she went to CR #1's room to give her medication on
the evening of 8/21/25. CR #1 told her she was not feeling good and could not breathe. MA D said CR #1
did not appear to have difficulty breathing because the resident was talking with her. She said CR #1
seemed like she was agitated. MA D said she went to LVN A and told her CR #1 could not breathe. MA D
said she, LVN A, RN C and the Restorative Aide went to CR #1's room. She said when LVN A spoke to CR
#1, LVN A's tone was not nice and asked her What's wrong with you?. MA D said she thought RN C may
have gone back to check her oxygen. MA D said CR #1 was ok whenever she gave her medication, she
said her pain medication may have kicked in. Interview with RN C on 10/30/25 at 4:16 pm, he said he was
new to the facility during the time of the incident. He said MA D told LVN A that CR #1 was not taking her
medication. LVN A told MA D she did not have to give CR #1 the medication because CR #1 had received
pain medication, and it was going to take a while for the pain meds to kick in. RN C said a different nurse
went into CR #1's room and he and LVN A wondered why she went in there. RN C said that nurse had
received a call from the family member to check on CR #1 because she thought CR #1 was having
shortness of breath. RN C said the Hospice Nurse also came to check CR #1's O2 stats and they were
normal. RN C said from his perspective, he did not see CR #1 struggling to breathe or struggling to talk. RN
C said that is probably why LVN A did not check CR #1's O2 stats. RN C said he thought the main issue
was the medication CR #1 was supposed to receive from MA D. He said the risk to the resident if there was
a lack of oxygen could be further damage to the resident. Interview with LVN A on 10/28/25 at 2:26 pm, she
said she saw the family member the day of the incident and the family member was happy. LVN A said
around 7 pm or 8 pm CR #1 was in pain, and she gave her pain medication. LVN A said MA D told her she
was about to give medication to CR #1 and the resident said she was short of breath. LVN A said when she
saw CR #1, she was not in any type of distress. LVN A said she told everyone in the room to come out of
the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676333
If continuation sheet
Page 2 of 3
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
12/01/2025
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
room and let CR #1 relax. LVN A said she saw LVN B enter CR #1's room and LVN A told her Leave my
patient alone. LVN B told her the family member called and told her CR #1 was short of breath and she was
in distress. LVN A said the Hospice nurse came and checked on CR #1 as well. LVN A said she was
suspended and then let go from the facility. LVN A said she did her job and took care of CR #1, she did not
think she did anything wrong. Interview with LVN B on 10/28/25 at 2:47 pm. She said CR #1's family
member called the facility that night and asked her to check on CR #1. LVN B said CR #1 was fine at the
time of her assessment. LVN B said the family member would call her sometimes and if there were any
concerns with CR #1, she would go to her room and CR #1 would tell her what was wrong. LVN B said the
family member would always watch through the camera and made sure CR #1 was ok. LVN B said she was
not in the room at the time to witness what anyone did or did not do. Interview with the DON, on 10/28/25 at
3:05 pm, he said MA D, went into CR #1's room to give her medication and CR #1 said she had shortness
of breath. The DON said MA D reported this to LVN A. The DON said LVN A immediately went in CR #1's
room and told her she needed to take her medications, and she did not see any shortness of breath. The
DON said there may have been some confusion LVN A thought MA D was reporting the resident was
refusing to take their meds. The DON said the family member showed the Administrator the video of the
incident. He said LVN A was fired, and the incident was reported to the state. The DON said the risk to the
resident when they are truly having respiratory distress could be detrimental. Interview with the
Administrator on 10/30.25 at 9:44 am, she said the footage that she saw was CR #1 stating I can't breathe.
She said MA D alerted LVN A. The Administrator said in the video, she saw LVN A tell CR # 1 I just gave
you your pain medication, you have to give it time to work, just calm down and then she left the room. The
Administrator said MA D stayed in the room. The Administrator said in the video CR #1 appeared to be in
pain; she did not see shortness of breath. She said MA D ended up giving meds to CR #1. She said CR #1
calmed down and fell asleep. The Administrator said LVN B assessed CR #1 after the family member called
her. The Administrator said LVN B alerted her of the incident. She said LVN A was terminated and did not
come back after her suspension. The Administrator said LVN A should have assessed the resident. She
said the risk to the resident when O2 is not checked, the resident could become non-responsive. Record
review of the policy titled Nursing Service and Sufficient Staff dated 10/24/22 read in part . providing care
included, but is not limited to, assessing, evaluating, planning and implementing resident care plans and
responding to resident's needs .
Event ID:
Facility ID:
676333
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the December 1, 2025 survey of Magnolia Crossing Nursing and Rehabilitation Cente?
This was a inspection survey of Magnolia Crossing Nursing and Rehabilitation Cente on December 1, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Magnolia Crossing Nursing and Rehabilitation Cente on December 1, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.