Misty Willow Healthcare And Rehabilitation Center
Misty Willow Healthcare and Rehabilitation Center in Houston, TX — inspection on September 24, 2025.
Found 5 citations. 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
was on leave. He said he review and let me know. In an interview on 9/24/25 at 9:43am, the
interaction with the AIT.
When asked what kind of threatening remarks, he said the family member
that he could no longer visit. He said he was unsure if a facility staff member discussed the visitation restriction with her. In a telephone interview on 9/24/25 at 10:21am, the AIT said he was at the facility temporarily when the Administrator was on leave. He said he was told by a staff member that Family Member A could not be at the facility. He said he spoke Spanish, so he volunteered to inform the family member. He said he told Family Member A that he was trespassing and had to leave, then the family member threatened to beat the staff and accused them of lying. He said the police were called and escorted him out. He said he could not remember the following: the staff member who told him that he could not visit, who made the decision regarding the visitation restriction, whether Family Member A was informed of the visitation restriction prior to conversation he had with him, and whether Resident #2 was informed of the visitation restriction. In a telephone interview on 9/24/25 at 10:47am, Resident #2's family member, Family Member B, stated Family Member A was caught looking at a staff member at the facility.
Family member B said the staff told Family Member A that he could no longer visit the facility.
Family member B said the police were present but did not charge him with any crime. In a telephone interview on 9/24/25 at 12:29pm, ADON B said LVN R told him that she was uncomfortable around Family Member A. He said he noticed Family Member A would stare at LVN R, put flowers on her car and follow her outside. He said LVN R thought she needed a restraining order. ADON B said he told Family Member A that he could not have these behaviors, and Family Member A threatened to kill him and verbally assaulted him. He said he notified the DON and the Administrator. He said he believed Family Member B told Resident #2 about the visitation restriction regarding Family Member A. In an interview on 9/24/25 at 2:50pm, the Administrator said they did not review the resident rights policy when addressing the visitation regarding Resident #2 and Family Member A. He said they reviewed the incidents from the perspective of staff safety. He said Resident #2 was upset because he tried to cheat on her. He said Resident #2 had not expressed concerns about the visitation restriction. He said it was not documented in her medical record because it was more of an issue between Family Member A and an employee. He said LVN R did not receive any type of documentation from the police except for a report number.
Record review of the facility policy regarding Visitation Rights of Residents dated 1/2025 stated, It is the policy of this facility to inform each resident and/or resident representative of the rights to receive visitors based on their preferences and any clinical or safety restrictions or limitation on these rights.
676251 09/24/2025
Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070
Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 09/19/25 or until substantial compliance established and continue monthly for 90
implemented sufficiently to remove the IJ by the following:
Record review of the facilities IJ Template revealed it was signed by the Medical Director (undated).
Record review of a Grievance Log and Incident Log dated May 2025 to September 2025 revealed the DON reviewed both and signed her name on the documents.
Record review of Safe Survey Questionnaires for Alleged Abuse conducted by the Social Worker revealed she interviewed 18 residents.
All residents stated they would speak to the social worker or administrator if abuse occurred, all residents were satisfied with care, and they reported no problems with other residents, staff.
Record Review of In-service attendance records dated 9/19/25 revealed the DON presented in-services to all staff, including administrative staff and nursing staff, therapy, housekeeping, maintenance.
Topics included: - Abuse prevention, freedom from abuse and neglect.- Reporting alleged violations of abuse, neglect, exploitation and mistreatment.- Reporting suspicion of a crime, freedom from abuse, neglect and exploitation.
Record review of an In-Service Attendance Record dated 9/20/25 at 11:00am revealed the Clinical Resource provided education to the Administrator, DON and Social Worker on the topic of conducting abuse and incident investigations/interviews which included the following: Define types of incidents requiring an investigation and reporting to appropriate agencies; Initiated the investigation and preparing for the interview- Includes review of medical records and assessment findings physical, psychological impact, personnel files, training records, policies, equipment, scene of the incident, staff schedules and assignments; Techniques for completing a successful and through interview; Analyze findings from investigation and interviews; Develop plan to prevent future occurrences and care plan updates; Maintaining investigation files and completing final report to appropriate agencies; Evaluation used scenario-based presentations with learner replies demonstrating learned techniques.
Interviews with CNA D, MA A, CNA E, LVN F, CNA F, CNA G, LVN G and LVN H on 9/21/25 between 5:37am and 3:31pm revealed they could reiterate the in-services they received, including a resident's right to be free from sexual abuse, their responsibility regarding incidents of abuse, abuse prevention, behaviors that could lead to abuse and identifying and locating care plan areas and interventions.
Interviews with the Social Worker, Administrator, DON and ADON on 9/21/25 between 1:57pm and 2:34pm revealed they could reiterate he in-services the received, including their responsibility regarding the abuse policy, abuse investigation, abuse prevention and care plan revisions. In an interview on 9/21/25 at 2:01pm, the MDS Coordinator said she had worked at the facility for one month.
She said they audited all residents' care plans to ensure they were current.
She said she was responsible for care planning.
She said she was informed of incidents by attending morning meetings and reviewing falls and changes of condition. On 9/21/25 at 3:37pm, the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems.
676251 09/24/2025
Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070
privacy.
When asked about abuse prevention, he said he would follow the guidance of the DON and
jeopardy to resident health or Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was safety requested.
The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of RemovalF607: Abuse
The facility failed to implement their written policies that
from sexual abuse.1.
Facility Medical Director was notified of the IJ on 09/19/2025 at 04:50 pm by the Administrator.2.
Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made on 09/19/25. 3.
The ED/ DON/ Social Worker and RN, Clinical Resource will be trained on Abuse/ Neglect Investigation and Reporting by Risk Management Resource on 9/20/2025.
This included how to conduct a thorough investigation to implement measures to prevent further incidents which would protect other residents.4.
Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 at 5PM regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s).
This training was given by RN, Clinical Resource on 09/19/25.
Training & Knowledge Check including Post-Test will be completed with all staff by 09/20/25.
Any remaining staff member(s) pending Training & Knowledge check will complete the Training & Knowledge Check including Post-Test prior to the start of their next will be completed with all staff prior to the scheduled shift.
Staff will not be allowed to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan. 5.
This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor.
These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.6. DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter.
This audit was completed on 9/19/25 and No additional discrepancies were identified.
Admissions Coordinator/ Designee will check Sex-Offender registry before admission.
Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents. 7.
Safe-Surveys were conducted on 09/19/25 by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident(s).
Interviewable resident(s) were included in the Safe-Surveys.
The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility to repor
676251 09/24/2025
Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070
analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property, or
jeopardy to resident health or Defining how care provision will be changed and/or improved to protect residents receiving services, safety if appropriate; Training staff on changes made and demonstration of staff competency after training is implemented; Identifying staff responsible for the implementation of corrective action; The expected
plan.
This was determined to be an Immediate Jeopardy (IJ) on 9/19/25 at 4:52pm.
The Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was requested.
The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of Removal F-F610: Abuse Investigation
The facility failed to have evidence that all alleged violations of sexual abuse are thoroughly investigated and failed to take steps to prevent further potential abuse and take appropriate corrective action as a result of investigation findings.1.
Facility Medical Director was notified of the IJ on 09/19/2025 at 04:50 pm by the Administrator.2.
Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made on 09/19/25. 3.
Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 at 5PM regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s).
This training was given by the RN, Clinical Resource on 09/19/25.
Training & Knowledge Check including Post-Test will be completed with all staff by 09/20/25.
Any remaining staff member(s) pending Training and knowledge check will complete the Training and Knowledge Check prior to the start of their next scheduled shift.
Staff will not be allowed to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan, as additional intervention tool to ensure timely interventions/investigation(s) are implemented.4. DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter.
This audit was completed on 9/19/25 and No additional discrepancies were identified.
Admissions Coordinator/ Designee will check Sex-Offender registry before admission.
Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents. 5.
This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor.
These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.6. DON/ designee/ Cluster Partners will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated appropriately.
This will be completed by 9/19/25. 7.
DON/ Designee will review the 24-[NAME]
676251 09/24/2025
Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070
Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 09/19/25 or
compliance.
The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following:
Record review of the facilities IJ Template revealed it was signed by the Medical Director (undated).
Record review of a Grievance Log and Incident Log dated May 2025 to September 2025 revealed the DON reviewed both and signed her name on the documents.
Record review of Safe Survey Questionnaires for Alleged Abuse conducted by the Social Worker revealed she interviewed 18 residents.
All residents stated they would speak to SW or administrator if abuse occurred, all satisfied with care, no problems with other residents, staff. RR of In-service attendance records dated 9/19/25 revealed the DON presented in-services to all staff, including administrative staff and nursing staff, therapy, housekeeping, maintenance.
Topics included: - Abuse prevention, freedom from abuse and neglect.- Reporting alleged violations of abuse, neglect, exploitation and mistreatment.- Reporting suspicion of a crime, freedom from abuse, neglect and exploitation.
Record review of an In-Service Attendance Record dated 9/20/25 at 11:00am revealed the Clinical Resource provided education to the Administrator, DON and Social Worker on the topic of conducting abuse and incident investigations/interviews which included the following: Define types of incidents requiring an investigation and reporting to appropriate agencies; Initiated the investigation and preparing for the interview- Includes review of medical records and assessment findings physical, psychological impact, personnel files, training records, policies, equipment, scene of the incident, staff schedules and assignments; Techniques for completing a successful and through interview; Analyze findings from investigation and interviews; Develop plan to prevent future occurrences and care plan updates; Maintaining investigation files and completing final report to appropriate agencies; Evaluation used scenario-based presentations with learner replies demonstrating learned techniques.
Interviews with CNA D, MA A, CNA E, LVN F, CNA F, CNA G, LVN G and LVN H on 9/21/25 between 5:37am and 3:31pm revealed they could reiterate the in-services they received, including a resident's right to be free from sexual abuse, their responsibility regarding incidents of abuse, abuse prevention, behaviors that could lead to abuse and identifying and locating care plan areas and interventions.
Interviews with the Social Worker, Administrator, DON and ADON on 9/21/25 between 1:57pm and 2:34pm revealed they could reiterate he in-services the received, including their responsibility regarding the abuse policy, abuse investigation, abuse prevention and care plan revisions. In an interview on 9/21/25 at 2:01pm, the MDS Coordinator said she had worked at the facility for one month.
She said they audited all resident's care plans to ensure there were current.
She said she was responsible for care planning.
She said she was informed of incidents by attending morning meetings and reviewing falls and changes of condition. On 9/21/25 at 3:37pm, the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems.
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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.