Magnolia Crossing Nursing And Rehabilitation Cente
Magnolia Crossing Nursing and Rehabilitation Cente in Houston, TX — inspection on December 1, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 .
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