Health inspection·June 16, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he would be upset because he would prefer to have his privacy as well. He said they currently have no spare curtains available for immediate replacement but he plans to order more next month. Interview with the Administrator on 06/16/23 at 10:29 AM, he said curtains were necessary to provide privacy to the residents because their room is their home and they should have the ability to have privacy regardless of what they were doing for themselves or what care they receive. He said, if he were Resident #43, he would feel frustrated for not having a privacy curtain. He said it was a residents' rights issue if the resident was not able to be given some kind of privacy. Record review of the facility's policy on Quality of Life - Dignity, dated October 2009, revealed, . 6) Resident's private space and property shall be respected at all times . 10) Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedure . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 2 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 3 residents (Resident #191). - The facility did not develop a base line care plan for Resident #191. This failure could affect residents who require baseline care plan, and could place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings include: Record review of Resident #191's admission record revealed a [AGE] year-old resident admitted on [DATE] and discharged on 1/17/2023. The admission record documented he had diagnoses including encephalopathy (a term used to describe a disease that affects brain structure or function), cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), lack of coordination, cognitive communication deficit (affects how people use and understand language due to impaired cognition), muscle weakness, unspecified convulsions ( is a general term used to describe uncontrollable muscle contractions), and transient ischemic attack (a temporary period of symptoms similar to those of a stroke). The admission record noted he had been a resident of the facility for 59 days. Record review of Resident #191's admission MDS dated [DATE] with an ARD of 11/22/2022 revealed a BIMS score of 3 indicating a severe cognitive impairment. The MDS revealed Resident #191 had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering. The MDS documented he required limited one-person assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and one-person assistance with transfers and locomotion but those activities only occurred once or twice in the days prior to the assessment. The MDS noted Resident #191 was occasionally incontinent of bladder and always incontinent of bowel, but he was not on a toileting program. The MDS documented he was administered antidepressant and diuretic medications three of the seven days prior to the assessment. The MDS revealed Resident #191 received OT, PT, and ST services. The MDS noted he participated in the assessment and had no guardian or legally authorized representative. The MDS documented Resident #191 planned to be discharged to the community and active discharge planning to return to the community existed. Record review of Resident #191's January 2023 MAR revealed prescriptions including Melatonin 3mg tablet one tablet at bedtime for sleep, Sertraline 25mg tablet one tablet one time daily for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Keppra 500mg tablet one tablet twice daily for seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). Record review of the facility's EHR revealed there was no initial care plan for Resident #191. Record review of Resident #191's census report dated 6/15/2023 revealed no stoppage in care between 11/19/2022 and 1/17/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 3 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 6/16/2023 at 9:07 AM with The MDS Coordinator, she said different staff assisted in the creation of the facility's care plans, but The MDS Coordinator said the MDS Team was responsible for ensuring they were completed in the EHR. The MDS Coordinator said the initial 24-hour care plan was created by the RN's. The MDS Coordinator said a resident who had resided at the facility for 59 days should have had a care plan. The MDS Coordinator said Resident #191 did not have a care plan of any kind in the EHR. The MDS Coordinator said she was unsure why Resident #191 did not have a completed baseline care plan. The MDS Coordinator said she was unsure if the lack of a care plan could cause a resident to have missed care, or any lack of care. Interview on 6/16/2023 at 10:18 AM with the DON, she said she had been employed by the facility since April of 2022. The DON said her duty is to oversee everything at the facility. The DON said Resident #191 should have had a care plan completed. The DON said a resident who had resided at the facility should have had a care plan completed. The DON said there was no reason not to have a baseline care plan or a care plan completed for Resident #191. The DON said if Resident #191 did not have any kind of care plan the facility would have had difficulties tracking any changes in his condition or plans. The DON said in an emergency, care could have been incomplete for Resident #191 without any form of care plan. Interview on 6/16/2023 at 10:35 AM with the Admin, he said he expects all residents of the facility to have a baseline and a care plan completed timely. The Admin said care plans should be updated with changes in plans of care, change in condition, or change in orders. The Admin said a resident who had resided at the facility for 59 days should have had a baseline and a care plan completed. The Admin said Resident #191 was at risk of not having orders followed appropriately, or not having his personal preferences adhered to. Record review of the facility's Comprehensive Person-Centered Care Planning policy dated January 2022 read in part .within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 4 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Residents #191) of three residents reviewed for comprehensive care plans. -The facility failed to ensure a comprehensive care plan was created or implemented for Resident #191 These failures could place the residents at risk for not receiving the appropriate care and services to maintain their highest level of well-being. Findings included : Record review of Resident #191's admission record revealed a [AGE] year-old resident admitted on [DATE] and discharged on 1/17/2023. The admission record documented he had diagnoses including encephalopathy (a term used to describe a disease that affects brain structure or function), cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), lack of coordination, cognitive communication deficit (affects how people use and understand language due to impaired cognition), muscle weakness, unspecified convulsions ( is a general term used to describe uncontrollable muscle contractions), and transient ischemic attack (a temporary period of symptoms similar to those of a stroke). The admission record noted he had been a resident of the facility for 59 days. Record review of Resident #191's admission MDS dated [DATE] with an ARD of 11/22/2022 revealed a BIMS score of 3 indicating a severe cognitive impairment. The MDS revealed Resident #191 had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering. The MDS documented he required limited one-person assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and one-person assistance with transfers and locomotion but those activities only occurred once or twice in the days prior to the assessment. The MDS noted Resident #191 was occasionally incontinent of bladder and always incontinent of bowel, but he was not on a toileting program. The MDS documented he was administered antidepressant and diuretic medications three of the seven days prior to the assessment. The MDS revealed Resident #191 received OT, PT, and ST services. The MDS noted he participated in the assessment and had no guardian or legally authorized representative. The MDS documented Resident #191 planned to be discharged to the community and active discharge planning to return to the community existed. Record review of Resident #191's January 2023 MAR revealed prescriptions including Melatonin 3mg tablet one tablet at bedtime for sleep, Sertraline 25mg tablet one tablet one time daily for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Keppra 500mg tablet one tablet twice daily for seizures (Sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). Record review of the facility's EHR revealed there was no completed comprehensive care plan for Resident #191. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 5 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #191's census report dated 6/15/2023 revealed no stoppage in care between 11/19/2022 and 1/17/2023. Interview on 6/16/2023 at 9:07 AM with The MDS Coordinator, she said if the facility's permanent MDS staff was present she assisted them and if not, she was The MDS Coordinator coordinator. The MDS Coordinator said different staff assisted in the creation of the facility's care plans, but The MDS Coordinator said the MDS team was responsible for ensuring they were completed in the EHR. The MDS Coordinator said the initial 24-hour care plan was created by the RN's and the following care plans were created and updated by The MDS Coordinator team. The MDS Coordinator said a resident who had resided at the facility for 59 days should have had a care plan. The MDS Coordinator said Resident #191 did not have a care plan of any kind in the EHR. The MDS Coordinator said the 24-hour care plan would trigger the continuing plan. The MDS Coordinator said she had opened Resident #191's entry, but she did not complete it. The MDS Coordinator said the facility's permanent MDS coordinator had completed the five-day MDS but had been out at the time Resident #191 arrived due to a family emergency. The MDS Coordinator said she was unsure why Resident #191 did not have a completed care plan. The MDS Coordinator said she was unsure if the lack of a care plan could cause a resident to have missed care, or any lack of care. The MDS Coordinator said she was unsure if the facility may have a copy of a paper care plan for Resident #191. Interview on 6/16/2023 at 10:18 AM with the DON, she said she had been employed by the facility since April of 2022. The DON said her duty is to oversee everything at the facility. The DON said Resident #191 should have had a care plan completed. The DON said a resident who had resided at the facility should have had a care plan completed. The DON said there was no reason not to have a care plan completed for Resident #191. The DON said if Resident #191 did not have a care plan the facility would have had difficulties tracking any changes in his condition or plans. The DON said in an emergency, care could have been incomplete for Resident #191 without a care plan. Interview on 6/16/2023 at 10:35 AM with the Admin, he said he expects all residents of the facility to have a care plan completed timely. The Admin said care plans should be updated with changes in plans of care, change in condition, or change in orders. The Admin said a resident who had resided at the facility for 59 days should have had a care plan completed. The Admin said Resident #191 was at risk of not having orders followed appropriately, or not having his personal preferences adhered to. Record review of the facility's Comprehensive Person-Centered Care Planning policy dated January 2022 read in part .the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident ., .the facility IDT will develop and implement a comprehensive person-centered care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) ., and .the facility will provide the resident and resident representative, if applicable, advance notice of care planning conference . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 6 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #38) of 3 resident reviewed for respiratory care. Residents Affected - Few -The facility failed to follow the physician orders for Resident #38's oxygen rate of 2L. This failure could place residents who received oxygen therapy at risk of respiratory complications. Findings included: Record review of Resident #38's face sheet revealed a [AGE] year-old -female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were pulmonary fibrosis (Scarring in the lungs), hypertension (high or raised blood pressure), cerebral infarction (Disrupted blood flow to the brain due to problems with the blood vessel), diabetes mellitus (body does not control the amount of glucose in the blood and kidneys) and atherosclerotic heart disease (thickening of the arteries caused by buildup of plaque). Record review of Resident #38's quarterly MDS dated [DATE] revealed BIMS at 13 indicating intact cognition. It also revealed resident required extensive assist with 2 to 3 staff assistance for ADL care. Further review of the resident MDS indicated the resident was on oxygen. Record review of Resident#38's care plan dated 04/04/22 revealed oxygen therapy was not care planned. Record review of Resident#38's order details revealed oxygen at 2L/min continuous per NC active date 11/25/22. Record review of Resident # 38's MAR dated June 2023 revealed O2 at 2L/min continuous per NC every shift order date 11/25/22 and discontinued 06/13/23. Record review of Resident#38's order summary report for June 2023 revealed may use oxygen at 2 to 3 liters/minute to keep oxygen saturation above or equal to 92% every shift active date 06/14/23. During an observation and interview on 06/13/23 at 10:12 a.m., revealed Resident #38's oxygen tank on the back of her wheelchair was set to 2.5 liters. Resident #38 said she did not change the oxygen set on the tank. She said her oxygen setting should be set to 4 Liters. Resident #38 denied any distress at this time. During an observation and interview on 06/13/23 at 10:15 a.m., ADON D said Resident # 38's oxygen tank was set to 2.5 L, and she turned it to 2 liters. She said the resident should be on 2 L, not 2.5 L. ADON D said oxygen should only be changed if the doctor gave the change order. She said if the resident was given oxygen below or above could cause a negative outcome; if Resident # 38 was given lower than ordered, it could cause hypoxia(oxygen is not available in sufficient amounts at the tissue level); and if she was given higher than ordered, it could cause hypercapnia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 7 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 06/14/23 at 9:07 a.m., revealed Resident 38's oxygen tank on the back of her wheelchair was set at 2.5 L. Resident # 38 said she could not have reached behind her wheelchair and adjusted the setting on the oxygen tank. During an observation and interview on 06/14/23 at 9:10 a.m., revealed Resident #38's oxygen tank was still on 2.5 liters. LVN H said Resident #38's oxygen tank was set at 2.5 L. She said Resident #38's oxygen should be set at 3 L because that was the order from the doctor. During an interview and record review of Resident # 38's order summary report on 06/14/23 at 9:15 a.m., ADON D said she could not find the order for the oxygen on Resident #38's order summary report, but she knew she had an order for oxygen for 2 liters. She would go and search through other Resident #38's orders and find out what happened. During an interview on 06/14/23 at 10:17 a.m., the DON said Resident #38's orders were discontinued by the DON from the northwest on 06/13/23 by mistake, but the resource nurse reentered and cross-checked all the medications. She said Resident #38 was on oxygen at 2 Liters on Monday (06/12/23), not at 2.5 Liters and should be on 2 Liters up till today but she would ask the physician change the order as of today (06/14/23). The DON said oxygen could be changed during an emergency, and the doctor would be notified because oxygen is considered medication. She said if the oxygen was increased more than what was ordered, it could cause Resident #38's natural drive to breathe would be reduced and could cause hypercapnia. She also said if Resident #38's oxygen setting was below the physician's order, the resident's oxygen saturation could be lowered, and the resident would have difficulty with breathing. The DON said she became aware the oxygen order was not in the physician's order when the surveyor asked about the oxygen order. She said the mistake that the oxygen order was dropped would not have been found out until medication reconciliation. She said two nurses had worked with Resident #38 since yesterday and did not pick up the resident's oxygen had fallen off (the resident oxygen was discontinued). During an interview on 06/14/23 at 4:51 p.m., LVN H said Resident # 38's oxygen tank was set to 2.5 L. She said when she looked at the order s today, she did not have any order and did not know what happened to the order. LVN H said she came to work today at 7:00 a.m. LVN H said she had not checked the order before the surveyor saw the resident, but she already knew she had order for oxygen because she had worked with the resident before. She said the resident has always been on 3 liters and did not know when it was changed. She said the resident could not change the setting on the O2 tank when she was sitting in the chair. Record review of the facility policy on oxygen administration reviewed/revised 4/4/2023 read in part . it is the policy of this facility that oxygen therapy is administered, as ordered by the physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 8 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6 percent based on 2 errors out of 29 opportunities, which involved 1 of 8 residents (Resident #5) reviewed for medication errors. Residents Affected - Few - MA A failed to administer medication as ordered to Resident #5 by administering OTC Lidocaine 4% Patch, a patch used for pain, instead of RX only Lidocaine 5% to the resident's right shoulder and lower back. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled pain. Findings Include: Record review of Resident #5's Face Sheet dated 06/14/23 revealed, a [AGE] year-old female admitted to the facility with diagnoses which included: muscle wasting, pain in left shoulder, pain in right shoulder, pain in right knee, pain in spine and difficulty walking. Record review of Resident #5's Quarterly MDS dated [DATE] revealed, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, supervision for most ADLS, use of a wheelchair, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #5's undated Care Plan revealed, focus- risk for pain related to osteoarthritis, pain in shoulders and back; intervention- administer analgesia medication as per orders. Record review of Resident #5's Order Summery Report dated 06/14/23 revealed, Lidocaine 5%- apply to lower back one time a day for pain with a start date of 01/08/21. Record review of Resident #5's Order Summery Report dated 06/14/23 revealed, Lidocaine 5%- Apply to right shoulder one time a day for pain and remove per schedule with a start date of 10/06/22. Observation on 06/14/23 at 08:40 AM revealed, MA A preparing medication for administration to Resident #5. She retrieved 2 Lidocaine 4% patches, cut open the packet, and entered into Resident #5's room. MA A labeled the patches with her initials + date and then applied one patch to Resident #5's right shoulder and the other to the resident's lower back. Interview on 06/14/23 at 11:08 AM, the DON said that prior to medication administration nursing staff must verify the patient, parameters and then the order against the medication to be administered She said Lidocaine 4% and Lidocaine 5% are not interchangeable because they are different doses. The DON said Lidocaine 4% is an OTC dose while Lidocaine 5% is a prescription. She said failure to administer Lidocaine as ordered could place residents at risk for inadequate pain control. Interview on 06/14/23 at 11:25 AM, MA A said prior to administering medications to residents nursing staff are expected to check the medication to be administered against the order. She said she had been applying Lidocaine 4% to Resident #5 since that was the only Lidocaine Patch available. MA A said that Resident #5 did not have any prescription strength Lidocaine (5%) in the facility and she had not noticed that the resident had received Lidocaine 4% instead of 5%. She said Lidocaine 4% and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 9 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5% percent were not interchangeable because they are different strengths and failure to administer the correct patch could place residents at risk of insufficient pain control. Interview on 06/14/23 at 11:48 AM, the Pharmacist said that Lidocaine 5% had not been delivered to the facility for Resident #5 since 10/19/22. He said on 10/19/22 the pharmacy delivered 14 Lidocaine 5% patches with instructions to apply once daily to the right shoulder. The Pharmacist said the facility had not received any other Lidocaine Patches with any order instructions except the application to the shoulder. Record review of the facility Policy titled Medication Administration-General Guidelines revised 11/13/18 revealed, Preparation: c- prior to administration the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions . the physician's order are checked for the correct dosage schedule. Administration: i-medications are administered in accordance with written orders of the attending physician. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 10 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication rooms (Medication Room) reviewed for medication storage. - The facility failed to ensure the Medication Room did not contain multidose insulin containers with no patient identifiers. This failure could place residents at risk of adverse medication reactions and infections. Findings Include: Observation on 06/14/23 at 09:10 AM, inventory of the medication room with the DON revealed: - one open and in use Lantus Insulin Vial with no patient identifiers. - one open and in use Humalog Flexpen with no patient identifiers. Interview on 06/14/23 at 09:19 AM, the DON said that all medications must have pharmacy labels, which include medication information as well as patient identifiers. She said the observed Lantus vial and HumaLOG Insulin pen were not appropriately labeled because they had no patient identifiers and not consistent with their facility labeling practices. The DON said since the medications lacked patient identifiers they could no longer be used and must be discarded in the drug disposal bin located in the medication room. She said the use of multidose insulin containers with no patient identifiers could place residents at risk of medication errors, receiving the wrong medication and infection if the medication is used on multiple people. Record review of the facility policy titled Medication Labels revised 11/13/18 revealed, a- each prescription label includes: 1- resident's name, 2- specific directions for use, including route of administration. Bimproperly or inaccurately labeled mediations are rejected and returned to the dispensing pharmacy. Gmedication containers having soiled, damaged, incomplete, illegible, or makeshift labels are returned to the issuing pharmacy for relabeling or destroyed in accordance with the medication destruction policy. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 11 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 3 residents (Resident #73) reviewed for diet. -The facility failed to ensure Resident #73 was provided a nutritional supplement as ordered. -This failure placed residents at risk of experiencing nutritional deficiencies and weight loss. Findings include: Record review of Resident #73's face sheet revealed an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with unspecified severe protein-calorie malnutrition, pressure ulcer of sacral region stage 4, edema and functional quadriplegia. Record review of Resident #73's MDS section K, dated 05/24/2023, revealed the resident had complaints of difficulty or pain when swallowing, loss of liquids/solids from mouth when eating or drinking and weight loss while not on prescribed weight-loss regimen during assessment the period. In section C, the MDS revealed the resident's BIMS score was 10 out of 15, indicating the resident's cognition was moderately impaired. Record review of Resident #73's care plan, as of 06/15/2023, revealed the resident had a nutritional problem r/t dx of severe malnutrition with the intervention of receiving his diet as ordered by the physician including Mechanical Soft, thin liquids, Med pass TID and Health shake TID Record review of Resident #73's physician orders revealed the resident was to receive a [No added salt] diet, with mechanical soft texture, thin liquids and a health shake with all meals starting since 2/16/2023 Record review of Resident #73's weight record revealed his weights was: 6/5/2023 12:03 - 157.2 Lbs 5/1/2023 17:10 - 162.0 Lbs 4/3/2023 08:41 - 155.2 Lbs 3/6/2023 08:14 - .0 Lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 12 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0803 1/23/2023 08:18 - 132.0 Lbs Level of Harm - Minimal harm or potential for actual harm 1/2/2023 08:22 - 134.2 Lbs Residents Affected - Some Record review of Resident #73's nutrition note, dated 5/10/2023, revealed the resident was assessed by the dietitian who noted, . Diet: . [No added salt], Mechanical Soft, Thin liquids. Good PO intake continues. Edentulous, no c/o chewing/swallowing problems. States he like to drink shakes. Able to feed self, often stays in bed, room. Supplement: Health Shake TID, Med Pass 90mL TID Skin: h/o CHF, diuretic therapy, edema-may expect weight changes. Stage 4 to sacrum, R ankle, [estimated] needs .102g [protein] . Increased protein/kcal needs related to wound healing, weight maintenance as evidence by pressure wounds, significant weight fluctuations x 6 mo. Goals: No worsening of wounds, no significant weight changes >5% +/- 162 x 1 month . Recommendations: Remains on supplements to maximize nutrient intake for wound healing, weight maintenance . Observations of Resident #73 on 06/13/23 at 12:39PM revealed the resident was lying in bed with lunch tray on his bedside table. His ticket read that resident had a vegetarian veg diet, and his tray consisted of just rice, squash, a slice of bread and fruit cobbler. There were no other food items or supplements on his tray. Interview with Resident #73 on 06/13/2023 at 12:45PM, he said that he was a vegetarian and he used to receive boosts or ensures with every meal but does not know why the doctor cancelled his orders for his supplements a while ago. He said he needs protein to stay alive so it important that he gets it. Interview with the Dietary Manager on 06/13/23 at 12:53PM, she said #73 should be getting substitutes for protein and should be getting a yogurt every meal as his protein. Observations of Resident #73 on 06/14/23 at 12:55PM, revealed the resident was consuming his lunch meal which consisted of broccoli, beans, a roll and yogurt. There were no other food items or supplements on his tray. Observations and Interview with Resident #73 on 06/15/23 at 12:40PM revealed the resident lying in bed while consuming his lunch meal which consisted of egg salad, sweet potatoes, yogurt and a health shake. He said today was the first time receiving the health shake as part of his meal and they had not been giving him this before. Interview with the Dietary Manager on 06/16/2023 at 12:48PM, she said she ran out of health shakes and had to acquire them from another sister facility. She stated everyone who was ordered a health shake should had received them as ordered. She stated the note on the meal ticket to add health shake to Resident #73's meal was added only after surveyor intervened. She said the risk of not providing health shakes to residents whom they were ordered for, was they could lose nutrients and experience weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 13 of 14 Printed: 05/15/2026 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 676251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the CNA P, on 06/15/23 at 1:15M, said today was the first time in a while that she had seen these health shakes being added on to residents' meal trays, including for Resident #73. Interview with the DON on 06/16/23 at 03:11 PM, she said health shakes were usually ordered to provide additional calories for resident who typically were experiencing weight loss. She said if the resident continued to lose weight while the intervention of health shakes for every meal was in place but not actually followed, we would not be able to confirm whether the health shakes helped the prevented further weight loss in the resident. Record review of the facility's policy on Nutrition, dated December 2011, revealed, . The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons overtime . staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a) Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676251 If continuation sheet Page 14 of 14