Misty Willow Healthcare And Rehabilitation Center

F-F689 Accepted and Monitoring began at 5:30PM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0689 3.28.25 at 5:30PM monitoring began interviewing facility staff employees, (ADON B; CNA's C, H, I, L,O, P, M, N; DON; LVN's C, D, E, and N; RN's B, C and D) revealed, each were interviewed and completed online Level of Harm - Immediate continuing education training in all areas of patient care with Relias (internet training); Train the Trainer for jeopardy to resident health or ADON's by the pharmacist; protocol for resident unwitnessed falls and head to toe assessments, transferring safety resident from the floor to the bed or wheelchair properly, completing training on falls by using posttest and demonstrating the proper way of transferring resident from the floor. Residents Affected - Some

During a Follow-Up Interview on 3.29.25 at 3:10 PM with DON revealed in-services will be monitored by utilizing cluster partners (other facility's under same corporate office) who will come out to the facility and conduct random interviews with staff. Continuous QAPI discussions. DON stated she conducted the in-service 12 medication administration training and found that staff needed updates. She stated there were some rights added as when she started in the nursing field there were only 5 medication administration rights training. The DON stated the MAR and TAR will be monitored by running daily reports to ensure proper documentation with confirmation of new medications. The reports will be daily with or without her working at

the facility. The DON stated the system she will use to verify staff competencies would be audits, random questioning, and return demonstration (having staff give examples).

The DON stated the most important thing learned from these citations was documentation is a big key in success and failure, and she learned more about staff weakness and strengths.

3.29.25 at 3:30pm IJ Lowered: The facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

During an interview on 3.29.25 at 4:45PM with Administrator- He stated the IJ's have taught him to look at processes and that documentation needs to be specific and completed on time. He stated more awareness is being put in place to ensure the documentation is appropriate along with ensuring in-service training is continuous in areas of resident care. The DON will view all documentation by running daily reports and confirming new medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47277 safety Based on interview, and record review, the facility failed to provide pharmaceutical services including Residents Affected - Few procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for CR#1 & CR#2 of 8 residents reviewed for pharmacy services.

The facility failed to ensure CR #1 received his medication as ordered when WCN administered non-scheduled aspirin without an order when CR #1 had a known head injury.

The facility failed to ensure CR#2 recevied his IV antibiotic medication as ordered by the physician.

An Immediate Jeopardy (IJ) was identified on 03.27.25 at 4:34 p.m. While the IJ was lowered on 03.29.25 at 3:30pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

These failures could place residents at risk of receiving inadequate treatments or results or ingesting medications for which they were not prescribed and ineffective therapeutic outcomes by not documenting when medications were given or not given.

Findings included:

Record review of CR#1's face sheet dated 11/8/2023 reflected an [AGE] year-old female, with an original admitted [DATE REDACTED]. Her diagnosis included: Cerebral Infarction of the right middle cerebral artery (stroke), hypertension (high blood pressure) and gastro-esophageal (digestive disorder).

Record review of CR#1's Quarterly MDS dated [DATE REDACTED], revealed the following:

CR#1's BIMS score of 06 (severe cognitive impairment), CR#1's Functional Limitation in Range of Motion indicates an impaired Upper and Lower Extremities, uses motorized wheelchair, is dependent on staff for all of her ADL needs, including, rolling to left and right; has had no fall history.

Record review of CR#1's orders dated 11/8/2023 revealed, CR#1 was prescribed Aspirin 81 Oral Tablet chewable (No order for aspirin to be used as a PRN pain medication). Give 1 by mouth one time a day for blood clot prevention. Start date 11/9/2023; Apixaban (blood thinner) dated 11/8/2023.

Record Review of Medication Administration policy dated 05/2007 reveals the following:

2. Medications must be administered in accordance with the written orders of the attending physician.

NOTE: If a dose seems excessive considering the resident's age and condition, or a drug order seems to be unrelated to the resident's current diagnosis or condition, the nurse should contact the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 3. All current drugs and dosage schedules must be recorded on the resident's electronic medication administration record (MAR). Level of Harm - Immediate jeopardy to resident health or 8. Unless otherwise specified by the resident's attending physician, routine medications should be safety administered as schedules.

Residents Affected - Few 10. The nurse administering the medications must initial the resident's electronic MAR, on the appropriate line and date for that specific day.

Record Review of nursing notes written by WCN dated 3/4/2025 at 8:27am, revealed, Resident observed lying on the floor feet facing foot bed, vitals taken, pain assessment made, head to toe assessment performed. Resident vitals 180/90 P-76 C/O pain from hip. PRN aspirin administered, resident noted with cut by right eye, EMS services immediately contacted, skin tear on left arm. Resident was not aware of how they ended up on the floor, seen by wound care physician, wounds cleansed, with wound cleanser, cut medicated with collagen powder, ST addressed with xeroform and dry dressing. RP notified; Dr. notified.

During the follow-Up Interview on 3.26.25 at 5:08pm with DON revealed she did not know CR#1 had sepsis prior to her hospitalization . She stated labs were not necessary because CR#1 never exhibited any symptoms that would be a cause for labs. DON stated because of the lack of symptoms, nursing staff did not monitor for signs or symptoms of sepsis. The DON stated labs are only ordered for someone in CR#'1's condition (CVA, Anticoagulants) when there are indicators like when there is a change of condition. DON stated when medications are administered, nursing staff must follow physician orders. She stated WCN gave CR#1 and aspirin (PRN) because it was for pain. The DON stated she spoke with the facility's medical director and CR#1's physician and was informed that CR#1's outcome would not have changed her injuries.

CR#2

Record review of CR#2's undated face sheet revealed a [AGE] year-old male initially admitted to the facility

on [DATE REDACTED], readmitted on [DATE REDACTED] and discharged on [DATE REDACTED] with a diagnosis of anemia (iron deficiency), hypertension (high blood pressure), Renal failure ( kidneys lose the ability to filter waste), Obstructive uropathy (urinary tract disorder); Dementia (decline in cognitive abilities), seizure disorder (abnormal brain signals).

Record review of CR#2's Quarterly MDS dated [DATE REDACTED], revealed the following: CR#2's did not have a BIMS score, which indicates a severe cognitive impairment; CR#2 uses a wheelchair; dependent on staff for toileting, showering, and getting dressed; totally dependent on staff for sitting and lying in bed; CR#2 is always incontinent for urinary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 Record review of CR#2's orders dated, 2/13/2025 for Trileptal oral tablet 300 MG give 1 tablet by mouth two times a day for status epilepticus (start date 1/26/2025 at 5:00pm); Apixaban Oral Tablet by mouth two times Level of Harm - Immediate a day for anticoagulant for 30 days (start 2/18/2025 at 8:00am); Apixaban Oral tablet 5 MG give 2 tablet by jeopardy to resident health or mouth two times a day of Anticoagulant for 3 days (start date-2/14/2025); change intravenous tubing with safety new IV bag every day shift (order date 1/26/2025 at 10:20am-D/C dated 2/26/2025 at 12:20am); Meropenem intravenous solution reconstituted 1 GM-Use 1 gram intravenously one time a day for UTI for 9 days (order Residents Affected - Few date 1/24/2025 at 7:14pm); Midline care: Change Central Line/Mid line dressing Q 7 days if visible for assessment. Change dressing PRN if wet, soiled, saturated or loose every day shift every 7 days (order date 1/26/2025 at 10:20am-D/C dated 2/13/2025); Mid line flushing: Flush with 5cc 0.9% NS IV solution before and after each med administration every day shift (order date 1/26/2025-D/D dated 2/14/2025); Tombramycin Sulfate Injection Solution 80 MG/2ML_use 4 ml intravenously one time a day every Mon, Wed, Fri for give after HD SEND WITH RESIDENT TO HD. THEY CAN ADMINISTER THERE (order datre 2/13/2025 4:29pm - D/C dated 2/14/2025 at 12:53pm); Cefdnir Capsule 300 MG_Give 1 capsule by mouth two times a day for infection for 7 days (order date 2/26/2025 at 0022); Insert peripheral IV one time only for IV antibiotics until 2/14/2025 11:59pm (order date 2/14/2025 at 7:11pm).

Record review of CR #2's care plan dated, revealed the following care areas:

Focus: [CR#2] has renal insufficiency r/t CKD stage 5 Hemodialysis 3X/WEEK EVER MWF. Created and initiated on 8/6/2024 and revision 2/24/2025.

Goal: [CR#2] will be free from infection through the review date. Date initiated and created 8/6/2024, Target date 1/21/2025.

Interventions: [CR#2] Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; seizures. Date initiated 8/6/2024.

Focus: [CR#2] has a Urinary Tract Infection. Date initiated, created and revised on 1/29/2025.

Goal: [CR#2] Urinary tract infection will resolve without complications by review date. Date initiated and created 1/29/2025. Target date: 1/21/2025

Interventions: [CR#2] Give antibiotic therapy as ordered, Monitor/document for side effects and effectiveness. Created 1/29/2025; Monitor/document/report to MD PRN for s/sx of UTI: Frequency, Urgency, Malaise, foul smelling urine, dysuria, Fever, nausea and vomiting, flank pain, Supra-pubic pain, Hematuria, Cloudy urine, Altered mental status, Loss of appetite, Behavioral changes. Date initiated 1/29/2025; Obtain vital signs as ordered.

Focus: [CR#2] At risk for impaired cognitive function/dementia or impaired thought processes r/t dx of Dementia, metabolic encephalopathy (serious neurological condition when the brain is damaged). BIMS score of 6 (Severe Impairment). Date initiated 7/19/2024 and revision on 8/6/2024.

Goal: [CR#2] Will maintain the level of cognitive function through the review date. Target Date: 1/21/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 Interventions: [CR#2] Communicate with family/caregivers regarding residents' capabilities and needs; Discuss concerns about confusion, disease process and alternative placement with family/caregivers; Level of Harm - Immediate monitor/document/report to MD any changes in cognitive function, specifically changes in: decision jeopardy to resident health or understanding others, level of consciousness, mental status. Date created 8/6/2024. safety Focus: [CR#2] ADL Self Care Performance Deficit r/t impaired mobility, dementia. Created 7/19/2024 and Residents Affected - Few Revision on 8/6/2024.

Goal: [CR#2] Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and personal hygiene with modified independence through the review date. Target date 1/21/2025.

Interventions: [CR#2] Discuss with resident/family POA care any concerns related to loss of independence, decline in function; Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function; Skin Inspection: Requires SKIN inspection. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.

Focus: [CR#2] Has bowel/bladder incontinence r/t Dementia, History of UTI, Impaired Mobility. Created and initiated on 8/6/2024.

Goal: [CR#2] Risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Target date: 1/21/2025.

Interventions: [CR#2] Monitor/document for s/sx UTI: Pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Initiate and Created 8/6/2024; Monitor/Document/report to MD possible medical causes of incontinence bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Date initiated 8/6/2024.

Focus: [CR#2] I am resistive to care will not allow staff to dress change, shower, and is refusing medication. CR#2 pulled out midline 1/28. Dated initiated 7/22/2024 and revision 1/29/2025.

Goal: [CR#2] Will cooperate with care through next review date. Target 1/21/2025.

Interventions: [CR#2] Allow to make decisions about treatment regime to provide a sense of control; educate resident/family/caregivers of possible outcome(s) of not complying with treatment care; encourage as much participation/interaction by the resident as possible during care activities. Initiated 7/22/2024.

Focus: [CR#2] Potential for a behavior problem r/t not drinking water, only consuming coffee and eating sugar packets. Educate provided on the need for water consumption.

Goal: [CR#2] Will have fewer episodes by review date. Created and initiated 11/15/2024. Target 1/21/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 Interventions: [CR#2] Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Created Level of Harm - Immediate 11/15/2024. jeopardy to resident health or safety Focus: [CR#2] Potential to demonstrate physical behaviors r/t Dementia; I have a habit of unplugging items to conserve energy. Date initiated and revision 1/10/2025. Residents Affected - Few Goal: [CR#2] Will demonstrate effective coping skills through the review date. Target 1/21/2025.

Interventions: [CR#2] Assess and address for contributing sensory deficits; provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; Document observed behavior and attempted interventions; Monitor/document/report to MD of danger to self and others. Date initiated 1/10/2025.

Focus: [CR#2] At risk for falls r/t hx of falls, impaired mobility. Initiated 7/19/2024. Revision 8/6/2024.

Goal: [CR#2] Will be free of falls through the review date. Target: 1/21/2025

Interventions: [CR#2] Be sure call light is within reach and encourage to use it to call for assistance as needed; Falling star program; Keep items, water, etc, in reach.

Focus: [CR#2] CR#2 had an actual fall related to poor communication/comprehension: 12/18/2024: Fall with no injury; 12/22/2024: Fall with no injury. (Created 11/19/2024. Revision on 2/24/2025)

Goal: [CR#2] Will resume usual activities without further incident through the review date. Target 1/21/2025.

Interventions: [CR#2] Psych consult (Continue interventions on the at-risk plan.

Focus: [CR#2] Has potential for pressure ulcer development r/t impaired mobility. Dated initiate 7/19/2024; Revision 8/6/2024.

Goal: [CR#2] Will have intact skin, free of redness, blisters, or discoloration by/through review date. Target 1/21/2025.

Interventions: [CR#2] Weekly head to toe skin at risk assessment. Initiated and Created 7/19/2024.

Record Review of hospital discharge summary dated 2/13/2025 revealed, instructions for administering the medication through catheter every other day. Give after HD for 3 sessions Monday, Wednesday Friday.

Record Review of nursing notes dated 2/17/2025 at 1:12pm by LVN D revealed, attempted to put IV line in CR#2 to receive post HD medication. CR#2 refused. Will try again upon return.

Record review of nursing notes dated 2/17/2025 at 1:12pm by LVN D revealed an attempt to put IV line in resident to receive post HD medication. Resident refused.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 Record Review of nursing notes dated 2/18/2025 at 10:11am by LVN D revealed, CR#2 continues to refuse IV insertion. NP contacted for other options. Awaiting reply. Level of Harm - Immediate jeopardy to resident health or Record Review fax dated 2/20/2025 at 1:30pm from ADON to dialysis, revealed CR#2 face sheet, diagnosis, safety hospital orders and hospital discharge instructions.

Residents Affected - Few Record Review of nursing notes dated 2/24/2025 at 11:55am by ADON revealed dialysis called in regards of tobramycin IV CR#2 is to receive x3 doses after dialysis. Facility stated fax received and antibiotics on order.

Record Review of nursing notes dated 2/24/2025 at 1:42pm by RN revealed CR#2 leaving for dialysis via EMS, vitals stable BP 110/62 T 98.4, HR 88 RR 18. Orientation at baseline CR#2 stated he was tired. No signs of distress noted.

Record review of nursing notes dated 2/25/2025 at 12:14pm revealed CR#2 lethargic, temp of 100.3 NP notified. New orders given for Rocephin injection, labs, cxr. 02 at 2L NC. FM at bedside. 650 mg of Tylenol given for fewer per NP. COC complete, labs drawn, results pending.

Change of Condition: Symptoms or signs noted of condition change: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Altered mental status.

Vital signs on 2/25/2025 revealed the following:

BP 103/54 - 2/25/2025 at 1:13 sitting l/arm

P76 -2/25/2025 at 1:13

R 18.0 2/25/2025 at 1:13

T 98.3 2/25/2025 (Forehead) at 1:13

02 92% 2/25/2025 at 1:12 Method: Oxygen via Nasal Cannula

Record Review of nursing notes regarding CR#2's last vitals taken below:

O2 Stats: 2/26/2025 at 9:45am 92% Oxygen via Nasal Cannula

Pain Level: 2/24/2025 at 9:06pm O value Numerical

Respiration: 2/26/2025 at 9:45am 32 Breaths/min

Pulse: 2/26/2025 at 9:45am 75 bpm regular

Blood Pressure: 2/26/2025 at 6:53am 12//65 Lying arm; 2/26/2025 at 9:45am 140/72 Lying arm.

Weights: 2/18/2025 at 9:56am 200.4 lbs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 Record review of nursing notes dated 2/26/2025 at 12:14am revealed CR#2's Xray results: Bilateral Interstitial infiltrates, concerning for edema vs PNA, nonspecific: Level of Harm - Immediate jeopardy to resident health or Reported to On-Call safety N/O: Lasix 40mg QD x 3 days Residents Affected - Few Cefdinir 300 mg BID x 7 days

Record review of nursing notes dated 2/26/2025 at 9:46am by ADON, revealed Medical Director given the results of the Xray and lab results and ordered CR#2 to be sent out to ER for further work up.

Record review of CR#2's report from hospital revealed the following report dated 2/26/2025:

CR#2 arrived at the hospital at 9:43am via, EMS.

O2 Flow rate (l/min) 4 l/min 02 Delivery Method: Nasal Canula.

Vitals: BP: 137/67

Pulse: 76

Resp: 16

Temp: 102.5 F (39.2 C)

Temp src: Temporal

GCS Total: 12

Blood Glucose Meter (mg/dl): 158

ECG Performed: Yes (NSR)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 During a telephoned Interview on 3/4/25 at 10:02am with FM stated CR #2 is no longer able to walk, talk, eat or swallow because of sepsis in his blood from having a serious UTI that the facility would not ensure he Level of Harm - Immediate received his medicine for. FM stated her Resident #2 came to the facility because of his chronic UTI and jeopardy to resident health or Infusion (antibiotics through IV). She stated her Resident #2 had a picc line (a thin, flexible tube inserted into safety a vein near the heart), which is where the antibiotics were administered by a nurse. She stated the UTI is a chronic issue for CR #2. FM stated CR #2 did not have sepsis when he was released from the hospital Residents Affected - Few February 13, 2025. FM stated she came to the facility Tuesday February 25, 2025, at 9:00am. Stated she gave CR #2 a kiss on his forehead and his eyes were rolling in the back of his head. She spoke with the nurse at this time. She stated she was a little irritated that the nurse didn't know he had a temperature but did not checked vitals. She stated ADON A came to the room and the nurse was finally getting the temperature.

She stated the nurse took Resident #2's temperature and it was 102.8 and he appeared to be lethargic. At

this time, she requested CR #2 to be put on oxygen. She stated CR #2 had received orders when he was released from the hospital on February 13, 2025, for antibiotics due to his UTI. FM stated at this time she was informed by the ADON A, that the medication (Tobramycin) for his UTI that was ordered on February 13, 2025, was never administered, and had expired because the Dialysis never gave it to him per hospital orders. FM stated this negligence caused CR #2 to have a more serious UTI and infection in his blood. FM stated ADON A told her the dialysis people were supposed to give the anti-biotics through the picc line, but

they hadn't as of this date. She further stated the ADON A told her the medication had expired; however, due to CR #2's fever, ADON A administered a medication called, Rocephin (used for infections). FM stated after being administered the shot CR #2 immediately broke out into a profuse sweat all over his body. The ADON

A told her that CR #2 was breaking his fever and that the sweating was okay. FM stated she's not sure how long CR #2 had been in this feverish lethargic condition. She stated facility sent CR #2 out to the hospital early that morning and never called her to even ensure he was sent out. She stated CR #2 had fallen a few weeks ago and now he has seizures. She stated CR #2 was in ICU a few weeks ago before he was released from the hospital, he now has had dialysis and he had the dialysis port, which is how the medication for his UTI was to be administered. FM stated the ADON told her that CR #2 would get antibiotics in the dialysis, but failed to tell her Dialysis never gave him the anti-biotics. She stated now the infection has spread from a UTI to Blood Infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 During an Interview on 3/4/25 at 2:44pm with ADON stated CR #2 was sent to hospital because he was lethargic. He stated there was an order for Tobramycin, an antibiotic for the UTI, which was identified through Level of Harm - Immediate labs while at the hospital. ADON A stated CR #2 returned to facility from hospital on 2.13.25. The CR #2 also jeopardy to resident health or returned from hospital with and order to be given 3 doses of tobramycin over the next 3 dialysis services safety which was to be administered after dialysis session, starting February 14, 2025. The ADON A stated he personally sent the medication to dialysis, along with the order from hospital. He stated he did not know that Residents Affected - Few the initial dose was not administered to CR #2 until he went into the medicine refrigerator on February 17, 2025, to retrieve CR #2's second dose. At this time, he stated he seen the initial dose from February 14, 2025. He stated he immediately called Dialysis and was informed that their protocol was to receive an email from the hospital, and they would fill the medication through their own system. The ADON A stated they further told him that they are not allowed to accept medication. ADON stated resident had been without the medication for a week and he wasn't getting any antibiotics during that time. He stated he called the doctor. Stated the Dr stated to send the order to dialysis, but ADON A told her that they refused to administer. At this time, he was given an order from the NP to put an IV in Resident #2's arm so facility nurses could administer

the antibiotic. He stated on February 17, 2025, at 1:13pm, attempted prevention measures by trying to put an IV in Resident #2's arm and he refused on 2/17/25 at 1:13pm and again on 2/18/25 at 10:11am. The ADON

A stated with Resident refusal for the IV port, the medication expired. ADON A stated he received an order from the NP to administer the Rocephin 1mg and Tylenol 650. He stated he was not aware that Resident #2 began to sweat profusely. He stated Resident #2 was talking to his FM during this time. The ADON stated on 2/20/2024, he faxed the order to dialysis in hopes of them filling the Thrombosis prescription. He stated he called dialysis to let them know he just faxed the order and was told they did not have the medication and it would take 7-10 to get it.

During an Interview on 3/5/2025 at10:00am with HAP- HAP stated CR #2 had an admittance from February 5, 2025 and discharged on [DATE REDACTED]. HAP stated on February 6, 2025, CR #2 labs showed he had a bacteria called pseudomonas, which is why he was prescribed Tobramycin. He stated there was an order for the medication to be administered by dialysis staff after his procedure. The antibiotic was for three doses. He stated the medication should have been given by the dialysis staff through the dialysis IV port, not the facility staff. He stated that according to the records, on February 11, 2025, at 10:00am, dialysis was set up by the hospital social worker. At this time, the order was given to the dialysis staff. HAP stated that there must have been a mix-up in the communication between the hospital, dialysis, and the facility. However, he stated that

the attending physician at the nursing facility should've figured it out even if CR #2 was sent back to the hospital to get the medication. This medicine was extremely important as the resident had an active bacterium. HAP stated CR #2 return to the hospital, February 26, 2025, and he now has a different bacteria called Staphylococcus Aureus. The order for Tobramycin would not have been affective for CR #2 anyway. Therefore, the resident, even if he had taken, the order would not have gotten better because he had a different bacterium. Doctor indicated that both bacteria are more healthcare bacteria, where they are contracted in healthcare rehab facilities.

During an Interview on 3/5/25 at 12:10pm with Dialysis CNM who stated he was made aware CR #2 was to receive 3 doses of Tobramycin; however, dialysis did not receive any notification from the hospital which is protocol. CR #2's first dialysis appointment was 2/14/2025. States the order was sent with medication and

they don't take orders from other doctors. He also stated there was no medicine on hand at this time. He stated he received a fax order from the facility on February 20, 2025, and the medicine arrived at the Dialysis center on February 28, 2025. He stated they have no records of the orders from the hospital on 2/11/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 During an telephone Interview on 3/9/2025 at 11:19am with FM - Stated she received a call from a doctor at

the hospital who told her that based on CR#2's wounds he would require surgery to insert a rectal tube. She Level of Harm - Immediate stated the doctor reiterated CR#2's should be strongly considered for Hospice due the wound and blood jeopardy to resident health or infection. safety

During a follow up Interview on 3/10/2025 at 9:45am with FM - who stated the facility never called and say Residents Affected - Few CR#2 was refusing medication. The facility would call FM when he needed a shower and was refusing, then family would talk with CR#2 and CR#2 would comply.

During a follow-up Interview on 3/11/2025 at 10:00am with FM stated the facility has always called her or another family member whenever CR #2 would refuse showers. She stated either of them would come to the facility and assist staff in giving Resident #2 his showers. FM stated this has happened on at least two occasions. She stated other times the facility had called was when CR #2 was walking and naked and pee, poop, and urine everywhere in the middle of the night. The facility called FM. However, FM stated she never received a called saying there was any problem getting the meds thru dialysis or that CR #2 had refused his med. She stated when she was informed by the facility that CR #2 hadn't had his medicine from dialysis, she went to the dialysis to speak with someone. FM stated Dialysis told her that they had already explained to

the nursing facility they could not administer that kind of medication, so they would have to get another kind of med. During this time, FM stated CR #2 had already missed all 3 doses of his medication and at this time

he was not talking, his fever was 102, and his forehead was hot, yet the ADON stated he was ok. FM stated

the ADON told nurse to go get meds so they can start administering medications for his infection. The ADON administered Rocephin medication, which he gave a shot in the buttocks area. FM stated ADON asked her to hold CR #2 while he administered the shot because it would typically burn. FM stated she tried getting him to eat doughnuts, but CR #2 would only open his mouth but could not chew. FM stated the ADON informed her that CR #2 had a sacrum wound. FM stated CR #2 had never had a wound prior to admittance to this facility. She stated had she known CR #2 had a wound she would not have left him in the facility. She found out about the wound Tuesday February 24, 2025, and he was sent to the hospital on Wednesday February 25, 2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 During an interview on 3/11/25 at 10:50am with NP - Confirmed CR#2 was his resident when CR#2 was in

the facility. NP initially stated he didn't' know why CR#2 was given the medication to be administered at Level of Harm - Immediate dialysis, then stated, I think it was an antibiotic because CR#2 had recurring UTI's. NP confirmed the jeopardy to resident health or medication should have been administered to CR#2 while at dialysis. He stated it was an IV medication to be safety administered in the dialysis port and the dialysis people know how to administer it. If the medication was given at facility, it will be washed out by dialysis procedure, which is why the nephrologist always want to Residents Affected - Few administer at dialysis. However, NP stated dialysis did not carry the medication, and they refused to give the medication that accompanied CR#2 from NF. He stated at this time he was informed that CR#2 had missed one dose. NP stated he informed the nursing facility staff to reach out to the nephrologist to see if they could order another medication or something else that they had since CR#2 was not getting the medication he should be getting for an infection. He stated the nephologist was the physician who originally ordered the medication and staff needed to follow up with them. The NP stated at this time he assumed the facility had reached out to the nephrologist as directed and they were given a different type of medication. NP further stated he directed staff to put in a Peripheral IV only with nephrologist approval to give medication. He stated nursing staff can't just put line on dialysis patient without nephrologist approval. NP stated nursing staff could have either got the medication changed or administer themselves through a midline (a thin tube inserted into

a vein), but they needed to consult with nephologist first. NP stated the facility never called him back afterwards with any results, so he assumed the medication was either changed or given. NP stated facility staff did not report any clinical symptoms that CR#2 had an untreated infection, no fever no chills reported, and no change in mood. He stated there was nothing reported to him that would indicate CR#2 had an untreated infection. NP stated he received a second telephone call from the facility indicating CR#2 had a symptom but couldn't recall what it was. He stated the exact time he was notified by nursing staff would be in

the nursing notes, because he couldn't remember. He stated he knew he was not getting it, but don't know how many doses were missed at that time. NP stated he thought he ordered a dose of Rocephin, which was

an antibiotic that would treat CR#2 symptoms for 24-48 hours and directed nursing staff to monitor vitals, and report to him any changes of conditions. NP stated he would have not advised staff to send CR#2 out to the hospital unless his vitals and symptoms worsen after given Rocephin. NP stated he was not saying to wait for a problem before doing something, but 24-48 hours would have been a good time to see if medication from nephologist could be changed. NP stated he reinforced instructions to facility staff to follow-up with nephrologist. He doesn't know if the nephologist ordered anything else. NP stated hospitals expects certain levels of care from nursing facilities then just always sending residents out without doing a full work up. He stated hospitals diagnose and do interventions, but they expect nursing facilities to treat residents as much as they can. He stated nursing should report any other change of condition to him. NP stated a lot of things that could happen when a resident's medication for infection isn't administered. He stated lethargy on dialysis patient could be caused by conditions other than sepsis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 676251 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676251 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

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 0755 During an Interview on 3/11/2025 at 11:54 am. with DON stated she knew on Friday, February 14, 2025, that

the facility was sending abx with CR #2 to dialysis. DON stated she was at a function with other Level of Harm - Immediate administrative staff and was not in the facility the week of February 17, 2025, but to her understanding she jeopardy to resident health or did not give any additional order, just waiting for dialysis to obtain the meds. DON stated she did know on safety Friday February 14, 2025, CR #2 did not get his medication. She stated ADON informed her on Monday February 17th, 2025, he was sending the orders to dialysis center. DON stated she never spoke with the Residents Affected - Few nephrologist concerning CR #2 not getting his medication. She stated when a resident does not get prescribed antibiotics there is a potential to go septic (life threatening condition that occurs when a body-wide infection causes dangerously low blood pressure and organ damage). DON stated CR #2 situation was unique because the order was for dialysis to administer the medication and not the facility. DON stated CR #2's physician was Medical Director for the facility and was also aware of what was going on. She stated the nursing notes noted CR #2's change of condition. The DON stated she understood that there was an attempt to start IV on Resident #2 in the facility, but CR #2 refused the IV. DON feels staff were communicating and following up with Resident #2's doctor, but unsure if staff painted a clear enough picture of everything they did as far documentation goes.

During a Telephone interview on 3/11/25 at 1:55pm with Medical Director revealed, she was aware of the issues surrounding CR #2 and his medication. She stated staff was in constant contact with the Dialysis and informed the Nephologist is the prescribing doctor over that department and ordered the medication. She stated without the medication a resident could present confused, infection. She further stated the facility attempted to initiate an IV in CR#2's arm and he refused.

An Immediate Jeopardy (IJ) was identified on 03.27.25 at 4:34 p.m. While the IJ was lowered on 03.29.25 at 3:30pm, the facility remained out of compliance at the severity level of no actual harm with potential for more tha [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 676251