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Misty Willow Healthcare: Immediate Jeopardy Abuse Findings - TX
The inspection was triggered by a complaint....
Latest reports, citations, and penalties from CMS data
The inspection was triggered by a complaint....
The injury was documented in a Situation, Background, Assessment and Recommendation communication record dated June 22, 2025....
The deficiency was cited at a level of minimal harm or potential for actual harm....
That distinction matters in a nursing home....
The deficiency was not an isolated incident....
The inspection covered a single tag, F0609, which addresses the requirement that nursing homes report allegations of abuse to state agencies....
The citation, recorded under F0657, concerns care plan revisions....
Inspectors classified the violation as an isolated deficiency, meaning it did not affect every resident....
Federal inspectors who visited the facility on September 30, 2025, following a complaint, found that pattern repeated across multiple residents....
The failure came to light during a complaint inspection on September 25, 2025....
The Director of Nursing, identified in inspection records as V2, confirmed on September 24 that staff were expected to follow all five of those standards....
The inspection, completed September 24, 2025, examined what happened between two residents identified in the report as R4 and R5....
Inspectors arrived on September 23, 2025, just after one in the afternoon, and found all of it standing open....
A cognitive assessment scored the resident at 15 out of 15, meaning fully intact....
Not what staff were supposed to do when they found the prescribed dressings on the floor and homemade ones in their place....
For context, coffee served at 99 degrees is closer to body temperature than to what most people would recognize as a hot drink....
A mental status assessment completed in early April 2025 gave her a score of 4 out of 15, indicating severe cognitive impairment....
That is what federal health inspectors concluded after visiting Roane General Hospital in Spencer, West Virginia, on September 25, 2025....
A small number of residents were affected....
Pressure ulcers, sometimes called bedsores, develop when sustained weight against a surface cuts off blood flow to the skin....