Misty Willow Healthcare And Rehabilitation Center

F 0564 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

a complaint. He said they followed the guidance of the police department which was to not allow him on the facility premises. He said Family Member A became aggressive and loud when they informed him of the visitation restriction. He said he was unaware of the facility provided any type of notice to Resident #2. He said some of the incident occurred in February 2025 when he was on leave. He said he review and let me know. In an interview on 9/24/25 at 9:43am, the Administrator said the AIT was at the facility in February 2025 when Family Member A was informed that he was not allowed to visit. He said Family Member A made threatening remarks during the interaction with the AIT. When asked what kind of threatening remarks, he said the family member stated he was going to beat someone. He said Resident #2 was informed by her other family members 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/24/2025

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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet