Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Misty Willow Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact resident with stroke-related hemiplegia, morbid obesity, and high fall risk required extensive assistance for transfers. During an assisted wheelchair-to-bed transfer by two CNAs, the resident slipped, was lowered to the floor, reported hearing a crack in her leg, and described crying out in pain as staff struggled to get her up, with her leg becoming caught under equipment. No nurse assessed her at the time, no fall was documented in the record, and the DON, MD, and family were not notified when the event occurred. Over the next days, the resident experienced significant pain and later swelling and severe leg pain before being sent to the hospital, where a left femur fracture was diagnosed. Surveyors found the facility failed to assess the resident after the fall and failed for several days to seek medical guidance or report a fall that resulted in pain, swelling, and a broken femur, constituting noncompliance with professional standards of practice and the resident’s care plan.
A resident with a history of stroke, hemiplegia, and significant mobility limitations experienced an assisted fall during a wheelchair-to-bed transfer performed by two CNAs, during which her leg slipped forward and she was lowered to the floor. The resident reported hearing a crack, crying on the floor, and later having severe pain and difficulty sleeping, while her roommate observed her curled up in bed, crying and complaining of a painful fall. Despite facility policy that all falls be reported to the DON, the fall was not promptly reported or fully assessed; staff accounts conflicted about whether an LVN had been notified and whether a head-to-toe assessment was attempted. Over the next days, the resident’s documented pain scores increased, and only after severe pain and visible swelling were noted by nursing leadership was she sent to the hospital, where a left femur fracture was diagnosed, and her family was informed of the fall. This sequence reflects a failure to follow fall protocols, ensure timely nursing assessment, and uphold the resident’s right to dignified care and communication.
The facility failed to store and label food properly in the refrigerator, freezer, and dry goods pantry, with multiple open, undated items including raw eggs, bacon, chicken, corn dogs, rice, grits, cornmeal, and sugar, plus debris on pantry floors and an unknown pan covered with torn foil. The DM was also observed in the active kitchen area without a beard net while food was being prepared. The DA E and DM stated that staff were responsible for properly closing and dating opened items, and the DM acknowledged he forgot to replace his beard net.
Mechanical Soft Diet Foods Served at Improper Texture: A dietary staff member plated mechanical soft meals with inconsistent texture, including hand-chopped enchiladas that were not checked for adequate size, a tray where only the pork chop was minced while carrots, bread, and cake remained unaltered, and another tray where red beans and rice with pork matched regular texture and vegetables and bread were not sufficiently altered. The DM and DON stated mechanical soft items should be chopped or very small, fine pieces, and acknowledged some items were too large.
Missing Thermometers and Temperature Logs in Resident Refrigerators: Two residents and another resident had personal refrigerators in their rooms, but no thermometers or temperature logs were present. One resident had a stroke history with nausea and vomiting, another had HF and stroke-related weakness with nausea and vomiting, and a third had stroke, uncontrolled DM II, and communication difficulty. Staff were unsure who was responsible for monitoring the refrigerators, and the DON/ADON reported they did not know why the units had not been checked or why thermometers were missing.
Unsafe Shower Chair Used for Resident Care: Two residents who needed assistance with showering and transfers were placed in a shower chair with wobbly, unstable legs. One resident with CHF, muscle weakness, and lack of coordination and another resident with cerebral aneurysm, epilepsy, and CHF both said they told staff the chair was unsafe and felt unsafe using it. Surveyors observed the shower chair in the 400-hall shower room and staff, including the CNA, LVN, DON, and Administrator, acknowledged it was unsafe and could cause a fall.
Missed Weekly PICC Dressing Change: A resident with osteomyelitis and severe cognitive impairment had a PICC line for IV antibiotics, but the dressing was not changed at the ordered 7-day interval. An LVN misread the dressing date and believed it was due later, while the DON confirmed nurses were responsible for weekly PICC dressing changes per order and facility policy.
Insulin was administered to a resident with DM and moderate cognitive impairment without first cleansing the injection site. An LPN checked the resident’s blood sugar, determined the sliding-scale dose, and injected insulin into the upper arm after the resident pointed to the site, but did not disinfect the skin. The LPN later acknowledged missing the step, and the DON confirmed the expectation to clean the area with an alcohol pad before insulin administration.
An LVN prepared a resident’s scheduled meds, including a controlled drug, seizure med, muscle relaxant, vitamin D, and multivitamin, then left them unattended on the bedside table while stepping away to address a G-tube blockage. The resident had MS, paraplegia, severe cognitive impairment, and a PEG tube. The DON later removed the meds and stated they should not have been left unsecured.
A male resident with severe cognitive impairment and a history of sexually inappropriate behaviors repeatedly touched female residents inappropriately, including incidents in hallways, the dining room, and resident rooms. Despite staff awareness and documentation of these behaviors, the facility did not implement effective supervision or interventions to prevent further abuse, resulting in multiple incidents involving vulnerable residents with cognitive impairments.
A male resident with severe cognitive impairment and a history of sexually inappropriate behaviors repeatedly inappropriately touched two female residents with severe cognitive impairment. Staff were not consistently informed or trained on the resident's behaviors or required interventions, and incidents were not always reported immediately to the Administrator. Care plans were not promptly updated, and supervision measures were inconsistently applied, resulting in repeated incidents of sexual abuse.
A male resident with a history of sexually inappropriate behaviors was involved in multiple incidents of sexual abuse against two female residents with severe cognitive impairment. Despite repeated incidents, the facility did not consistently update care plans, inform staff of necessary interventions, or provide adequate supervision, resulting in ongoing risk of abuse and lack of thorough investigation.
A resident with severe cognitive impairment and a history of sexually inappropriate behaviors repeatedly touched other residents inappropriately over several months. The care plan was not adequately updated after each incident, and staff, including LVNs and CNAs, were not consistently informed or trained on interventions to prevent further occurrences. This lack of timely care plan revision and insufficient staff awareness resulted in ongoing risk to other residents.
A resident with dementia and depression was not informed by facility staff of a visitation restriction placed on her family member due to safety concerns involving staff. The facility did not document or communicate the restriction to the resident, instead relying on another family member to relay the information, and did not follow its own policy requiring notification of visitation rights and restrictions.
A resident with severe cognitive impairment and total dependence for care was found on the floor by her roommate, displaying signs of injury including head bleeding and hip pain. Staff failed to immediately assess her condition, did not administer ordered PRN pain medication, and moved her from the floor to the bed before calling 911, contrary to care plan and physician orders. The resident sustained a hip fracture and head injury, and was left unsupervised with her roommate after the incident.
A resident with severe cognitive impairment and hemiplegia was found on the floor after a fall and complained of hip pain. Staff lifted the resident from the floor to the bed without following proper assessment and transfer protocols, resulting in multiple injuries including a head laceration and femur fracture. Staff interviews revealed inconsistent understanding and application of fall and transfer procedures, and the transfer was not performed according to facility policy.
Two residents did not receive medications as ordered due to failures in medication administration and communication. One resident was given aspirin without a physician's order following a head injury, and another did not receive prescribed IV antibiotics for a UTI due to miscommunication between the facility and dialysis center, as well as incomplete follow-up and documentation by staff.
The facility failed to maintain proper infection control practices, as a CNA did not follow hand hygiene protocols during incontinence care for a resident, and a wound care nurse neglected hand hygiene before and after assessing a resident's heels. Both staff members acknowledged the importance of hand hygiene but did not adhere to the facility's policy.
A resident with dementia and other medical conditions was not afforded privacy during Foley catheter care, as CNAs failed to close the blinds, compromising the resident's dignity. The facility's policy and care plan emphasized the importance of privacy, which was not adhered to during this incident.
A resident with multiple health issues, including dementia and diabetes, developed a pressure ulcer on the right heel due to the facility's failure to offload the heels as per the care plan. Despite having heel protectors available, staff did not use them, and the resident's heels were not offloaded during care, leading to an unstageable pressure wound. Interviews confirmed that it was the responsibility of both nursing staff and CNAs to prevent such injuries, as per facility policy.
A resident with a history of urinary tract infections and other health issues did not receive proper incontinence care, as a CNA failed to follow the facility's perineal care policy. This included not opening the labia to clean and not wiping around the buttocks, which was confirmed by the DON as a risk for infections.
A resident requiring continuous oxygen therapy had an unlabeled oxygen humidifier, contrary to facility policy. The resident, with chronic obstructive pulmonary disease and other conditions, was observed with the unlabeled equipment. An LVN admitted responsibility for ensuring proper labeling, which should be checked every shift. The facility's policy requires humidifiers to be dated and replaced every ten days.
The facility failed to properly label medications, including eye drops and nasal sprays, on medication carts and in the medication room. Observations revealed that several medications were opened but not labeled with resident names or dates, contrary to facility policy. The DON confirmed that all medications must have pharmacy labels with open dates to ensure effectiveness, and improperly labeled medications must be discarded.
Failure to Assess and Report Assisted Fall Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively intact resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices following an assisted fall. The resident was an older female with multiple significant diagnoses, including hypertension, type 2 diabetes, anemia, stroke with left-sided hemiplegia/hemiparesis, cognitive communication deficit, muscle weakness, morbid obesity, and high fall risk. Her MDS showed she required substantial to total assistance for bed mobility and transfers, including dependence on staff for sit-to-stand and bed-to-chair transfers. Her care plan identified her as at risk for falls related to weakness and hemiplegia and documented the need for assistance with ADLs and transfers. According to interviews and record review, the resident reported that on an evening after dinner she fell during a transfer from wheelchair to bed when two CNAs attempted to assist her. She stated her leg slipped forward, she heard a crack, and the CNAs lowered her to the floor. While on the floor, she reported hollering and crying in pain as the CNAs tried to get her up, during which her leg became caught under the wheelchair and then under the bed. She stated no nurse was called to assess her, and no nurse came to evaluate her for pain or injury at that time. A roommate later reported seeing the resident in bed crying and curled up, saying she had a nasty fall and was in pain, and that the resident continued whining and whimpering for hours. Facility documentation showed no fall entry in the progress notes between the dates surrounding the alleged event, and the incident report later created reflected only that the resident was alert in bed alleging a fall a few days prior, with no specific date and no witnesses. The DON stated she was not notified of the fall when it occurred, despite facility protocol requiring the DON to be called for all falls, and that she only learned of the event days later when the resident complained of pain and swelling in the left leg. The DON’s investigation found that two CNAs had assisted the transfer when the resident slipped to the floor and that they claimed to have reported the fall to a nurse, while the LVN on duty denied being informed of any fall. During the period after the fall and before hospital transfer, documentation showed administration of PRN acetaminophen for pain, but there was no contemporaneous nursing assessment or documentation of a fall, and the family was not informed of the fall until the resident was sent to the hospital, where she was diagnosed with a left femur fracture. The facility’s failure included not promptly assessing the resident after the assisted fall, not documenting the fall in the medical record at the time it occurred, not notifying the DON, physician, or family when the fall happened, and not seeking timely medical guidance despite the resident’s subsequent complaints of pain and later-observed swelling and severe leg pain. The surveyors determined that the facility failed to seek medical guidance or report a fall that resulted in injury, including pain, swelling, and a broken femur, for approximately three days, and that the nurse failed to assess the resident after the fall. These failures were cited as noncompliance with the requirement to provide treatment and care in accordance with professional standards of practice and the resident’s comprehensive assessment and care plan. The report also notes that this deficient practice was identified as Immediate Jeopardy to resident health and safety at a specific time and date, based on the delay in appropriate medical evaluation and treatment following the fall and resulting fracture. The Immediate Jeopardy was later removed, but the facility remained out of compliance at a lower scope and severity while it continued to monitor implementation and effectiveness of its corrective actions. The failures were described as placing residents at risk for delay of appropriate medical treatment leading to pain, discomfort, and death.
Failure to Follow Fall Protocols and Provide Timely Assessment After Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to treat a cognitively intact resident with respect and dignity and to follow fall protocols, including timely nursing assessment and reporting, after an assisted fall. The resident was an older female with a history of stroke resulting in hemiplegia/hemiparesis on the left side, muscle weakness, lack of coordination, morbid obesity, and other neurologic and functional impairments. Her discharge MDS showed a BIMS score of 13/15, indicating she was cognitively intact, and she required extensive assistance for bed mobility and transfers, with helpers doing all the effort or requiring two or more helpers. Her care plan identified her as at risk for falls related to weakness and hemiplegia/hemiparesis. According to the complaint and interviews, the resident experienced an assisted fall during a wheelchair-to-bed transfer performed by two CNAs. One CNA reported that during the transfer the resident began to slip, her leg slipped forward, and she was slowly lowered to the floor. The resident stated she heard a crack, was lowered to the floor, cried while on the floor, and that the CNAs struggled to get her back into bed. She reported significant pain that night, difficulty sleeping, and emotional distress as she replayed the fall in her mind. Her roommate later observed her curled up in bed, crying and whimpering, and reported that the resident said she had a “nasty fall” and was in pain. The roommate stated the resident continued to whine and whimper in bed for hours. The facility did not ensure that the fall was promptly assessed and reported according to protocol. The DON stated that all falls were to be reported to her, but she was not notified until days later, after the resident complained of leg pain. There were conflicting accounts among staff: the CNAs stated they reported the fall to an LVN, while the LVN initially stated she had not been made aware of the fall, then later stated she was contacted by the ADON about a reported fall and was instructed to perform a head-to-toe assessment, which she said the resident refused. The resident’s pain assessments on the MAR showed varying pain scores over the days following the fall, culminating in a severe pain score, and only then was she assessed by nursing leadership, found to have pain and swelling in the left leg, and sent to the hospital where a left femur fracture was diagnosed. The family was not informed of the fall until the day of transfer to the hospital. These actions and inactions demonstrate that the facility did not follow its fall protocols, did not ensure timely nursing assessment after the fall, and did not uphold the resident’s right to dignified care and communication about her condition.
Improper Food Storage and Staff Hair Restraint Use
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen. Observation of the walk-in refrigerator found an open box exposing raw, in-shell eggs on trays with no date, an open box of raw bacon in an open plastic bag with no open date, and an open bag of sliced potatoes with the top loosely folded over and not secured, with no dates on the bag. Observation of the walk-in freezer found an open box of individually quick-frozen raw chicken in an open bag with no date and an open box of bulk corn dogs with the interior bag opened and items exposed to air, also not dated. Observation of dry goods storage found an open bag of basmati rice exposed to air and not dated, an open bag of grits with the top loosely rolled down and not secured and dated opened 12/23, debris and particles on the floor under shelving, a pan covered in foil with a tear containing unknown contents dated 4/16/25, and open bags of cornmeal and sugar with tops loosely rolled down and unsecured and undated. During kitchen activity, the DM was observed draining oil from a deep fryer without wearing a beard net while food was actively being prepared. The DA E stated that whoever returned food items to the refrigerator, freezer, or pantry was responsible for closing and dating them properly, and the DM stated he had forgotten to replace his beard net when he returned to the active cooking area.
Mechanical Soft Diet Foods Served at Improper Texture
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual needs for residents ordered mechanical soft diets. During meal service on 12/02/2025, a dietary staff member plated chicken enchiladas for a mechanical soft meal and quickly hand-chopped the enchilada in the pan with a serving spatula before plating. The chicken in the enchiladas had originally been sliced, and there was no check to ensure the chicken or tortilla pieces were an adequate size for a mechanical soft diet. On 12/03/2025, observation of lunch test trays showed a regular texture plate and a mechanical soft plate with boneless pork chop with gravy, sliced carrot coins, mashed potatoes, bread roll, and cake. The mechanical soft plate had the pork chop finely minced with gravy on top, but the carrots, bread roll, and cake were not mechanically altered. On 12/04/2025, a mechanical soft meal tray on 100 hall was observed with red beans and rice with pork, halved brussels sprouts, and a bread roll. The red beans and rice with pork was the same texture and particle size as the regular texture plate, the brussels sprouts were only halved, and the bread roll was served whole. During interviews, the dietary manager stated he had not observed the mechanical soft plates and was unaware that the enchiladas were not uniformly chopped for the mechanical soft orders. He also stated that mechanical soft food should be chopped or ground fine but still identifiable, and acknowledged that the carrots and brussels sprouts shown in photographs were too large for a mechanical soft diet. The DON stated that mechanical soft food should be soft, chopped or very small, fine pieces that are easy to chew and swallow, and agreed that the photographed vegetables were too large in size.
Missing Thermometers and Temperature Logs in Resident Refrigerators
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 3 of 8 residents reviewed for in-room refrigerators. Residents #45, #73, and #89 each had personal refrigerators in their rooms, but no thermometers were inside the units and no temperature logs were attached to them. The report states that the facility did not monitor refrigerator temperatures for these residents. Resident #89 was a female with a history of cerebral infarction due to embolism of the middle cerebral artery and a care plan noting occasional nausea and vomiting. During observation and interview, she had two small refrigerators in her room, and neither had a thermometer or temperature log. She said she had received the refrigerators a couple of months earlier, was not aware a thermometer was needed, and did not recall anyone checking the temperatures. She stated she had not consumed anything spoiled from the refrigerators. Resident #45 was a female with diagnoses including hypertensive heart disease with heart failure and right-side paralysis and weakness following stroke, and her care plan noted occasional nausea and vomiting. Resident #73 was a female with diagnoses including nontraumatic intracerebral hemorrhage, uncontrolled diabetes mellitus II, and communication difficulty, with a care plan focused on diabetes management and nutritional compliance. Observation with both residents revealed two personal refrigerators without thermometers or temperature logs. Staff interviews showed uncertainty about who was responsible for monitoring the refrigerators, and the housekeeping supervisor and ADON stated they did not know why the refrigerators had not been monitored or why thermometers were missing.
Unsafe Shower Chair Used for Resident Care
Penalty
Summary
The facility failed to ensure that the environment remained free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents for two residents who required assistance with showering and shower transfers. Resident #21 was cognitively intact with a BIMS score of 14 and had diagnoses including acute on chronic systolic CHF, muscle weakness, lack of coordination, anxiety disorder, and CKD. Her MDS showed she needed assistance with showering and transfers, and her care plan identified her as a fall risk related to muscle weakness and needing help with ADLs. During an interview, she stated that staff placed her in a shower chair with legs that moved around and wobbled, that she told staff the chair was unsafe, and that nothing had changed. She said she felt unsafe because the chair could make her fall. Resident #47 had diagnoses including cerebral aneurysm, muscle weakness, epilepsy, chronic diastolic CHF, and a cerebrospinal fluid drainage device. Her quarterly MDS showed a BIMS score of 11, indicating mild cognitive impairment, and she also required assistance with showering and shower transfers. Her care plan identified an ADL deficit requiring showering assistance and noted she was a fall risk. During an interview, she stated that the shower chair she had been placed in was very flimsy because the legs wobbled, that she told the CNA it was unsafe, and that the CNA said she could not do anything about it. She said the chair made her feel unsafe. On observation, surveyors found the shower chair in the 400-hall shower room had wobbly legs and was unsafe for use, and a video was taken of the chair. Staff interviews confirmed the chair was unsafe and could cause a resident to fall. CNA A stated she did not use that shower chair to shower residents and said staff were waiting for a new shower bench to arrive. LVN B stated she was not aware of the faulty chair and said the concern was that a resident could be injured by falling. The DON and Administrator both acknowledged the chair was unsafe and that only safe shower chairs were expected to be used, while the facility policy stated residents were to be given appropriate treatment and services to maintain or improve abilities.
Missed Weekly PICC Dressing Change
Penalty
Summary
The facility failed to ensure that Resident #25’s PICC line dressing was changed every 7 days as ordered. Resident #25 was a female admitted and readmitted with a primary diagnosis of other acute osteomyelitis of the right ankle and foot, and her quarterly MDS showed a BIMS score of 00, indicating severe cognitive impairment. Her physician orders for December 2025 directed that the PICC line dressing be changed every 7 days if the site was visible for assessment, and sooner if wet, soiled, saturated, or loose. Her care plan also identified osteomyelitis of the right ankle and included intravenous Ceftazidime and Vancomycin for 37 days. On observation, the PICC line in the upper right arm had two ports and the dressing was intact, but it was dated 11/20/25. The LVN stated she believed the dressing had been dated 11/27/25 and thought it would be changed in a couple of days, explaining that she had assessed the site before medication administration and that it was an honest mistake to misread the date. She also stated the risk of not changing the IV dressing was infection. The DON stated nurses were responsible for assessing PICC dressings and completing weekly dressing changes as ordered, and the Administrator stated the expectation was for nursing to work with the DON and have processes in place to prevent the risk of infection. The facility policy stated the transparent dressing is changed every 7 days or sooner if loosened or if moisture, fluid, blood, or exudate is present.
Insulin Injection Given Without Skin Disinfection
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when LVN C administered insulin to Resident #71 without first cleaning and disinfecting the injection site. Resident #71 was a [AGE]-year-old male admitted to the facility with diagnoses including malignant neoplasm of the prostate, cerebral infarction, and diabetes mellitus due to underlying condition with diabetic neuropathy. His quarterly MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and his active physician orders included NovoLog FlexPen subcutaneous insulin on a sliding scale for diabetes mellitus. During observation, LVN C checked Resident #71's blood sugar, obtained a reading of 262, and stated she would administer 6 units of insulin as ordered. Resident #71 was lying in bed with his upper right arm exposed and pointed to that area when asked where he wanted the injection. LVN C pushed up his shirt sleeve and gave the insulin injection to the upper right arm without disinfecting the skin. When interviewed immediately afterward, LVN C stated she missed disinfecting the area before giving the injection and said she did not know why she missed the step. The DON stated she was not aware of the incident and confirmed the expectation was to clean the skin with an alcohol pad before insulin administration. Facility policy also required cleansing the injection site with alcohol and following infection control procedures during medication administration.
Unsecured medications left at bedside during G-tube medication administration
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and accessible only to authorized personnel for one resident who was reviewed for medication storage. Resident #92 was a female with multiple sclerosis, paraplegia, impulsiveness, high blood pressure, gastrostomy status, and severe cognitive impairment with a BIMS score of 00. Her MAR showed scheduled medications due at 09:00 AM, including Pregabalin, Baclofen, Cholecalciferol, Levetiracetam, and Centrum liquid, all to be given via PEG tube. During a medication observation, an LVN prepared those medications and brought them with water to flush the resident’s G-tube at the bedside. While attempting to address a slight blockage in the G-tube, the LVN left the room to get something from the medication room and left the medications unattended on the resident’s bedside table. The medications were not locked in the medication cart or medication room, and no staff were in the room while the LVN was away. The DON later removed the medications from the room and stated the nurse should not have left them at the bedside. The LVN stated it was an honest mistake and acknowledged that leaving medication unattended meant anyone could have access to it.
Failure to Prevent Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, resulting in multiple incidents involving a male resident who inappropriately touched female residents on several occasions. The male resident, who had severe cognitive impairment and a history of sexually inappropriate behaviors, was observed by staff touching the breasts and thighs of female residents, some of whom also had severe cognitive impairment and were unable to advocate for themselves. These incidents occurred in various locations within the facility, including hallways, the dining room, and resident rooms, and were witnessed by CNAs and reported to nursing staff. Despite the initial incident of sexual abuse, the facility did not implement effective measures to prevent further occurrences. The male resident continued to have access to vulnerable female residents, and additional incidents of inappropriate touching were documented over several months. Staff interviews revealed that the male resident would sometimes offer snacks to other residents as a means of interaction, and that supervision and monitoring were inconsistent. Care plans for the involved residents noted their cognitive impairments and wandering behaviors, but interventions to prevent abuse were not adequately enforced or updated in a timely manner following each incident. Documentation and interviews indicated that staff were aware of the male resident's behaviors and the risks posed to other residents, yet failed to consistently separate him from potential victims or provide sufficient supervision. The facility's policies required protection from abuse, but these were not effectively implemented, resulting in repeated incidents. The failures placed residents at risk of abuse, mental anguish, and fearfulness, as confirmed by the survey findings.
Failure to Prevent and Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse, specifically sexual abuse, among residents. Over a four-month period, a male resident with severe cognitive impairment and a history of sexually inappropriate behaviors inappropriately touched at least two female residents, both of whom also had severe cognitive impairment and were unable to advocate for themselves. Despite documented incidents of inappropriate touching, including fondling of breasts and inner thighs, the facility did not consistently update care plans, provide adequate supervision, or ensure staff were informed of the resident's behaviors and necessary interventions. Staff members, including LVNs and CNAs, were not consistently aware of the male resident's history of sexual behaviors or the interventions required to prevent further incidents. Several staff interviews revealed a lack of specific training or in-service education regarding the resident's behaviors and the facility's abuse prevention protocols. In some cases, staff did not immediately report incidents of abuse to the Administrator as required by policy, and there was confusion about the appropriate steps to take following such incidents. The care plans for the involved residents were not always updated promptly to reflect new risks or interventions after incidents occurred. The facility's failure to separate residents after incidents, provide 1:1 supervision when indicated, and ensure all staff were aware of and trained on abuse prevention measures contributed to repeated occurrences of sexual abuse. The male resident continued to have access to vulnerable female residents, and interventions such as increased supervision or room changes were inconsistently applied. These failures placed residents at risk of further abuse, mental anguish, and fearfulness, as documented by surveyor observations, interviews, and record reviews.
Removal Plan
- Facility Medical Director was notified of the Immediate Jeopardy (IJ) by the Administrator.
- Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made.
- The ED/ DON/ Social Worker and RN, Clinical Resource will be trained on Abuse/ Neglect Investigation and Reporting by Risk Management Resource, including how to conduct a thorough investigation to implement measures to prevent further incidents and protect other residents.
- Training and knowledge checks (Post-Test) were initiated with all staff on shift 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. Training & Knowledge Check including Post-Test will be completed with all staff. 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 scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks.
- 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.
- 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.
- 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 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.
- Safe-Surveys were conducted 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 report.
Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of sexual abuse and did not take adequate steps to prevent further potential abuse for two residents with severe cognitive impairment. Over a four-month period, a male resident with a history of sexually inappropriate behaviors was involved in multiple incidents of sexual abuse against two female residents and an unidentified female resident. Despite documented incidents where the male resident was observed touching female residents inappropriately, the facility did not consistently implement or update interventions to prevent recurrence, nor did they ensure that all staff were informed of the resident's behaviors and the necessary supervision measures. Record reviews and staff interviews revealed that the male resident had a documented history of sexually inappropriate behaviors, including touching female residents' breasts and inner thighs. Staff members reported that they were not always informed of the resident's history or the interventions required to prevent further incidents. In several cases, staff intervened only after witnessing inappropriate behavior, and there was a lack of evidence that care plans were updated or that supervision was consistently provided following each incident. Additionally, some incidents were not reported or investigated according to the facility's abuse prevention policy, and staff training on specific interventions for the resident was lacking. The affected female residents had severe cognitive impairment and were unable to advocate for themselves or recall the incidents. The facility's failure to thoroughly investigate all allegations, update care plans, and ensure staff were adequately trained and informed resulted in repeated incidents of sexual abuse. The lack of consistent supervision and failure to implement protective measures placed residents at risk of further abuse, mental anguish, and fearfulness.
Removal Plan
- Facility Medical Director was notified of the Immediate Jeopardy (IJ) by the Administrator.
- Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made.
- Training and knowledge checks (Post-Test) were initiated with all staff on shift 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).
- Training & Knowledge Check including Post-Test will be completed with all staff. 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.
- 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.
- 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. 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.
- 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.
- 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.
- DON/ Designee will review the 24-[NAME]
Failure to Update and Implement Comprehensive Care Plan for Resident with Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address the nursing, mental, and psychosocial needs of a resident who exhibited sexually inappropriate behaviors. Despite multiple incidents of the resident inappropriately touching other residents over a four-month period, the care plan was not revised in a timely or adequate manner to reflect new interventions or increased supervision. Nursing staff, including LVNs and CNAs, were not consistently aware of or trained on specific interventions to prevent further incidents, and several staff members reported not being informed of the resident's behaviors or the necessary preventive measures. The resident in question had a history of severe cognitive impairment, mild depression, and diagnoses including dementia and adjustment disorder with anxiety. Multiple documented incidents occurred in which the resident touched female residents inappropriately, often targeting those with poor cognition who could not advocate for themselves. Staff responses to these incidents varied, with some staff intervening immediately and others unaware of the resident's behavioral history or required interventions. The care plan was only sporadically updated, and interventions such as 1:1 supervision were inconsistently implemented or communicated among staff. Interviews with staff revealed gaps in communication, training, and care plan updates following each incident. Some staff were unaware of the resident's behavioral risks until after witnessing an incident, and others did not review the care plan or receive specific in-services related to the resident's behaviors. The lack of a coordinated, updated care plan and insufficient staff awareness placed other residents at risk of not having their behavioral needs met, potentially leading to further abuse and emotional distress.
Failure to Inform Resident of Visitation Rights and Restrictions
Penalty
Summary
The facility failed to inform a resident of her visitation rights and the related facility policy and procedures, including any safety restrictions or limitations, the reasons for such restrictions, and to whom the restrictions applied. This deficiency was identified for one resident who was not notified by the facility when her family member was no longer allowed to visit due to safety concerns. The resident, who had diagnoses of dementia, adjustment disorder, and depression, reported feeling lonely and isolated, and stated she missed her family member, who had not been allowed to visit for several months. She also stated she never received any policy or notice about the visitation restriction. Interviews with facility staff, including the former DON, social worker, administrator, and ADON, revealed that the family member was restricted from visiting after incidents involving inappropriate behavior toward a staff member, which led to police involvement. The administrator and other staff members confirmed that the decision to restrict visitation was made for staff safety, but there was no documentation in the resident's medical record regarding the restriction, nor evidence that the resident was formally informed by facility staff. Instead, it was believed that another family member had informed the resident about the restriction. The facility's own policy required informing residents and/or their representatives of their visitation rights and any clinical or safety restrictions. However, the administrator acknowledged that the resident rights policy was not reviewed or followed when addressing the visitation issue, and the incident was handled primarily from the perspective of staff safety. There was no documentation or formal communication to the resident regarding the restriction, resulting in the resident being unaware of her rights and the reasons for the limitation.
Failure to Provide Person-Centered Care and Proper Response After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, and total dependence for activities of daily living was found on the floor by her roommate. Staff failed to immediately assess and respond to the resident's condition according to her care plan and physician orders. The resident was observed to be face down, bleeding from the head, and later complained of hip pain. Despite these symptoms, staff picked the resident up from the floor and placed her in bed before calling 911, potentially causing further harm. The resident's care plan included interventions for fall risk, pain management, and monitoring for complications due to her medical history, which included a stroke, hypertension, and use of anticoagulants. However, staff did not follow these interventions. The resident's verbal complaints of pain were not adequately addressed, and her prescribed PRN pain medication was not administered as ordered. Additionally, the staff left the resident and her roommate alone in the room after the incident, contrary to expectations for supervision and safety. EMS documentation and hospital records confirmed that the resident sustained a right femoral fracture, head laceration, and brain bleed. The EMS report noted that the resident was found on the bed with no sheets, indicating she had been moved from the floor by staff prior to their arrival. Interviews with staff revealed inconsistencies in the assessment and response to the fall, with some staff unsure of the appropriate actions to take and others acknowledging that the resident's position and complaints of pain were not properly addressed before moving her. The failure to follow established protocols and care plans resulted in significant injury and ultimately the resident's death.
Failure to Ensure Safe Transfer After Resident Fall Resulting in Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure a resident was free from accident hazards and received adequate supervision and assistance during a transfer after a fall. The resident, an elderly female with a history of stroke, severe cognitive impairment, hemiplegia, and total dependence for activities of daily living, was found face down on the floor. Despite her verbal complaint of hip pain, staff lifted her from the floor and placed her in bed without proper precautions, potentially causing further harm. The resident sustained multiple injuries, including a laceration above the eye, a closed head injury, and a broken femur. Interviews and record reviews revealed that staff did not follow appropriate assessment and transfer protocols. Staff acknowledged hearing the resident complain of hip pain but proceeded to move her, with one staff member later admitting that moving the resident could have caused further injury. The facility's policy required a two-person lift with specific support for the head, torso, and hips, but staff described lifting the resident by her head, legs, and ankles, which was not in accordance with policy. Further interviews with nursing and administrative staff indicated inconsistent understanding and application of fall and transfer protocols. Some staff believed it was acceptable to move the resident after a basic assessment, while others stated that a resident with pain or possible injury should not be moved until EMS arrived. Documentation of assessments and vital signs was incomplete, and there was confusion about the correct procedure for transferring a resident after a fall, especially when injury was suspected.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for two residents. For one resident with a history of stroke, hypertension, and severe cognitive impairment, a nurse administered a non-scheduled aspirin as a PRN pain medication without a physician's order, despite the resident having a known head injury. The resident's medication administration record did not reflect an order for PRN aspirin, and facility policy required medications to be administered only as ordered by the physician and documented accordingly. For another resident with diagnoses including anemia, renal failure, dementia, and a history of chronic urinary tract infections (UTIs), the facility failed to ensure the resident received prescribed IV antibiotic therapy as ordered by the physician. The resident was discharged from the hospital with orders for Tobramycin to be administered post-dialysis, but due to miscommunication between the facility, dialysis center, and hospital, the medication was not administered. Facility staff became aware that the medication had not been given only after discovering the initial dose was still in the refrigerator days later. Attempts to administer the medication at the facility were unsuccessful due to the resident's refusal of IV insertion, and there was no evidence that the nephrologist was consulted for alternative arrangements in a timely manner. Interviews and record reviews revealed that staff did not consistently communicate medication refusals or administration issues to the resident's family or the prescribing physicians. Documentation was incomplete regarding the administration or refusal of medications, and there was a lack of follow-up to ensure the resident received necessary antibiotic therapy. These failures resulted in residents not receiving medications as ordered and not having medication administration properly documented, as required by facility policy.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices by staff members. Specifically, CNA W did not follow proper hand hygiene protocols during incontinence care for a resident. CNA W was observed using the same gloves to handle clean wipes, apply barrier cream, and change the resident's brief without washing hands before or after the procedure. This resident, who was moderately cognitively impaired and required extensive assistance with activities of daily living, was at risk due to these lapses in infection control. Additionally, the wound care nurse did not practice hand hygiene before and after assessing another resident's heels. The nurse entered the resident's room, applied gloves without washing or sanitizing hands, and left the room without performing hand hygiene after removing the gloves. Both staff members acknowledged the importance of hand hygiene in preventing infections, yet failed to adhere to the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent the spread of infections.
Failure to Ensure Privacy During Catheter Care
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident during Foley catheter care. The resident, a male with a history of dementia, urinary retention, acute kidney failure, hydronephrosis, benign prostatic hyperplasia, and diabetes mellitus, was observed in bed with an indwelling Foley catheter. During a scheduled catheter care session, two CNAs provided care without closing the blinds to the resident's window, thereby compromising the resident's privacy. The resident's care plan included interventions to promote dignity by ensuring privacy during personal care. However, during the catheter care, the CNAs did not adhere to this aspect of the care plan. An interview with one of the CNAs revealed an acknowledgment of the oversight, rating her performance as 7.5 out of 10 due to the failure to close the blinds. The Director of Nursing confirmed that privacy should be provided during care to promote dignity, aligning with the facility's policy on dignity, which emphasizes maintaining and protecting resident privacy during personal care.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to the development of a pressure ulcer on the resident's right heel. The resident, a male with multiple diagnoses including dementia, diabetes mellitus, and impaired mobility, was admitted without any pressure ulcers. However, the care plan identified a potential for pressure ulcer development due to impaired mobility, with interventions such as weekly skin assessments and floating heels as tolerated. Despite these interventions, the resident developed an unstageable pressure wound on the right heel, measuring 6cm x 7.5cm, which was observed during a care session. During an observation, the resident was found in bed without his heels being offloaded, and no heel protectors were in use, despite the presence of heel protectors in the resident's drawer. Interviews with the CNA and RN revealed that it was the responsibility of both the nursing staff and CNAs to ensure the resident's heels were offloaded to prevent pressure injuries. The facility's policy on skin and wound management emphasized the importance of preventing new pressure injuries and providing necessary treatment for existing ones, which was not adhered to in this case.
Inadequate Incontinence Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, a female with a history of urinary tract infection, cerebrovascular disease, muscle wasting, type 2 diabetes, and morbid obesity, was always incontinent of bowel and bladder and required extensive assistance with all activities of daily living. During an observation, a CNA did not perform proper perineal care by failing to open the labia to clean and not wiping around the buttocks after an incontinent episode. The CNA, despite being deemed competent in performing perineal care, acknowledged the importance of proper cleaning to prevent infections. The facility's policy on perineal care, which includes specific steps for cleaning the perineal and rectal areas, was not followed. The Director of Nursing confirmed that not adhering to these procedures placed residents at risk of urinary tract infections.
Failure to Label Oxygen Humidifier
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as evidenced by the lack of proper labeling on the resident's oxygen humidifier. The resident, a [AGE] year-old with multiple medical conditions including chronic obstructive pulmonary disease and dementia, was observed with an unlabeled oxygen humidifier. The resident's care plan and physician's orders specified the need for continuous oxygen therapy and regular changes of the oxygen tubing and humidifier bottle. However, the humidifier was not labeled with the date it was last changed, which is a requirement according to the facility's policy. During an interview, a Licensed Vocational Nurse (LVN) acknowledged that the resident often changes the humidifier independently, with supplies provided by family members. Despite this, the LVN admitted that it was her responsibility to ensure the humidifier was labeled correctly, which should have been checked every shift. The facility's policy, last revised in 2007, mandates that oxygen therapy equipment be maintained in a clean and sanitary manner, with pre-filled humidifiers dated and replaced every ten days or as needed. This oversight in labeling could potentially affect the quality of oxygen support provided to residents.
Improper Labeling of Medications in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles, which included the appropriate accessory and cautionary instructions and expiration dates. During an observation, it was found that the medication carts for Halls 300 and 400 contained several medications, such as Dorzol/Timolol solution, Latanoprost solution, Fluticasone Propionate nasal spray, and various eye drops, that were opened but not labeled with the resident's name or dated. This oversight was confirmed during an interview with a medication aide (MA A), who acknowledged that opened medications should be dated and labeled with the resident's name to determine when they should be discarded. Additionally, the medication room refrigerator contained vials of Tuberculin Purified Protein Derivative (PPD) that were open but not dated. The Director of Nursing (DON) confirmed that all medications must have pharmacy labels, including the open date, to ensure their effectiveness. The lack of proper labeling and patient identifiers on the medications observed was inconsistent with the facility's labeling practices, as outlined in their policy. The DON stated that medications lacking patient names could no longer be used and must be discarded, as the use of multidose PPD containers without an open date could lead to medication errors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 574 citations issued within 25 miles in the last 12 months — including the 52 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Houston Transitional Care | 0.4 mi | ★★★★★ | 1 | 0 |
| Champions Healthcare At Willowbrook | 1 mi | ★★★★★ | 14 | 0 |
| Fallbrook Rehabilitation And Care Center | 3 mi | ★★★★★ | 17 | 4 |
| Park Manor Of Cyfair | 3 mi | ★★★★★ | 1 | 0 |
| Cypress Creek Rehabilitation And Healthcare Center | 4.3 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Misty Willow Healthcare And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.