Misty Willow Healthcare And Rehabilitation Center
Misty Willow Healthcare and Rehabilitation Center in Houston, TX — inspection on March 29, 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
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.
676251
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.