Misty Willow Healthcare Medication Failures - TX
HOUSTON, TX - Misty Willow Healthcare and Rehabilitation Center received an immediate jeopardy citation from federal inspectors in March 2025 after failing to ensure two residents received prescribed medications, resulting in one resident developing sepsis and another receiving an unauthorized medication following a head injury.
Critical Medication Administration Breakdown
The most serious violation occurred when a dialysis patient with a urinary tract infection went nearly two weeks without receiving prescribed antibiotics, ultimately developing sepsis that left him unable to walk, talk, eat, or swallow. The resident had been discharged from the hospital on February 13, 2025, with clear orders for three doses of Tobramycin, an IV antibiotic, to be administered after each dialysis session to treat a pseudomonas bacterial infection.
The breakdown began when the facility sent the medication with the resident to his first dialysis appointment on February 14, 2025, but the dialysis center refused to administer it, citing their protocol requiring direct orders from the hospital rather than accepting medications from nursing facilities. The facility's nursing staff did not discover the medication had not been given until February 17, when they found the original dose still in their refrigerator.
When nursing staff contacted the dialysis center, they learned that the center required electronic orders directly from the hospital and would not accept the medication the facility had provided. The Assistant Director of Nursing (ADON) then attempted to establish an IV line to administer the antibiotics at the facility, but the resident with dementia refused the procedure on February 17 and again on February 18.
Rather than pursuing alternative solutions or escalating the communication breakdown between providers, facility staff allowed the situation to continue. The ADON did not send orders to the dialysis center until February 20, six days after the first missed dose. Even then, the medication did not arrive at the dialysis center until February 28 - by which time the resident had already developed sepsis and been hospitalized.
Dangerous Consequences of Medication Gaps
Pseudomonas infections are particularly serious in vulnerable nursing home populations, especially those with compromised immune systems or chronic conditions like kidney disease requiring dialysis. These bacteria are resistant to many common antibiotics, making targeted treatment with specific medications like Tobramycin essential. When left untreated, pseudomonas infections can rapidly progress from localized urinary tract infections to systemic sepsis.
Sepsis is a life-threatening condition where the body's response to infection causes widespread inflammation, potentially leading to organ failure and death. In elderly patients with multiple comorbidities, the progression from infection to sepsis can occur within days. The resident's family member reported finding him on February 25 with a temperature of 102.8 degrees, appearing lethargic with "his eyes rolling in the back of his head."
The facility's delay in addressing the medication administration problem meant the resident went approximately 11 days without the prescribed antibiotic treatment. During this critical period, his urinary tract infection progressed to sepsis, and by the time he was hospitalized, laboratory tests revealed he had developed a different, more serious bacterial infection (Staphylococcus Aureus) that would not have responded to the original Tobramycin prescription anyway.
Unauthorized Medication Administration Following Head Injury
In a separate incident involving immediate jeopardy, facility staff administered aspirin as a pain medication to a resident with a known head injury and stroke history, despite having no physician order for aspirin to be used for pain management. The resident had been found on the floor of her room with a head injury, elevated blood pressure (180/90), and a cut near her right eye.
The nursing notes revealed that a Weekend Charge Nurse administered "PRN aspirin" for the resident's reported hip pain following the fall. However, the resident's medication orders only included aspirin 81mg daily for blood clot prevention, with no authorization for additional aspirin use as a pain medication. This was particularly dangerous because the resident was already taking Apixaban, a blood thinner, and had suffered a head injury that could potentially cause brain bleeding.
Administering aspirin to someone with a head injury significantly increases the risk of intracranial hemorrhage, especially when combined with other anticoagulant medications. The resident had a history of cerebral infarction (stroke) and was taking blood-thinning medications, making any additional anticoagulant effects from unauthorized aspirin potentially life-threatening.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Misty Willow Healthcare and Rehabilitation Center in Houston, TX was cited for violations during a health inspection on March 29, 2025.
Rather than pursuing alternative solutions or escalating the communication breakdown between providers, facility staff allowed the situation to continue.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.