Health inspection·September 24, 2025

F 0564 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform each resident of his or her visitation rights and related facility policy and procedures, including any safety restrictions or limitation on such rights, the reason for the restriction or limitation, and to whom the restrictions apply for 1 of 17 residents (Resident #2) reviewed for resident rights. Resident #2 was not informed by the facility when her family member was no longer allowed to visit due to safety restrictions after February 2025. This failure placed residents at risk of not being informed of their rights, confusion and sadness. The findings included: Record review of Resident #2's admission Record generated on 9/23/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), adjustment disorder (a mental disorder defined by maladaptive response to a psychosocial stressor) and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). She was [AGE] years of age. Record review of Resident #2's admission Agreement dated 1/23/24 and signed by Resident #2's family member revealed the family member acknowledged that she was informed verbally and in writing of the resident right's as guaranteed through applicable federal and state laws. Record review of Resident #2's Care Plan dated 1/15/24 revealed she was using an antidepressant medication related to depression. Interventions included monitoring, documenting and reporting to physicians for ongoing signs or symptoms of depression, including sadness, irritability, anger, crying, worthlessness, etc. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 8, indicating she had moderate cognitive impairment. She reported feeling sometimes lonely or isolated from those around her. Record review of Resident #2's electronic medical record revealed there were no documents or progress notes regarding visitation restriction. In an interview on 9/17/25 at 10:22am, Resident #2 said she missed her family member, Family Member A, since he was not allowed to visit. She said Family Member A was no longer allowed to visit because he liked LVN R and would look at her. She said the staff asked the family member to leave her alone. She said one staff member yelled at Family Member A because he liked LVN R, and the family member yelled back and threatened him. She said, I cry because I miss him, it's been so long. She said she had not seen him in months. She said she never received a policy or notice about the visitation restriction. In a telephone interview on 9/19/25 at 11:21am, the Former DON said Family Member A was not allowed to visit because he stalked a charge nurse and the police were involved. She said the Administrator handled the situation, so he would know more about it. She said that was all she remembered. In an interview on 9/23/25 at 11:55am, the Social Worker said she was aware that Resident #2's Family Member A could not visit. She said she did know the details. In an interview on 9/23/25 at 3:15pm, the Administrator said Resident #2's family member, Family Member A, was trying to engage in an inappropriate relationship with LVN R. He said he dropped gifts on her car. He said the employee went to the police and filed Page 1 of 32 676251 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0564 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a complaint. He said they followed the guidance of the police department which was to not allow him on the facility premises. He said Family Member A became aggressive and loud when they informed him of the visitation restriction. He said he was unaware of the facility provided any type of notice to Resident #2. He said some of the incident occurred in February 2025 when he was on leave. He said he review and let me know. In an interview on 9/24/25 at 9:43am, the Administrator said the AIT was at the facility in February 2025 when Family Member A was informed that he was not allowed to visit. He said Family Member A made threatening remarks during the interaction with the AIT. When asked what kind of threatening remarks, he said the family member stated he was going to beat someone. He said Resident #2 was informed by her other family members that he could no longer visit. He said he was unsure if a facility staff member discussed the visitation restriction with her. In a telephone interview on 9/24/25 at 10:21am, the AIT said he was at the facility temporarily when the Administrator was on leave. He said he was told by a staff member that Family Member A could not be at the facility. He said he spoke Spanish, so he volunteered to inform the family member. He said he told Family Member A that he was trespassing and had to leave, then the family member threatened to beat the staff and accused them of lying. He said the police were called and escorted him out. He said he could not remember the following: the staff member who told him that he could not visit, who made the decision regarding the visitation restriction, whether Family Member A was informed of the visitation restriction prior to conversation he had with him, and whether Resident #2 was informed of the visitation restriction. In a telephone interview on 9/24/25 at 10:47am, Resident #2's family member, Family Member B, stated Family Member A was caught looking at a staff member at the facility. Family member B said the staff told Family Member A that he could no longer visit the facility. Family member B said the police were present but did not charge him with any crime. In a telephone interview on 9/24/25 at 12:29pm, ADON B said LVN R told him that she was uncomfortable around Family Member A. He said he noticed Family Member A would stare at LVN R, put flowers on her car and follow her outside. He said LVN R thought she needed a restraining order. ADON B said he told Family Member A that he could not have these behaviors, and Family Member A threatened to kill him and verbally assaulted him. He said he notified the DON and the Administrator. He said he believed Family Member B told Resident #2 about the visitation restriction regarding Family Member A. In an interview on 9/24/25 at 2:50pm, the Administrator said they did not review the resident rights policy when addressing the visitation regarding Resident #2 and Family Member A. He said they reviewed the incidents from the perspective of staff safety. He said Resident #2 was upset because he tried to cheat on her. He said Resident #2 had not expressed concerns about the visitation restriction. He said it was not documented in her medical record because it was more of an issue between Family Member A and an employee. He said LVN R did not receive any type of documentation from the police except for a report number. Record review of the facility policy regarding Visitation Rights of Residents dated 1/2025 stated, It is the policy of this facility to inform each resident and/or resident representative of the rights to receive visitors based on their preferences and any clinical or safety restrictions or limitation on these rights. 676251 Page 2 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure each resident was free from abuse for 2 of 17 residents (CR #2, Resident #5) reviewed for abuse in that: 1. CR #1 sexually abused Resident #5 on 4/19/25 when he touched her breast.2. CR #1 sexually abused an unknown female resident on 5/21/25 when he touched her thigh.3. CR #1 sexually abuse CR #2 on 7/14/25 when he touched her breast and on 8/3/25 when he touched her breast and in between her thighs. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish and fearfulness. The findings included: Resident #5 Record review of Resident #5's admission Record generated on 9/19/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), muscle weakness, macular degeneration (an eye disease that causes vision loss), anxiety disorder (a mental health condition characterized by excessive worry, fear and nervousness) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs). She was [AGE] years of age. Record review of Resident #5's Care Plan dated 11/14/22 revealed she was at risk of impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. Interventions included: - Administer medications as ordered. (created on 2/24/23)- Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.Use simple directive sentences. (created on 11/14/22)- Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. (created on 2/24/23)- Needs supervision/assistance with all decision making. (created on 11/14/22) Record review of Resident #5's Care Plan dated 3/20/25 revealed she had potential for behavioral problems related to self-propelling in a wheelchair and at times refused to be redirected. Interventions included: - Anticipate and meet needs. (created on 3/20/25)- Stop and talk with resident when passing by. (created on 3/20/25)Engage in simple, structured activities such as bible study, nail spa and church services. (created on 11/20/23). - Introduce to residents with similar background, interests and encourage/facilitate interaction. (created on 11/20/23)- Needs assistance/escort activity functions. (created on 11/20/23). Record review Resident #5's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 0, indicating severe cognitive impairment. She required partial/moderate assistance for transfers, used a wheelchair for mobility, and required supervision while ambulating. Record review of Resident #5's Nurse Progress Note dated 4/19/25 at 8:52am revealed a nurse documented the following: Notified by CNA this resident was coming down the hall, another male resident was coming the opposite way, the male resident stopped this resident and reached out and was touched her breast. full body assessment of resident for any injuries or bruising, no noted injuries or bruising from interaction noted . In an observation on 9/17/25 at 3:58pm, Resident #5 was sitting in a wheelchair in a common area of the facility. She was not interviewable. She propelled herself in her wheelchair using her feet to ambulate. CR #2 Record review of CR #2's admission Record generated on 9/18/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of dementia, depression and adjustment disorder. She was [AGE] years of age. Record review of CR #2's Care Plan dated 5/8/25 revealed she was at risk of impaired cognitive function or impaired thought processes. Interventions 676251 Page 3 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some included: - Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.use simple, directive sentences. - Social Services to provide psychosocial support as needed. Further record review of CR #2's Care Plan dated 5/8/25 revealed she was an elopement risk/wanderer related to disoriented to place, impaired safety awareness. The care plan stated she wandered into other resident's rooms and was initiated on 6/4/25. Interventions included: - Document wandering behavior and attempt diversional interventions.- Monitor wander guard placement on left lower leg. Record review of CR #2's admission MDS assessment dated [DATE] revealed she had a BIMS of 1, indicating she has severe cognitive impairment. She was dependent on staff for transfers, walking and assistance with using a manual wheelchair. Record review of CR #2's Nurse Progress Note dated 7/14/25 at 6:06pm revealed LVN E documented that a CNA reported that another resident was observed touching CR #2's breast over her clothing. The nurse completed a full body assessment with no pain or injury. Record review of CR #2's nurse progress notes revealed on 7/15/25 at 10:30pm, she was observed walking with a walker into another resident's room and she was redirected. On 7/16/25 at 6:54pm, CR #2 was diverted out of entering other resident's room. On 7/18/25 at 6:26pm, a nurse noted CR #2 was redirected several times when going into other resident's rooms. In a telephone interview on 9/18/25 at 5:11pm, CR #2's Responsible Party said CR #2's medical condition affected her memory. She said when she was at the facility she was fondled by a male resident a couple of times. She said CR #2 would not have liked that at all. She said CR #2 could not remember the incidents when she asked her about them. She said she felt like CR #2 needed a room closer to the nurse's station for more supervision. She said CR #2 had dementia, did not know how to speak for herself and wandered. She described CR #2 as an independent, outspoken church-lady. CR #1 Record review of CR #1's care profile generated on 9/17/25 revealed he was admitted to the facility on [DATE]. He had diagnoses of diabetes (a chronic condition where the body cannot regulate blood sugar levels effectively), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), cognitive communication deficit, adjustment disorder with anxiety, and dementia. He was [AGE] years of age. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 3, indicating he had severe cognitive impairment. He had a PHQ-9 score of 7, indicating he had mild depression symptoms. No behaviors were noted. He required supervision for transfers and wheelchair mobility assistance. Record review of CR #1's Nurse Progress Note dated 4/19/25 at 8:43am revealed LVN A documented the following: Notified by CNA this resident was coming down the hall, another resident was coming the opposite was (sic), this resident stopped resident in the hall and was seen by CNA reaching out and touching the female residents (sic) breast, the female resident was trying to move his hand away and notified me the nurse. I spoke with resident about how this was inappropriate and he should not be touching other resident in that way. Resident stated ‘that's my friend and I was just saying hello.' Removed female resident from the situation.notified Administrator and DON.will be keeping residents apart and this resident in line of sight for monitoring. Further record review of CR #1's Nurse Progress Notes revealed he was sent to a local Behavioral hospital on 4/19/25 and returned on 4/29/25. Record review of a Provider Investigation Report dated 4/25/25 revealed a witness statement from CNA T. CNA T wrote, (CR #1) was rolling his wheelchair from (the hallway) towards the main nursing station. (Resident #5) was also in her wheelchair in (hallway). As (CR #1) approached closer to (Resident #5), he stopped his wheelchair and started touching (Resident #5) inappropriately on her left breast area and (Resident #5) was trying to push away (CR #1)'s hand. I immediately intervened and separated the residents. Record review of CR #1's care plan dated initiated on 5/1/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female 676251 Page 4 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some residents and staff related to poor impulse control. Interventions included: Assess and anticipate resident needs: food thirst, toileting, comfort level etc. (created 5/1/25); Cognitive assessment (created 5/1/25); Evaluate for side effects of medications (created 5/1/25); Psychiatric/psychogeriatric consult as indicated. (created 5/1/25). Record review of CR #1's Nurse Progress Note dated 5/17/25 at 12:46pm revealed LVN A documented the following: Resident was told several times by a female resident to please leave her alone and stop talking to her, resident would not listen and kept staring and trying to ask her questions, another nurse intervened and asked resident to move away from the female, female resident stated he was making her feel uncomfortable, resident continued to try to talk to female, finally resident rollway away to hallway, then was seen stopping and looking every residents (sic) room for a couple of minutes before rolling to the next doorway, this nurse approached resident asking why he was looking in everyone's room, he stated just wanted to see what they were doing. Educated on giving people privacy. In a telephone interview on 9/18/25 at 10:07am, LVN A said when she worked at the facility, she cared for CR #1. She said CR #1 would say inappropriate comments to female residents or try to touch them inappropriately. She said when CR #1 started displaying these behaviors, he would talk to residents who could speak up for themselves and ask him to stop. She said when CR #1 touched Resident #5 inappropriately, Resident #5 could not ask him to stop. Record review of CR #1's Nurse Progress Note dated 5/21/25 at 12:13am revealed LVN B documented the following: Upon arrival at facility (CNA A) reported that resident (CR #1) was caught in the dining room with his hand under the table trying to inappropriately touch a female resident. When asked to remove his hand resident stated, ‘That's my wife.' Female resident was removed from dining room. CNA says the incident was reported.will monitor. In a telephone interview on 9/18/25 at 10:30am, LVN B said there was an incident in May 2025 when CR #1 tried to grab another resident's vagina area during her shift and a CNA reported it to her. In a telephone interview on 9/19/25 at 11:56am, LVN B said she could not remember the name of the resident who CR #1 tried to touch in May 2025. She said it was a resident who had poor cognition. In an interview on 9/18/25 at 3:00pm, CNA A said on the day of the incident, she was charting when she looked into the dining room and saw a female resident sitting with CR #1, and CR #1's hand was on her thigh beneath the table. She said it occurred on the 2pm-10pm shift, and it happened after lunchtime. She said she believed the female resident was Resident #5 but could not say for sure. She said the female resident did not react to being touched. She said she told LVN A and LVN B. She said CR #1 liked to give other residents snacks like chips and candy. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 11, indicating moderate cognitive impairment. He had a PHQ-9 score of 1, indicating minimal depression symptoms. No behaviors were noted. He required setup assistance for sit to stand and chair/bed-to-chair transfers and was independent with wheelchair mobility. Record review of CR #1's Nurse Progress Note dated 7/14/25 at 7:24pm revealed LVN C documented the following: CNA reported to supervisor that resident was observed touching the breast of another resident. Resident will received (sic) order from MD to go to (local behavioral hospital), RP notified. Record review of CR #1's Nurse Progress Notes dated between 7/14/25 at 10:00pm and 7/15/25 at 7:15am revealed a nurse documented every 15-minute observations of CR #1. On 7/15/25 at 2:46pm, a nurse documented CR #1 was transferred to a local acute care hospital. A nurse documented that he returned with a diagnosis of injury to left rotator cuff on 7/15/25 at 10:45pm. The nurse stated, ADON, (Administrator) and family made aware and will address further in the morning. Record review of CR #1's care plan updated on 7/15/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. The following interventions were added: New order to send to (behavioral hospital), 676251 Page 5 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some monitor by staff until transfer. (created 7/15/25) Stop and guide resident away from behavioral act. (created 7/15/25) Record review of a witness statement dated 7/14/25 and signed by the Administrator revealed CNA B stated on 7/14/25 at approximately 4:40pm, she witnessed CR #1 touching CR #2's breast area. In a telephone interview on 9/18/25 at 11:30am, LVN C said it was reported to her that he had a history of sexual behaviors. She said in July 2025, a CNA witnessed CR #1 touch CR #2 inappropriately. She said the CNA immediately separated them, put CR #1 on 1:1 supervision, and notified the DON. She said CR #1 was on 1:1 supervision until he left for the hospital. She said she could not remember what happened when CR #1 returned from the hospital but believed 1:1 supervision continued. In an interview on 9/20/25 at 2:15pm, CNA B said CR #1 was cognitively intact and went to church every Sunday. She said CR #2 had short-term memory loss and could not remember one conversation to the next. She said CR #2 used a wheelchair and wandered around the facility. She said CR #2 liked to go by CR #1's room because he kept snacks in his room. She said one day about a month and a half ago, CR #2 was in CR #1's room laying down with his head by the footboard and touching CR #2's breast. She said she removed CR #2 from the room, notified the Administrator and the LVN E. She said after the incident, she kept an eye of CR #1 and made sure no one went into his room. She said CR #2 wandered and she tried to keep track of where she was at all times. She said interventions to prevent another incident of abuse was primarily supervision. Record review of CR #1's Social Service progress notes revealed on 7/17/25 at 1:39pm, the Social Worker documented that she was providing ongoing education and resources to CR #1's responsible party related to CR #1's behaviors. She stated she provided a list of facilities to consider for transfer and the responsible party was undecided. Record review of CR #1's Social Services progress notes revealed on 7/18/25 at 11:13am, a referral was pending with a local behavioral health hospital. On 7/21/25 at 4:49pm, a referral was submitted to a local nursing facility. On 7/31/25 at 4:46pm, a referral was submitted to another local nursing facility. Record review of CR #1's Nurse Progress Note dated 8/3/25 at 6:03pm, LVN D documented the following: Aide found resident in this resident room and he was touching breast and inner thighs inappropriate (sic). Resident looked at the aide who spoke to this nurse and he said you tattled on me. Staff got resident out. Notified DON. Notified MD. Notified Administrator. Activated one on one sitter (a method of monitoring provided by one person to another).sent out to (local acute care hospital). Record review of a witness statement signed by CNA C dated 8/3/25 revealed on 8/3/25 around 2:45pm, she searched for CR #2 in the hallway and found her in CR #1's room. I witnessed, (CR #1) was laying on the footboard side of this bed and he was touching (CR #2) inappropriately on her left breast and saw (CR #2) had a donut in her hand, which was given by (CR #1) from his bag full of donuts. As I started approaching to move (CR #2) away from (CR #1), he stating touching (CR #2) (sic) inside upper legs area. I immediately verbalized, ‘(CR #1), please stop'. After hearing me, he stopped touching (CR#2) and in told him that I will go ahead and notify the charge nurse. In response (CR #1) responded stating, ‘Don't do that. Don't tell her.' In a telephone interview on 9/18/25 at 11:49am, LVN D said she worked at the facility briefly to help since she worked at the same company. She said an incident occurred with CR #1 during her second day at the facility. She said a CNA reported to her that CR #1 offered the resident across the hall a donut then touched her inappropriately in her room. She said the CNA separated them, put him on 1:1 supervision, reported it to the DON, then he left for the hospital. In a telephone interview on 9/18/25 at 12:12pm, CNA C said she was caring for CR #1 and CR #2 when an incident occurred in August 2025. She said CR #2 moved around the facility in a wheelchair. She said they were directly across the hall from each other. She said on the day of the incident, she noticed she had not seen CR #2 in a while. She said when she walked into her room, CR #1 was 676251 Page 6 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some laying on the bed with his head near the footboard with a bag of donut holes. She said he was touching CR #2's breast and between her legs. She said she told him, You know that is wrong. She said he responded, Please don't tell. She said she removed CR #2 from the room and informed the nurse. She said the nurse told her to monitor him so she stayed by his room until she left for the day. In an interview on 9/18/25 at 4:56pm, the DON said after CR #1's first sexual abuse incident in April 2025 he was sent to a psychiatric hospital and returned with no recommendations for 1:1 supervision. She said there was not a need for it based on report to the facility. She said he continued psychology services at the facility. She said she was not aware of the incident that occurred in May 2025. She said after CR #1's sexual abuse incident in July 2025, they implemented 1:1 supervision until his psychiatrist discontinued the intervention. She said after the incident in August 2025 he (CR#1) was placed on 1:1 supervision and was discharged immediately to the hospital and did not return. In an interview on 9/18/25 at 6:36pm, the Administrator said after CR #1's first sexual abuse incident in April 2025, they started discussions with his family and learned that he had similar behaviors with his family members. He said if the behavior did not improve then he would need to be discharged . He said after the incident, he would keep his hands to himself in the common areas and would sit on the patio. He said he was not aware of the incident that happened in May 2025. He said when another incident occurred in July 2025, they tried to give CR #1's family member the final call on locating another facility for him. He said CR #1 could propel himself in his wheelchair and they monitored him but also wanted to protect his privacy. He said the last two sexual abuse incidents occurred in a resident's room. He said they were trying to balance supervision and privacy. He said the incidents were surprising and there were no signs or indications that he would act again. He said he told CR #1 that his behavior was inappropriate. In a telephone interview on 9/19/25 at 11:21am, the Former DON said that she worked at the facility until 7/8/25. She said CR #1 had no sexual behaviors prior to the first sexual abuse incident in April 2025. She said after the incident, he was on psychology services, increased monitoring, and believed they updated his care plan. Record review of the facility's Abuse: Prevention of and Prohibition Against policy revised on 12/2024 stated, It is the policy of this facility that each resident has the right to be free from abuse, neglect.abuse is willful infliction of injury.physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes.sexual abuse. This was determined to be an Immediate Jeopardy (IJ) on 9/19/25 at 4:52pm. The Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of RemovalF600: AbuseThe facility failed to ensure residents were free from abuse when a male resident touched a female resident sexually inappropriately. The facility failed to protect residents from additional abuse immediately after each sexual abuse incident. 1. Facility Medical Director was notified of the IJ on 09/19/2025 at 04:50 pm by the Administrator.2. Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made on 09/19/25. 3. Resident#1 is no longer the resident at the facility. CR #1 was discharged to a appropriate facility on 08/03/2025 per Responsible Party/Family approval/consent. Resident #5, CR #2 (Victim) and CR #1 (Alleged Perpetrator), Responsible Party/Family were notified on the same date for each reported incident(s) dated 4/19/25; 07/14/25 & 08/03/25. 4. Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 at 5PM regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). This training was given by the RN, Clinical Resource on 09/19/25. Training & Knowledge Check 676251 Page 7 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some including Post-Test will be completed with all staff by 09/20/25. Any remaining staff member(s) pending Training and knowledge check will complete the Training and Knowledge Check prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box (in the system) 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.5. 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 was identified, this will be investigated and reported as per provider letter. This audit was completed on 9/19/25 and No additional discrepancies were identified. Admissions Coordinator/ Designee will check Sex-Offender registry before admission as additional intervention to identify potential new admission resident for similar sexual behavior. Any new potential resident, flagged for Inappropriate sexual behaviors, will not be admitted to facility to ensure the Abuse Prevention & Prohibition for in-house residents and staff. This a facility intervention, not a policy change.6. DON/ designee will review the 24-hour report daily for identified behaviors. 7. An ad hoc (a non-scheduled QA meeting) meeting will be called regarding items in the IJ templates and will be completed on 09/20/25. Attendees included the DON, Administrator, Medical Director, ADON, Clinical Resource, with inclusion the plan of removal items and interventions.8. Safe- Surveys were conducted on 09/19/25 by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident (s). Interviewable resident(s) were included in the Safe-Surveys. The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility/ who to report for alleged abuse. Interviewed residents were able to answer who to report at (to) facility for any alleged abuse. 9. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 09/19/25 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Record review of the facilities IJ Template revealed it was signed by the Medical Director (undated). Record review of a Grievance Log and Incident Log dated May 2025 to September 2025 revealed the DON reviewed both and signed her name on the documents. Record review of Safe Survey Questionnaires for Alleged Abuse conducted by the Social Worker revealed she interviewed 18 residents. All residents stated they would speak to the social worker or administrator if abuse occurred, all residents were satisfied with care, and they reported no problems with other residents, staff. Record Review of In-service attendance records dated 9/19/25 revealed the DON presented in-services to all staff, including administrative staff and nursing staff, therapy, housekeeping, maintenance. Topics included: - Abuse prevention, freedom from abuse and neglect.- Reporting alleged violations of abuse, neglect, exploitation and mistreatment.- Reporting suspicion of a crime, freedom from abuse, neglect and exploitation. Record review of an In-Service Attendance Record dated 9/20/25 at 11:00am revealed the Clinical Resource provided education to the Administrator, DON and Social Worker on the topic of conducting abuse and incident investigations/interviews which included the following: Define types of incidents requiring an investigation and reporting to appropriate agencies; Initiated the investigation and preparing for the interview- Includes review of medical records and assessment findings physical, psychological impact, personnel files, training records, policies, equipment, scene of the incident, staff schedules and assignments; Techniques for completing a successful and through interview; 676251 Page 8 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Analyze findings from investigation and interviews; Develop plan to prevent future occurrences and care plan updates; Maintaining investigation files and completing final report to appropriate agencies; Evaluation used scenario-based presentations with learner replies demonstrating learned techniques. Interviews with CNA D, MA A, CNA E, LVN F, CNA F, CNA G, LVN G and LVN H on 9/21/25 between 5:37am and 3:31pm revealed they could reiterate the in-services they received, including a resident's right to be free from sexual abuse, their responsibility regarding incidents of abuse, abuse prevention, behaviors that could lead to abuse and identifying and locating care plan areas and interventions. Interviews with the Social Worker, Administrator, DON and ADON on 9/21/25 between 1:57pm and 2:34pm revealed they could reiterate he in-services the received, including their responsibility regarding the abuse policy, abuse investigation, abuse prevention and care plan revisions. In an interview on 9/21/25 at 2:01pm, the MDS Coordinator said she had worked at the facility for one month. She said they audited all residents' care plans to ensure they were current. She said she was responsible for care planning. She said she was informed of incidents by attending morning meetings and reviewing falls and changes of condition. On 9/21/25 at 3:37pm, the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. 676251 Page 9 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse for 2 of 17 residents (CR #2, Resident #5) reviewed for abuse. The facility failed to implement written policies regarding abuse prevention and protection when CR #1 sexually abused Resident #5, an unidentified female resident, and CR #2 within a 4-month period between 4/19/25 and 8/3/25. The facility failed to ensure LVN B and CNA A, with knowledge of an allegation of sexual abuse on 5/21/25, reported the abuse immediately to the Administrator. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish and fearfulness. The findings included: Record review of the facility's policy titled ‘Abuse: Prevention of and Prohibition Against' dated 12/2024 stated, .Prevention.The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by.Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validating that the Facility has deployed the correct number of competent staff on each shift to meet the needs of the residents. Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as.Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing. Wandering into other's rooms/space. Protection.If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation:.Increase supervision of the alleged victim and residents.Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor and intervene as necessary to maximize resident health and safety. Resident #5 Record review of Resident #5's admission Record generated on 9/19/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of Alzheimer's disease, muscle weakness, macular degeneration, anxiety disorder and bipolar disorder. She was [AGE] years of age. Record review of Resident #5's Care Plan dated 11/14/22 revealed she was at risk of impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. Interventions included: - Administer medications as ordered. (created on 2/24/23)- Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.Use simple directive sentences. (created on 11/14/22)- Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. (created on 2/24/23)- Needs supervision/assistance with all decision making. (created on 11/14/22) Record review of Resident #5's Care Plan dated 3/20/25 revealed she had a potential for behavioral problems related to self-propelling in a wheelchair and at times refused to be redirected. Interventions included: - Anticipate and meet needs. (created on 3/20/25)- Stop and talk with resident when passing by. (created on 3/20/25)- Engage in simple, structured activities such as bible Residents Affected - Some 676251 Page 10 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some study, nail spa and church services. (created on 11/20/23). - Introduce to residents with similar background, interests and encourage/facilitate interaction. (created on 11/20/23)- Needs assistance/escort activity functions. (created on 11/20/23). Record review Resident #5's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 0, indicating severe cognitive impairment. She required partial/moderate assistance for transfers, used a wheelchair for mobility, and required supervision while ambulating. In an observation on 9/17/25 at 3:58pm, Resident #5 was sitting in a wheelchair in a common area of the facility. She was not interviewable. She propelled herself in her wheelchair using her feet to ambulate. Record review of Resident #5's Nurse Progress Note dated 4/19/25 at 8:52am revealed a nurse documented the following: Notified by CNA this resident was coming down the hall, another male resident was coming the opposite way, the male resident stopped this resident and reached out and was touching her breast. full body assessment of resident for any injuries or bruising, no noted injuries or bruising from interaction noted . CR #2 Record review of CR #2's admission Record generated on 9/18/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of dementia, depression and adjustment disorder. She was [AGE] years of age. Record review of CR #2's Care Plan dated 5/8/25 revealed she was at risk of impaired cognitive function or impaired thought processes. Interventions included: - Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.use simple, directive sentences. - Social Services to provide psychosocial support as needed. Further record review of CR #2's Care Plan dated 5/8/25 revealed she was an elopement risk/wanderer related to disoriented to place, impaired safety awareness. The care plan stated she wandered into other resident's rooms and was initiated on 6/4/25. Interventions included: - Document wandering behavior and attempt diversional interventions.- Monitor wander guard placement on left lower leg. Record review of CR #2's admission MDS assessment dated [DATE] revealed she had a BIMS of 1, indicating she has severe cognitive impairment. She was dependent on staff for transfers, walking and assistance with using a manual wheelchair. Record review of CR #2's Nurse Progress Note dated 7/14/25 at 6:06pm revealed LVN E documented that a CNA reported that another resident was observed touching CR #2's breast over her clothing. The nurse completed a full body assessment with no pain or injury. Record review of CR #2's nurse progress notes revealed on 7/15/25 at 10:30pm, she was observed walking with a walker into another resident's room and she was redirected. On 7/16/25 at 6:54pm, CR #2 was diverted out of entering other resident's room. On 7/18/25 at 6:26pm, a nurse noted CR #2 was redirected several times when going into other resident's rooms. In a telephone interview on 9/18/25 at 5:11pm, CR #2's Responsible Party said CR #2's medical condition affected her memory. She said when she was at the facility she was fondled by a male resident a couple of times. She said CR #2 would not have liked that at all. She said CR #2 could not remember the incidents when she asked her about them. She said she felt like CR #2 needed a room closer to the nurse's station for more supervision. She said CR #2 had dementia, did not know how to speak for herself and wandered. She described CR #2 as an independent, outspoken church-lady. CR #1 Record review of CR #1's care profile generated on 9/17/25 revealed he was admitted to the facility on [DATE]. He had diagnoses of diabetes, chronic obstructive pulmonary disease, cognitive communication deficit, adjustment disorder with anxiety, and dementia. He was [AGE] years of age. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 3, indicating he had severe cognitive impairment. He had a PHQ-9 score of 7, indicating he had mild depression symptoms. No behaviors were noted. He required supervision for transfers and wheelchair mobility assistance. Record review of CR #1's Nurse Progress Note dated 4/19/25 at 8:43am revealed LVN A documented the following: Notified by CNA this resident was coming down the hall, another resident was coming the opposite was (sic), this 676251 Page 11 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some resident stopped resident in the hall and was seen by CNA reaching out and touching the female residents (sic) breast, the female resident was trying to move his hand away and notified me the nurse. I spoke with resident about how this was inappropriate and he should not be touching other resident in that way. Resident stated ‘that's my friend and I was just saying hello.' Removed female resident from the situation.notified Administrator and DON.will be keeping residents apart and this resident in line of sight for monitoring. Further record review of CR #1's Nurse Progress Notes revealed she was sent to a local Behavioral hospital on 4/19/25 and returned on 4/29/25. Record review of a Provider Investigation Report dated 4/25/25 and signed by the Administrator revealed on 4/19/25, CR #1 touched Resident #5's left breast area. Resident #5 was assessed on 4/19/25 at 8:10am and education was provided to CR #1 that the behavior was inappropriate. The nurse notified Resident #5's responsible party and physician, CR #1's responsible party. The psychological service provider assessed CR #1 on 4/19/25 at 2:20pm and made a recommendation for behavioral hospital evaluation. Education was provided to facility staff regarding resident rights, types of abuse, abuse reporting, resident-to-resident altercation reporting guidelines. The Administrator noted the allegation was unsubstantiated, stating, (CR #1) did not exhibit any signs or symptoms of the inappropriate behavior. Facility staff, who witnessed the incident intervened immediately and separate the residents for resident safety. (Psychological Services) provider assessed (CR #1) on 4/19/25 and sent the referral for in-patient treatment.(CR #1) is currently at the hospital.(Resident #5) is also stable with normal vitals and no signs or symptoms of distress. Record review of CR #1's care plan dated initiated on 5/1/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. Interventions included: Assess and anticipate resident needs: food thirst, toileting, comfort level etc. (created 5/1/25) Cognitive assessment (created 5/1/25) Evaluate for side effects of medications (created 5/1/25) Psychiatric/psychogeriatric consult as indicated. (created 5/1/25) Record review of CR #1's Nurse Progress Note dated 5/17/25 at 12:46pm revealed LVN A documented the following: Resident was told several times by a female resident to please leave her alone and stop talking to her, resident would not listen and kept staring and trying to ask her questions, another nurse intervened and asked resident to move away from the female, female resident stated he was making her feel uncomfortable, resident continued to try to talk to female, finally resident rollway away to hallway, then was seen stopping and looking every residents (sic) room for a couple of minutes before rolling to the next doorway, this nurse approached resident asking why he was looking in everyone's room, he stated just wanted to see what they were doing. Educated on giving people privacy. In a telephone interview on 9/18/25 at 10:07am, LVN A said when she worked at the facility, she cared for CR #1. She said CR #1 would say inappropriate comments to female residents or try to touch them inappropriately. She said when CR #1 started displaying these behaviors, he would talk to residents who could speak up for themselves and ask him to stop. She said when CR #1 touched Resident #5 inappropriately, Resident #5 could not ask him to stop. When asked about interventions for CR #1 to prevent behaviors like this, she said separate him from the residents he was bothering, provide activities and provide 1:1 supervision. She said she could not recall if CR #1's interventions were updated when he returned from the behavioral hospital in April 2025, and could not recall if she received training on his interventions. She said she stopped working at the facility in June 2025. Record review of CR #1's Nurse Progress Note dated 5/21/25 at 12:13am revealed LVN B documented the following: Upon arrival at facility (CNA A) reported that resident was caught in the dining room with his hand under the table trying to inappropriately touch a female resident. When asked to remove his hand resident stated, ‘That's my wife.' Female resident was removed from dining 676251 Page 12 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some room. CNA says the incident was reported.will monitor. In a telephone interview on 9/18/25 at 10:30am, LVN B said she was not informed of CR #1's sexual behaviors when she started caring for him. She said she heard rumors from other staff but had not experienced it herself. She said there was an incident in May 2025 when CR #1 tried to grab another resident's vagina during her shift and a CNA reported it to her. She said the incident would have been reportable based on the abuse policy, so she would have reported it to the Former DON. She said CR #1 roamed around the facility freely when he was not provided 1:1 supervision. She said it would have been impossible to keep an eye on him. LVN B said she was not provided any in-services regarding his behaviors or interventions. She said the in-services she received were generally about abuse reporting and behavior monitoring. In a telephone interview on 9/19/25 at 11:56am, LVN B said she could not remember the name of the resident who CR #1 tried to touch in May 2025. She said it was a resident who had poor cognition. In an interview on 9/18/25 at 3:00pm, CNA A said she was not aware of CR #1's sexual behaviors or sexual abuse allegations prior to witnessing an incident in May 2025. She said on the day of the incident, she was charting when she looked into the dining room and saw a female resident sitting with CR #1, and CR #1's hand was on her thigh beneath the table. She said it occurred on the 2pm-10pm shift and it happened after lunchtime. She said she believed the female resident was Resident #5, but could not say for sure. She said the female resident did not react to being touched. She said she told LVN A and LVN B. She said CR #1 liked to give other residents snacks like chips and candy. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 11, indicating moderate cognitive impairment. He had a PHQ-9 score of 1, indicating minimal depression symptoms. No behaviors were noted. He required setup assistance for sit to stand and chair/bed-to-chair transfers and was independent with wheelchair mobility. Record review of CR #1's Nurse Progress Note dated 7/14/25 at 7:24pm revealed LVN C documented the following: CNA reported to supervisor that resident was observed touching the breast of another resident. Resident will received (sic) order from MD to go to (local behavioral hospital), RP notified. Record review of CR #1's Nurse Progress Notes dated between 7/14/25 at 10:00pm and 7/15/25 at 7:15am revealed a nurse documented every 15-minute observations of CR #1. On 7/15/25 at 2:46pm, a nurse documented CR #1 was transferred to a local acute care hospital. A nurse documented that he returned with a diagnosis of injury to left rotator cuff on 7/15/25 at 10:45pm. The nurse stated, ADON, (Administrator) and family made aware and will address further in the morning. In a telephone interview on 9/18/25 at 11:30am, LVN C said she did not have anything in place, and she was not told to have anything in place before CR #1 touched CR #2's breast. She said it was reported to her that he had a history of sexual behaviors. She said, I didn't have any interventions with him, that was the care plan team's job. She said in July 2025, a CNA witnessed CR #1 touch CR #2 inappropriately. She said the CNA immediately separated them, put CR #1 on 1:1 supervision, and notified the DON. She said CR #1 was on 1:1 supervision until he left for the hospital. She said she could not remember what happened when CR #1 returned from the hospital but believed 1:1 supervision continued. In an interview on 9/20/25 at 2:15pm, CNA B said she was shocked to learn that CR #1 had sexually inappropriate behaviors. She said she first found out about his behaviors when they had in-services regarding sexual abuse and reporting. She said CR #1 was cognitively intact and went to church every Sunday. She said CR #2 had short-term memory loss and could not remember one conversation to the next. She said CR #2 used a wheelchair and wandered around the facility. She said CR #2 liked to go by CR #1's room because he kept snacks in his room. She said one day about a month and a half ago, CR #2 was in CR #1's room laying down with his head by the footboard and touching CR #2's breast. She said she removed CR #2 from the room, notified the Administrator and the LVN E. She said after the 676251 Page 13 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some incident, she kept an eye of CR #1 and made sure no one went into his room. She said CR #2 wandered and she tried to keep track of where she was at all times. She said interventions to prevent another incident of abuse was primarily supervision. Record review of CR #1's care plan updated on 7/15/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. The following interventions were added: New order to send to (behavioral hospital), monitor by staff until transfer. (created 7/15/25) Stop and guide resident away from behavioral act. (created 7/15/25) Record review of CR #1's Social Service progress notes revealed on 7/17/25 at 1:39pm, the Social Worker documented that she was providing ongoing education and resources to CR #1's responsible party related to CR #1's behaviors. She stated she provided a list of facilities to consider for transfer and the responsible party was undecided. Record review of CR #1's Social Services progress notes revealed on 7/18/25 at 11:13am, a referral was pending with a local behavioral health hospital. On 7/21/25 at 4:49pm, a referral was submitted to a local nursing facility. On 7/31/25 at 4:46pm, a referral was submitted to another local nursing facility. Record review of a Provider Investigation Report dated 7/21/25 and signed by the Administrator revealed on 7/14/25, CNA B observed CR #1 touch CR #2's right breast area. The charge nurse received an order to send CR #1 to an acute care hospital for a psychological evaluation and further assessment. CR #1 refused to go to the hospital on 7/14/25 and 1:1 supervision was provided. CR #1 agreed to go to the hospital on 7/15/25 and returned on 7/15/25 with no new orders. All staff were educated on the topics of resident rights, types of abuse, mandatory reporting for any alleged or witnessed abuse immediately. The Administrator noted that the allegation was substantiated. CR #1 was seen by Psychological Services on 7/17/25 with no change to established plan of care. Social Services provided psychosocial support to CR #2 with no further concerns identified. Record review of CR #1's Nurse Progress Note dated 8/3/25 at 6:03pm, LVN D documented the following: Aide found resident in this resident room and he was touching breast and inner thighs inappropriate (sic). Resident looked at the aide who spoke to this nurse and he said you tattled on me. Staff got resident out. Notified DON. Notified MD. Notified Administrator. Activated on on one sitter.sent out to (local acute care hospital). Record review of a Provider Investigation Report dated 8/10/25 signed by the Administrator revealed on 8/3/25, CNA C observed CR #1 touch CR #2's breast and inner thigh area. The charge nurse assessed CR #2 and notified her responsible party and physician. Charge nurse received orders from CR #1's physician to be sent to an acute care hospital and was provided 1:1 supervision until he discharged . CR #1 was transferred to another facility when he left the acute care hospital. The Administrator noted the allegation was substantiated. In a telephone interview on 9/18/25 at 11:49am, LVN D said she worked at the facility briefly to help since she worked at the same company. She said an incident occurred with CR #1 during her 2nd day at the facility. She said she was told that CR #1 had a tendency to make sexual comments and had an incident with another resident. She said she did not review CR #1's care plan. She said a CNA reported to her that CR #1 offered the resident across the hall a donut then touched her inappropriately in her room. She said the CNA separated them, put him on 1:1 supervision, reported it to the DON, then he left for the hospital. In a telephone interview on 9/18/25 at 12:12pm, CNA C said before the incident between CR #1 and CR #2 in August 2025, she heard from other staff about CR #1's sexual behaviors, but did not know for sure. She said she was not informed of interventions or prevention measures. She said she had a few in-services regarding reporting incidents of sexual abuse to the Administrator and DON. She said she was caring for CR #1 and CR #2 when an incident occurred in August 2025. She said CR #2 moved around the facility in a wheelchair. She said they were directly across the hall from each other. She said on the day of the incident, she 676251 Page 14 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some noticed she had not seen CR #2 in a while. She said when she walked into her room, CR #1 was laying on the bed with his head near the footboard with a bag of donut holes. She said he was touching CR #2's breast and between her legs. She said she told him, You know that is wrong. She said he responded, Please don't tell. She said she removed CR #2 from the room and informed the nurse. She said the nurse told her to monitor him so she stayed by his room until she left for the day. In an interview on 9/18/25 at 2:42pm, the Social Worker said after CR #1 inappropriately touched a resident in April 2025, the facility staff had a meeting with him and his family to discuss the behavior, the facility's expectations, and process that would follow if it happened again. She said the facility staff were monitoring his behavior and provided supervision. She said they tried to find CR #1 long-term placement after the incident in July 2025. She said she worked with his family members to send referrals to their preferred facility. After the incident in July 2025, CR #1 was provided increased monitoring and he was not provided 1:1 supervision. She said he liked to go outside and sit on the porch. She said CR #1 had critical thinking and understood conversations. She said Resident #5 and CR #2 could communicate but could not comprehend what was going on. In an interview on 9/18/25 at 4:12pm, the DON said in a meeting with CR #1's family members in April 2025 they reported that CR #1 had a history of sexual abuse or sexual behaviors when he was at home with his family. She said they had a recent change in management and she knew the previous DON was working on reeducation. She said the facility did not provide in-services specifically about CR #1 and the education provided to staff after incidents was about reporting abuse to the Administrator and resident rights. In an interview on 9/18/25 at 4:56pm, the DON said after CR #1's first sexual abuse incident in April 2025 he was sent to a psychiatric hospital and returned with no recommendations for 1:1 supervision. She said there was not a need for it based on report to the facility. She said he continued psychology services at the facility. She said she was not aware of the incident that occurred in May 2025. She said after CR #1's sexual abuse incident in July 2025, they implemented 1:1 supervision until his psychiatrist discontinued the intervention. She said after the incident in August 2025 he was placed on 1:1 supervision and was discharged immediately to the hospital and did not return. In an interview on 9/18/25 at 6:36pm, the Administrator said after CR #1's first sexual abuse incident in April 2025, they started discussions with his family and learned that he had similar behaviors with his family members. He said if the behavior did not improve then he would need to be discharged . He said after the incident, he would keep his hands to himself in the common areas and would sit on the patio. He said he was not aware of the incident that happened in May 2025 but if he had he would have reported it to HHSC and completed an investigation. He said when another incident occurred in July 2025, they tried to give CR #1's family member the final call on locating another facility for him. He said CR #1 could propel himself in his wheelchair and they monitored him but also wanted to protect his privacy. He said the last two sexual abuse incidents occurred in a resident's room. He said they were trying to balance supervision and privacy. He said the incidents were surprising and there were no signs or indications that he would act again. He said he told CR #1 that his behavior was inappropriate. He said CR #2 and Resident #5 had poor cognition and did not approach the point of assessing their ability to consent. In an interview on 9/19/25 at 1:19pm, the Administrator, when asked about protection measures that were in place for Resident #5 after the sexual abuse incident in April 2025, he said Resident #5 wandered the hallways daily. He said they tried to bring her to the activity room and keep Resident #5 away from CR #1. He said he was not aware of an incident or behaviors occurring in May 2025. He said the staff should know to report incidents to the Administrator since he is the abuse coordinator. He said he could not say why it was not reported. He said if he was aware he would 676251 Page 15 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some follow same course of action and identify victim, get them psychological support, assess, notify, and look at changes to the plan of care. He said after the incident that occurred between CR #1 and CR #2 in July 2025, he was sent to the hospital and returned the same day. He said when he returned, he spoke to the resident about the behavior and how it could not reoccur. He said he could not prevent CR #2 from being in the hallway, and did not move her to a different room. He said he was unsure what else he could have done. In a telephone interview on 9/19/25 at 11:21am, the Former DON said that she worked at the facility until 7/8/25. She said CR #1 had no sexual behaviors prior to the first sexual abuse incident in April 2025. She said after the incident, he was on psychology services, increased monitoring, and believed they updated his care plan. She said she was not aware of the incident that occurred in May 2025. In a telephone interview on 9/19/25 at 12:11pm, the Psychiatric NP said there was no approved treatment for inappropriate sexual behaviors. He said they will try and antidepressant. He said when CR #1 returned from the behavioral health hospital, they put him on Depakote. He said he had to decrease the dosage because he was experiencing sedative side effects. In an telephone interview on 9/19/25 at 1:53pm, the Psychiatric NP said on 7/17/25 he increased CR #1's antidepressant dose. He said he could not remember if he made recommendations for supervision as there was nothing in his notes about supervision. He said they talk about each case during weekly meetings. When asked about facility staff stating he recommended to discontinue 1:1 supervision, he said he must have decided CR #1 was stable. He said the facility would closely monitor him but not continue 1:1 supervision unless they were concerned about something. He said he ultimately put the decision for amount of supervision on the facility because they were with the resident. He said it would be difficult for the facility to prevent him from having sexual behaviors. In a telephone interview on 9/24/25 at 12:29pm, ADON B said Resident #5 had a behavior of wandering in her wheelchair. He said the staff knew to supervise and redirect her when needed. He said he could not recall if Resident #5's plan of care changed after she was sexually abused by CR #1 in April 2025. He said after the sexual abuse incident in July 2025 between CR #1 and CR #2, he said they watched CR #1 when he was around a female resident. He said they did not want to isolate anyone and wanted to respect their privacy. When asked about abuse prevention, he said he would follow the guidance of the DON and Administrator. This was determined to be an Immediate Jeopardy (IJ) on 9/19/25 at 4:52pm. The Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of RemovalF607: Abuse The facility failed to implement their written policies that prohibit and prevent abuse in that the facility failed to take measures to prevent and protect residents from sexual abuse.1. Facility Medical Director was notified of the IJ on 09/19/2025 at 04:50 pm by the Administrator.2. Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made on 09/19/25. 3. The ED/ DON/ Social Worker and RN, Clinical Resource will be trained on Abuse/ Neglect Investigation and Reporting by Risk Management Resource on 9/20/2025. This included how to conduct a thorough investigation to implement measures to prevent further incidents which would protect other residents.4. Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 at 5PM regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). This training was given by RN, Clinical Resource on 09/19/25. Training & Knowledge Check including Post-Test will be completed with all staff by 09/20/25. Any remaining staff member(s) pending Training & Knowledge check will complete the Training & Knowledge Check including Post-Test prior to the start of their next will be completed with all staff prior to the scheduled shift. Staff will not be allowed 676251 Page 16 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan. 5. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.6. DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter. This audit was completed on 9/19/25 and No additional discrepancies were identified. Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents. 7. Safe-Surveys were conducted on 09/19/25 by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident(s). Interviewable resident(s) were included in the Safe-Surveys. The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility to repor 676251 Page 17 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to have evidence that all alleged violations of sexual abuse were thoroughly investigated for 2 of 17 residents (CR #2, Resident #5) reviewed for abuse. The facility failed to take steps to prevent further potential abuse and take appropriate corrective action as a result of investigation findings when CR #1 sexually abused CR #2, an unidentified female resident and Resident #5 within a 4-month period between 4/19/25 and 8/3/25. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish and fearfulness. The findings included: Resident #5 Record review of Resident #5's admission Record generated on 9/19/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of Alzheimer's disease, muscle weakness, macular degeneration, anxiety disorder and bipolar disorder. She was [AGE] years of age. Record review of Resident #5's Care Plan dated 11/14/22 revealed she was at risk of impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. Interventions included:- Administer medications as ordered. (created on 2/24/23)- Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.Use simple directive sentences. (created on 11/14/22)- Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. (created on 2/24/23)- Needs supervision/assistance with all decision making. (created on 11/14/22) Record review of Resident #5's Care Plan dated 3/20/25 revealed she had a potential for behavioral problems related to self-propelling in a wheelchair and at times refused to be redirected. Interventions included:Anticipate and meet needs. (created on 3/20/25)- Stop and talk with resident when passing by. (created on 3/20/25)- Engage in simple, structured activities such as bible study, nail spa and church services. (created on 11/20/23).- Introduce to residents with similar background, interests and encourage/facilitate interaction. (created on 11/20/23)- Needs assistance/escort activity functions. (created on 11/20/23). Record review Resident #5's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 0, indicating severe cognitive impairment. She required partial/moderate assistance for transfers, used a wheelchair for mobility, and required supervision while ambulating. In an observation on 9/17/25 at 3:58pm, Resident #5 was sitting in a wheelchair in a common area of the facility. She was not interviewable. She propelled herself in her wheelchair using her feet to ambulate. Record review of Resident #5's Nurse Progress Note dated 4/19/25 at 8:52am revealed a nurse documented the following: Notified by CNA this resident was coming down the hall, another male resident was coming the opposite way, the male resident stopped this resident and reached out and was touching her breast. full body assessment of resident for any injuries or bruising, no noted injuries or bruising from interaction noted . CR #2 Record review of CR #2's admission Record generated on 9/18/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of dementia, depression and adjustment disorder. She was [AGE] years of age. Record review of CR #2's Care Plan dated 5/8/25 revealed she was at risk of impaired cognitive function or impaired thought processes. Interventions included:- Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.use simple, directive sentences.- Social Services to provide psychosocial support as needed. Further record review of CR #2's Care Plan dated 5/8/25 revealed she was an elopement risk/wanderer related to disoriented to place, impaired safety Residents Affected - Some 676251 Page 18 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some awareness. The care plan stated she wandered into other resident's rooms and was initiated on 6/4/25. Interventions included:- Document wandering behavior and attempt diversional interventions.- Monitor wander guard placement on left lower leg. Record review of CR #2's admission MDS assessment dated [DATE] revealed she had a BIMS of 1, indicating she has severe cognitive impairment. She was dependent on staff for transfers, walking and assistance with using a manual wheelchair. Record review of CR #2's Nurse Progress Note dated 7/14/25 at 6:06pm revealed LVN E documented that a CNA reported that another resident was observed touching CR #2's breast over her clothing. The nurse completed a full body assessment with no pain or injury. Record review of CR #2's nurse progress notes revealed on 7/15/25 at 10:30pm, she was observed walking with a walker into another resident's room and she was redirected. On 7/16/25 at 6:54pm, CR #2 was diverted out of entering other resident's room. On 7/18/25 at 6:26pm, a nurse noted CR #2 was redirected several times when going into other resident's rooms. In a telephone interview on 9/18/25 at 5:11pm, CR #2's Responsible Party said CR #2's medical condition affected her memory. She said when she was at the facility she was fondled by a male resident a couple of times. She said CR #2 would not have liked that at all. She said CR #2 could not remember the incidents when she asked her about them. She said she felt like CR #2 needed a room closer to the nurse's station for more supervision. She said CR #2 had dementia, did not know how to speak for herself and wandered. She described CR #2 as an independent, outspoken church-lady. CR #1 Record review of CR #1's care profile generated on 9/17/25 revealed he was admitted to the facility on [DATE]. He had diagnoses of diabetes, chronic obstructive pulmonary disease, cognitive communication deficit, adjustment disorder with anxiety, and dementia. He was [AGE] years of age. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 3, indicating he had severe cognitive impairment. He had a PHQ-9 score of 7, indicating he had mild depression symptoms. No behaviors were noted. He required supervision for transfers and wheelchair mobility assistance. Record review of CR #1's Nurse Progress Note dated 4/19/25 at 8:43am revealed LVN A documented the following: Notified by CNA this resident was coming down the hall, another resident was coming the opposite was (sic), this resident stopped resident in the hall and was seen by CNA reaching out and touching the female residents (sic) breast, the female resident was trying to move his hand away and notified me the nurse. I spoke with resident about how this was inappropriate and he should not be touching other resident in that way. Resident stated ‘that's my friend and I was just saying hello.' Removed female resident from the situation.notified Administrator and DON.will be keeping residents apart and this resident in line of sight for monitoring. Further record review of CR #1's Nurse Progress Notes revealed she was sent to a local Behavioral hospital on 4/19/25 and returned on 4/29/25. Record review of a Provider Investigation Report dated 4/25/25 and signed by the Administrator revealed on 4/19/25, CR #1 touched Resident #5's left breast area. Resident #5 was assessed on 4/19/25 at 8:10am and education was provided to CR #1 that the behavior was inappropriate. The nurse notified Resident #5's responsible party and physician, CR #1's responsible party. The psychological service provider assessed CR #1 on 4/19/25 at 2:20pm and made a recommendation for behavioral hospital evaluation. Education was provided to facility staff regarding resident rights, types of abuse, abuse reporting, resident-to-resident altercation reporting guidelines. The Administrator noted the allegation was unsubstantiated, stating, (CR #1) did not exhibit any signs or symptoms of the inappropriate behavior. Facility staff, who witnessed the incident intervened immediately and separate the residents for resident safety. (Psychological Services) provider assessed (CR #1) on 4/19/25 and sent the referral for in-patient treatment.(CR #1) is currently at the hospital.(Resident #5) is also stable with normal vitals and no signs or symptoms of distress. Record review of CR #1's care plan dated initiated on 5/1/25 676251 Page 19 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. Interventions included: Assess and anticipate resident needs: food thirst, toileting, comfort level etc. (created 5/1/25) Cognitive assessment (created 5/1/25) Evaluate for side effects of medications (created 5/1/25) Psychiatric/psychogeriatric consult as indicated. (created 5/1/25) Record review of CR #1's Nurse Progress Note dated 5/17/25 at 12:46pm revealed LVN A documented the following: Resident was told several times by a female resident to please leave her alone and stop talking to her, resident would not listen and kept staring and trying to ask her questions, another nurse intervened and asked resident to move away from the female, female resident stated he was making her feel uncomfortable, resident continued to try to talk to female, finally resident rollway away to hallway, then was seen stopping and looking every residents (sic) room for a couple of minutes before rolling to the next doorway, this nurse approached resident asking why he was looking in everyone's room, he stated just wanted to see what they were doing. Educated on giving people privacy. In a telephone interview on 9/18/25 at 10:07am, LVN A said when she worked at the facility, she cared for CR #1. She said CR #1 would say inappropriate comments to female residents or try to touch them inappropriately. She said when CR #1 started displaying these behaviors, he would talk to residents who could speak up for themselves and ask him to stop. She said when CR #1 touched Resident #5 inappropriately, Resident #5 could not ask him to stop. When asked about interventions for CR #1 to prevent behaviors like this, she said separate him from the residents he was bothering, provide activities and provide 1:1 supervision. She said she could not recall if CR #1's interventions were updated when he returned from the behavioral hospital in April 2025, and could not recall if she received training on his interventions. She said she stopped working at the facility in June 2025. Record review of CR #1's Nurse Progress Note dated 5/21/25 at 12:13am revealed LVN B documented the following: Upon arrival at facility (CNA A) reported that resident was caught in the dining room with his hand under the table trying to inappropriately touch a female resident. When asked to remove his hand resident stated, ‘That's my wife.' Female resident was removed from dining room. CNA says the incident was reported.will monitor. In a telephone interview on 9/18/25 at 10:30am, LVN B said she was not informed of CR #1's sexual behaviors when she started caring for him. She said she heard rumors from other staff but had not experienced it herself. She said there was an incident in May 2025 when CR #1 tried to grab another resident's vagina during her shift and a CNA reported it to her. She said the incident would have been reportable based on the abuse policy, so she would have reported it to the Former DON. She said CR #1 roamed around the facility freely when he was not provided 1:1 supervision. She said it would have been impossible to keep an eye on him. LVN B said she was not provided any in-services regarding his behaviors or interventions. She said the in-services she received were generally about abuse reporting and behavior monitoring. In a telephone interview on 9/19/25 at 11:56am, LVN B said she could not remember the name of the resident who CR #1 tried to touch in May 2025. She said it was a resident who had poor cognition. In an interview on 9/18/25 at 3:00pm, CNA A said she was not aware of CR #1's sexual behaviors or sexual abuse allegations prior to witnessing an incident in May 2025. She said on the day of the incident, she was charting when she looked into the dining room and saw a female resident sitting with CR #1, and CR #1's hand was on her thigh beneath the table. She said it occurred on the 2pm-10pm shift and it happened after lunchtime. She said she believed the female resident was Resident #5, but could not say for sure. She said the female resident did not react to being touched. She said she told LVN A and LVN B. She said CR #1 liked to give other residents snacks like chips and candy. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 11, indicating moderate cognitive impairment. 676251 Page 20 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some He had a PHQ-9 score of 1, indicating minimal depression symptoms. No behaviors were noted. He required setup assistance for sit to stand and chair/bed-to-chair transfers and was independent with wheelchair mobility. Record review of CR #1's Nurse Progress Note dated 7/14/25 at 7:24pm revealed LVN C documented the following: CNA reported to supervisor that resident was observed touching the breast of another resident. Resident will received (sic) order from MD to go to (local behavioral hospital), RP notified. Record review of CR #1's Nurse Progress Notes dated between 7/14/25 at 10:00pm and 7/15/25 at 7:15am revealed a nurse documented every 15-minute observations of CR #1. On 7/15/25 at 2:46pm, a nurse documented CR #1 was transferred to a local acute care hospital. A nurse documented that he returned with a diagnosis of injury to left rotator cuff on 7/15/25 at 10:45pm. The nurse stated, ADON, (Administrator) and family made aware and will address further in the morning. In a telephone interview on 9/18/25 at 11:30am, LVN C said she did not have anything in place, and she was not told to have anything in place before CR #1 touched CR #2's breast. She said it was reported to her that he had a history of sexual behaviors. She said, I didn't have any interventions with him, that was the care plan team's job. She said in July 2025, a CNA witnessed CR #1 touch CR #2 inappropriately. She said the CNA immediately separated them, put CR #1 on 1:1 supervision, and notified the DON. She said CR #1 was on 1:1 supervision until he left for the hospital. She said she could not remember what happened when CR #1 returned from the hospital but believed 1:1 supervision continued. In an interview on 9/20/25 at 2:15pm, CNA B said she was shocked to learn that CR #1 had sexually inappropriate behaviors. She said she first found out about his behaviors when they had in-services regarding sexual abuse and reporting. She said CR #1 was cognitively intact and went to church every Sunday. She said CR #2 had short-term memory loss and could not remember one conversation to the next. She said CR #2 used a wheelchair and wandered around the facility. She said CR #2 liked to go by CR #1's room because he kept snacks in his room. She said one day about a month and a half ago, CR #2 was in CR #1's room laying down with his head by the footboard and touching CR #2's breast. She said she removed CR #2 from the room, notified the Administrator and the LVN E. She said after the incident, she kept an eye of CR #1 and made sure no one went into his room. She said CR #2 wandered and she tried to keep track of where she was at all times. She said interventions to prevent another incident of abuse was primarily supervision. Record review of CR #1's care plan updated on 7/15/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. The following interventions were added: New order to send to (behavioral hospital), monitor by staff until transfer. (created 7/15/25) Stop and guide resident away from behavioral act. (created 7/15/25) Record review of CR #1's Social Service progress notes revealed on 7/17/25 at 1:39pm, the Social Worker documented that she was providing ongoing education and resources to CR #1's responsible party related to CR #1's behaviors. She stated she provided a list of facilities to consider for transfer and the responsible party was undecided. Record review of CR #1's Social Services progress notes revealed on 7/18/25 at 11:13am, a referral was pending with a local behavioral health hospital. On 7/21/25 at 4:49pm, a referral was submitted to a local nursing facility. On 7/31/25 at 4:46pm, a referral was submitted to another local nursing facility. Record review of a Provider Investigation Report dated 7/21/25 and signed by the Administrator revealed on 7/14/25, CNA B observed CR #1 touch CR #2's right breast area. The charge nurse received an order to send CR #1 to an acute care hospital for a psychological evaluation and further assessment. CR #1 refused to go to the hospital on 7/14/25 and 1:1 supervision was provided. CR #1 agreed to go to the hospital on 7/15/25 and returned on 7/15/25 with no new orders. All staff were educated on the topics of resident rights, types of abuse, mandatory reporting for any alleged or witnessed abuse 676251 Page 21 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some immediately. The Administrator noted that the allegation was substantiated. CR #1 was seen by Psychological Services on 7/17/25 with no change to established plan of care. Social Services provided psychosocial support to CR #2 with no further concerns identified. Record review of CR #1's Nurse Progress Note dated 8/3/25 at 6:03pm, LVN D documented the following: Aide found resident in this resident room and he was touching breast and inner thighs inappropriate (sic). Resident looked at the aide who spoke to this nurse and he said you tattled on me. Staff got resident out. Notified DON. Notified MD. Notified Administrator. Activated on on one sitter.sent out to (local acute care hospital). Record review of a Provider Investigation Report dated 8/10/25 signed by the Administrator revealed on 8/3/25, CNA C observed CR #1 touch CR #2's breast and inner thigh area. The charge nurse assessed CR #2 and notified her responsible party and physician. Charge nurse received orders from CR #1's physician to be sent to an acute care hospital and was provided 1:1 supervision until he discharged . CR #1 was transferred to another facility when he left the acute care hospital. The Administrator noted the allegation was substantiated. In a telephone interview on 9/18/25 at 11:49am, LVN D said she worked at the facility briefly to help since she worked at the same company. She said an incident occurred with CR #1 during her 2nd day at the facility. She said she was told that CR #1 had a tendency to make sexual comments and had an incident with another resident. She said she did not review CR #1's care plan. She said a CNA reported to her that CR #1 offered the resident across the hall a donut then touched her inappropriately in her room. She said the CNA separated them, put him on 1:1 supervision, reported it to the DON, then he left for the hospital. In a telephone interview on 9/18/25 at 12:12pm, CNA C said before the incident between CR #1 and CR #2 in August 2025, she heard from other staff about CR #1's sexual behaviors, but did not know for sure. She said she was not informed of interventions or prevention measures. She said she had a few in-services regarding reporting incidents of sexual abuse to the Administrator and DON. She said she was caring for CR #1 and CR #2 when an incident occurred in August 2025. She said CR #2 moved around the facility in a wheelchair. She said they were directly across the hall from each other. She said on the day of the incident, she noticed she had not seen CR #2 in a while. She said when she walked into her room, CR #1 was laying on the bed with his head near the footboard with a bag of donut holes. She said he was touching CR #2's breast and between her legs. She said she told him, You know that is wrong. She said he responded, Please don't tell. She said she removed CR #2 from the room and informed the nurse. She said the nurse told her to monitor him so she stayed by his room until she left for the day. In an interview on 9/18/25 at 2:42pm, the Social Worker said after CR #1 inappropriately touched a resident in April 2025, the facility staff had a meeting with him and his family to discuss the behavior, the facility's expectations, and process that would follow if it happened again. She said the facility staff were monitoring his behavior and provided supervision. She said they tried to find CR #1 long-term placement after the incident in July 2025. She said she worked with his family members to send referrals to their preferred facility. After the incident in July 2025, CR #1 was provided increased monitoring and he was not provided 1:1 supervision. She said he liked to go outside and sit on the porch. She said CR #1 had critical thinking and understood conversations. She said Resident #5 and CR #2 could communicate but could not comprehend what was going on. In an interview on 9/18/25 at 4:12pm, the DON said in a meeting with CR #1's family members in April 2025 they reported that CR #1 had a history of sexual abuse or sexual behaviors when he was at home with his family. She said they had a recent change in management and she knew the previous DON was working on reeducation. She said the facility did not provide in-services specifically about CR #1 and the education provided to staff after incidents was about reporting abuse to the Administrator and resident rights. In an interview on 676251 Page 22 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 9/18/25 at 4:56pm, the DON said after CR #1's first sexual abuse incident in April 2025 he was sent to a psychiatric hospital and returned with no recommendations for 1:1 supervision. She said there was not a need for it based on report to the facility. She said he continued psychology services at the facility. She said she was not aware of the incident that occurred in May 2025. She said after CR #1's sexual abuse incident in July 2025, they implemented 1:1 supervision until his psychiatrist discontinued the intervention. She said after the incident in August 2025 he was placed on 1:1 supervision and was discharged immediately to the hospital and did not return. In an interview on 9/18/25 at 6:36pm, the Administrator said after CR #1's first sexual abuse incident in April 2025, they started discussions with his family and learned that he had similar behaviors with his family members. He said if the behavior did not improve then he would need to be discharged . He said after the incident, he would keep his hands to himself in the common areas and would sit on the patio. He said he was not aware of the incident that happened in May 2025 but if he had he would have reported it to HHSC and completed an investigation. He said when another incident occurred in July 2025, they tried to give CR #1's family member the final call on locating another facility for him. He said CR #1 could propel himself in his wheelchair and they monitored him but also wanted to protect his privacy. He said the last two sexual abuse incidents occurred in a resident's room. He said they were trying to balance supervision and privacy. He said the incidents were surprising and there were no signs or indications that he would act again. He said he told CR #1 that his behavior was inappropriate. He said CR #2 and Resident #5 had poor cognition and did not approach the point of assessing their ability to consent. In an interview on 9/19/25 at 1:19pm, the Administrator, when asked about protection measures that were in place for Resident #5 after the sexual abuse incident in April 2025, he said Resident #5 wandered the hallways daily. He said they tried to bring her to the activity room and keep Resident #5 away from CR #1. He said he was not aware of an incident or behaviors occurring in May 2025. He said the staff should know to report incidents to the Administrator since he is the abuse coordinator. He said he could not say why it was not reported. He said if he was aware he would follow same course of action and identify victim, get them psychological support, assess, notify, and look at changes to the plan of care. He said after the incident that occurred between CR #1 and CR #2 in July 2025, he was sent to the hospital and returned the same day. He said when he returned, he spoke to the resident about the behavior and how it could not reoccur. He said he could not prevent CR #2 from being in the hallway, and did not move her to a different room. He said he was unsure what else he could have done. In a telephone interview on 9/19/25 at 11:21am, the Former DON said that she worked at the facility until 7/8/25. She said CR #1 had no sexual behaviors prior to the first sexual abuse incident in April 2025. She said after the incident, he was on psychology services, increased monitoring, and believed they updated his care plan. She said she was not aware of the incident that occurred in May 2025. In a telephone interview on 9/19/25 at 12:11pm, the Psychiatric NP said there was no approved treatment for inappropriate sexual behaviors. He said they will try and antidepressant. He said when CR #1 returned from the behavioral health hospital, they put him on Depakote. He said he had to decrease the dosage because he was experiencing sedative side effects. In an telephone interview on 9/19/25 at 1:53pm, the Psychiatric NP said on 7/17/25 he increased CR #1's antidepressant dose. He said he could not remember if he made recommendations for supervision as there was nothing in his notes about supervision. He said they talk about each case during weekly meetings. When asked about facility staff stating he recommended to discontinue 1:1 supervision, he said he must have decided CR #1 was stable. He said the facility would closely monitor him but not continue 1:1 supervision unless they were concerned about something. He said he ultimately put the decision 676251 Page 23 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some for amount of supervision on the facility because they were with the resident. He said it would be difficult for the facility to prevent him from having sexual behaviors. In a telephone interview on 9/24/25 at 12:29pm, ADON B said Resident #5 had a behavior of wandering in her wheelchair. He said the staff knew to supervise and redirect her when needed. He said he could not recall if Resident #5's plan of care changed after she was sexually abused by CR #1 in April 2025. He said after the sexual abuse incident in July 2025 between CR #1 and CR #2, he said they watched CR #1 when he was around a female resident. He said they did not want to isolate anyone and wanted to respect their privacy. When asked about abuse prevention, he said he would follow the guidance of the DON and Administrator. Record review of the facility's policy titled ‘Abuse: Prevention of and Prohibition Against' dated 12/2024 stated, .Investigation. All identified events are reported to the Administrator immediately. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below).All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Protection.If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation:.Increase supervision of the alleged victim and residents.Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor and intervene as necessary to maximize resident health and safety.Reporting/Response.At the conclusion of the investigation, the Facility will take action, as necessary, in light of the information gathered, which may include but is not limited to: If the allegation is substantiated, analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property, or exploitation occurred, and determining what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services, if appropriate; Training staff on changes made and demonstration of staff competency after training is implemented; Identifying staff responsible for the implementation of corrective action; The expected date for implementation; and Identifying staff responsible for monitoring the implementation of the plan. This was determined to be an Immediate Jeopardy (IJ) on 9/19/25 at 4:52pm. The Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of Removal F610: Abuse Investigation The facility failed to have evidence that all alleged violations of sexual abuse are thoroughly investigated and failed to take steps to prevent further potential abuse and take appropriate corrective action as a result of investigation findings.1. Facility Medical Director was notified of the IJ on 09/19/2025 at 04:50 pm by the Administrator.2. Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made on 09/19/25. 3. Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 at 5PM regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). This training was given by the RN, Clinical Resource on 09/19/25. Training & Knowledge Check including Post-Test will be completed with all staff by 09/20/25. Any remaining staff member(s) pending Training and 676251 Page 24 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some knowledge check will complete the Training and Knowledge Check prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors check care plan, as additional intervention tool to ensure timely interventions/investigation(s) are implemented.4. DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter. This audit was completed on 9/19/25 and No additional discrepancies were identified. Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents. 5. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.6. DON/ designee/ Cluster Partners will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated appropriately. This will be completed by 9/19/25. 7. DON/ Designee will review the 24-[NAME] 676251 Page 25 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's nursing, mental and psychosocial needs for 1 of 17 residents (CR #1) reviewed for comprehensive care plans in that: CR #1's care plan was not revised when he sexually abused Resident #5, an unidentified resident and CR #2 and had one sexual inappropriate behavior within a 4-month period between 4/19/25 and 8/3/25. Nursing staff, including LVN B, CNA A, LVN C, CNA B, LVN D and CNA C, were unaware of interventions for CR #1 that would prevent further sexual abuse from occurring. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of not having their behavioral needs met, which could lead to abuse, emotional distress and serious harm. The findings included: Record review of CR #1's care profile generated on 9/17/25 revealed he was admitted to the facility on [DATE]. He had diagnoses of diabetes, chronic obstructive pulmonary disease, cognitive communication deficit, adjustment disorder with anxiety, and dementia. He was [AGE] years of age. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 3, indicating he had severe cognitive impairment. He had a PHQ-9 score of 7, indicating he had mild depression symptoms. No behaviors were noted. He required supervision for transfers and wheelchair mobility assistance. Record review of CR #1's Nurse Progress Note dated 4/19/25 at 8:43am revealed LVN A documented the following: Notified by CNA this resident was coming down the hall, another resident was coming the opposite was (sic), this resident stopped resident in the hall and was seen by CNA reaching out and touching the female residents (sic) breast, the female resident was trying to move his hand away and notified me the nurse. I spoke with resident about how this was inappropriate and he should not be touching other resident in that way. Resident stated ‘that's my friend and I was just saying hello.' Removed female resident from the situation.notified Administrator and DON.will be keeping residents apart and this resident in line of sight for monitoring. Further record review of CR #1's Nurse Progress Notes revealed he was sent to a local Behavioral hospital on 4/19/25 and returned on 4/29/25. Record review of a Provider Investigation Report dated 4/25/25 and signed by the Administrator revealed on 4/19/25, CR #1 touched Resident #5's left breast area. Resident #5 was assessed on 4/19/25 at 8:10am and education was provided to CR #1 that the behavior was inappropriate. The nurse notified Resident #5's responsible party and physician, CR #1's responsible party. The psychological service provider assessed CR #1 on 4/19/25 at 2:20pm and made a recommendation for behavioral hospital evaluation. Education was provided to facility staff regarding resident rights, types of abuse, abuse reporting, resident-to-resident altercation reporting guidelines. The Administrator noted the allegation was unsubstantiated, stating, (CR #1) did not exhibit any signs or symptoms of the inappropriate behavior. Facility staff, who witnessed the incident intervened immediately and separate the residents for resident safety. (Psychological Services) provider assessed (CR #1) on 4/19/25 and sent the referral for in-patient treatment.(CR #1) is currently at the hospital.(Resident #1) is also stable with normal vitals and no signs or symptoms of distress. Record review of CR #1's care plan dated initiated on 5/1/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. Interventions 676251 Page 26 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some included: Assess and anticipate resident needs: food thirst, toileting, comfort level etc. (created 5/1/25) Cognitive assessment (created 5/1/25) Evaluate for side effects of medications (created 5/1/25) Psychiatric/psychogeriatric consult as indicated. (created 5/1/25) Record review of CR #1's Nurse Progress Note dated 5/17/25 at 12:46pm revealed LVN A documented the following: Resident was told several times by a female resident to please leave her alone and stop talking to her, resident would not listen and kept staring and trying to ask her questions, another nurse intervened and asked resident to move away from the female, female resident stated he was making her feel uncomfortable, resident continued to try to talk to female, finally resident rollway away to hallway, then was seen stopping and looking every residents (sic) room for a couple of minutes before rolling to the next doorway, this nurse approached resident asking why he was looking in everyone's room, he stated just wanted to see what they were doing. Educated on giving people privacy. In a telephone interview on 9/18/25 at 10:07am, LVN A said when she worked at the facility, she cared for CR #1. She said CR #1 would say inappropriate comments to female residents or try to touch them inappropriately. She said when CR #1 started displaying these behaviors, he would talk to residents who could speak up for themselves and ask him to stop. She said when CR #1 touched Resident #5 inappropriately, Resident #5 could not ask him to stop. When asked about interventions for CR #1 to prevent behaviors like this, she said separate him from the residents he was bothering, provide activities and provide 1:1 supervision. She said she could not recall if CR #1's interventions were updated when he returned from the behavioral hospital in April 2025 and could not recall if she received training on his interventions. She said she stopped working at the facility in June 2025. Record review of CR #1's Nurse Progress Note dated 5/21/25 at 12:13am revealed LVN B documented the following: Upon arrival at facility (CNA A) reported that resident was caught in the dining room with his hand under the table trying to inappropriately touch a female resident. When asked to remove his hand resident stated, ‘That's my wife.' Female resident was removed from dining room. CNA says the incident was reported.will monitor. In a telephone interview on 9/18/25 at 10:30am, LVN B said she was not informed of CR #1's sexual behaviors when started caring for him. She said she heard rumors from other staff but had not experienced it herself. She said there was an incident in May 2025 when CR #1 tried to grab another resident's vagina during her shift and a CNA reported it to her. She said the incident would have been reportable based on the abuse policy, so she would have reported it to the Former DON. She said CR #1 roamed around the facility freely when he was not provided 1:1 supervision. She said it would have been impossible to keep an eye on him. She said was not provided any in-services regarding his behaviors or interventions. She said the in-services she received were generally about abuse reporting and behavior monitoring. In a telephone interview on 9/19/25 at 11:56am, LVN B said she could not remember the name of the resident who CR #1 tried to touch in May 2025. She said it was a resident who had poor cognition. In an interview on 9/18/25 at 3:00pm, CNA A said she was not aware of CR #1's sexual behaviors or sexual abuse allegations prior to witnessing an incident in May 2025. She said on the day of the incident, she was charting when she looked into the dining room and saw a female resident sitting with CR #1, and CR #1's hand was on her thigh beneath the table. She said it occurred on the 2pm-10pm shift and it happened after lunchtime. She said she believed the female resident was Resident #5, but could not say for sure. She said the female resident did not react to being touched. She said she told LVN A and LVN B. She said CR #1 liked to give other residents snacks like chips and candy. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 11, indicating moderate cognitive impairment. He had a PHQ-9 score of 1, indicating minimal depression symptoms. No behaviors were noted. He required setup assistance for sit to stand and chair/bed-to-chair 676251 Page 27 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some transfers and was independent with wheelchair mobility. Record review of CR #1's Nurse Progress Note dated 7/14/25 at 7:24pm revealed LVN C documented the following: CNA reported to supervisor that resident was observed touching the breast of another resident. Resident will received (sic) order from MD to go to (local behavioral hospital), RP notified. Record review of CR #1's Nurse Progress Notes dated between 7/14/25 at 10:00pm and 7/15/25 at 7:15am revealed a nurse documented every 15-minute observations of CR #1. On 7/15/25 at 2:46pm, a nurse documented CR #1 was transferred to a local acute care hospital. A nurse documented that he returned with a diagnosis of injury to left rotator cuff on 7/15/25 at 10:45pm. The nurse stated, ADON, (Administrator) and family made aware and will address further in the morning. In a telephone interview on 9/18/25 at 11:30am, LVN C said she did not have anything in place, and she was not told to have anything in place before CR #1 touched CR #2's breast. She said it was reported to her that he had a history of sexual behaviors. She said, I didn't have any interventions with him, that was the care plan team's job. She said in July 2025, a CNA witnessed CR #1 touch CR #2 inappropriately. She said the CNA immediately separated them, put CR #1 on 1:1 supervision, and notified the DON. She said CR #1 was on 1:1 supervision until he left for the hospital. She said she could not remember what happened when CR #1 returned from the hospital but believed 1:1 supervision continued. In an interview on 9/20/25 at 2:15pm, CNA B said she was shocked to learn that CR #1 had sexually inappropriate behaviors. She said she first found out about his behaviors when they had in-services regarding sexual abuse and reporting. She said CR #1 was cognitively intact and went to church every Sunday. She said CR #2 had short-term memory loss and could not remember one conversation to the next. She said CR #2 used a wheelchair and wandered around the facility. She said CR #2 liked to go by CR #1's room because he kept snacks in his room. She said one day about a month and a half ago, CR #2 was in CR #1's room laying down with his head by the footboard and touching CR #2's breast. She said she removed CR #2 from the room, notified the Administrator and the LVN E. She said after the incident, she kept an eye of CR #1 and made sure no one went into his room. She said CR #2 wandered and she tried to keep track of where she was at all times. She said interventions to prevent another incident of abuse was primarily supervision. Record review of CR #1's care plan updated on 7/15/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. The following interventions were added: New order to send to (behavioral hospital), monitor by staff until transfer. (created 7/15/25) Stop and guide resident away from behavioral act. (created 7/15/25) Record review of a Provider Investigation Report dated 7/21/25 and signed by the Administrator revealed on 7/14/25, CNA B observed CR #1 touch CR #2's right breast area. The charge nurse received an order to send CR #1 to an acute care hospital for a psychological evaluation and further assessment. CR #1 refused to go to the hospital on 7/14/25 and 1:1 supervision was provided. CR #1 agreed to go to the hospital on 7/15/25 and returned on 7/15/25 with no new orders. All staff were educated on the topics of resident rights, types of abuse, mandatory reporting for any alleged or witnessed abuse immediately. The Administrator noted that the allegation was substantiated. CR #1 was seen by Psychological Services on 7/17/25 with no change to established plan of care. Social Services provided psychosocial support to CR #2 with no further concerns identified. Record review of CR #1's Nurse Progress Note dated 8/3/25 at 6:03pm, LVN D documented the following: Aide found resident in this resident room and he was touching breast and inner thighs inappropriate (sic). Resident looked at the aide who spoke to this nurse and he said you tattled on me. Staff got resident out. Notified DON. Notified MD. Notified Administrator. Activated on on one sitter.sent out to (local acute care hospital). Record review of a Provider Investigation Report dated 8/10/25 signed by the Administrator revealed on 8/3/25, CNA C 676251 Page 28 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some observed CR #1 touch CR #2's breast and inner thigh area. The charge nurse assessed CR #2 and notified her responsible party and physician. Charge nurse received orders from CR #1's physician to be sent to an acute care hospital and was provided 1:1 supervision until he discharged . CR #1 was transferred to another facility when he left the acute care hospital. The Administrator noted the allegation was substantiated. In a telephone interview on 9/18/25 at 11:49am, LVN D said she worked at the facility briefly to help since she worked at the same company. She said an incident occurred with CR #1 during her 2nd day at the facility. She said she was told that CR #1 had a tendency to make sexual comments and had an incident with another resident. She said she did not review CR #1's care plan. She said a CNA reported to her that CR #1 offered the resident across the hall a donut then touched her inappropriately in her room. She said the CNA separated them, put him on 1:1 supervision, reported it to the DON, then he left for the hospital. In a telephone interview on 9/18/25 at 12:12pm, CNA C said before the incident between CR #1 and CR #2 in August 2025, she heard from other staff about CR #1's sexual behaviors, but did not know for sure. She said she was not informed of interventions or prevention measures. She said she had a few in-services regarding reporting incidents of sexual abuse to the Administrator and DON. She said she was caring for CR #1 and CR #2 when an incident occurred in August 2025. She said CR #2 moved around the facility in a wheelchair. She said they were directly across the hall from each other. She said on the day of the incident, she noticed she had not seen CR #2 in a while. She said when she walked into her room, CR #1 was laying on the bed with his head hear the footboard with a bag of donut holes. She said he was touching CR #2's breast and between her legs. She said she told him, You know that is wrong. She said he responded, Please don't tell. She said she removed CR #2 from the room and informed the nurse. She said the nurse told her to monitor him so she stayed by his room until she left for the day. In an interview on 9/18/25 at 2:42pm, the Social Worker said after CR #1 inappropriately touched a resident in April 2025, the facility staff had a meeting with him and his family to discuss the behavior, the facility's expectations, and process that would follow if it happened again. She said the facility staff were monitoring his behavior and provided supervision. She said they tried to find CR #1 long-term placement after the incident in July 2025. She said she worked with his family members to send referrals to their preferred facility. After the incident in July 2025, CR #1 was provided increased monitoring and he was not provided 1:1 supervision. She said he liked to go outside and sit on the porch. She said CR #1 had critical thinking and understood conversations. She said Resident #5 and CR #2 could communicate but could not comprehend what was going on. In an interview on 9/18/25 at 4:12pm, the DON said in a meeting with CR #1's family members in April 2025 they reported that CR #1 had a history of sexual abuse or sexual behaviors when he was at home with his family. She said the facility communicated care plan interventions to nursing staff by conducting nurse huddles daily at 9am and 4pm, conducting in-services, all-staff meetings monthly and utilizing the resident's electronic medical record. She said they had a recent change in management and she knew the previous DON was working on reeducation. She said the facility did not provide in-services specifically about CR #1 and the education provided to staff after incidents was about reporting abuse to the Administrator and resident rights. In an interview on 9/18/25 at 4:56pm, the DON said after CR #1's first sexual abuse incident in April 2025 he was sent to a psychiatric hospital and returned with no recommendations for 1:1 supervision. She said there was not a need for it based on report to the facility. She said he continued psychology services at the facility. She said she was not aware of the incident that occurred in May 2025. She said after CR #1's sexual abuse incident in July 2025, they implemented 1:1 supervision until his psychiatrist discontinued the intervention. She said after the incident in August 2025 he was 676251 Page 29 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some placed on 1:1 supervision and was discharged immediately to the hospital and did not return. In an interview on 9/18/25 at 6:36pm, the Administrator said after CR #1's first sexual abuse incident in April 2025, they started discussions with his family and learned that he had similar behaviors with his family members. He said if the behavior did not improve then he would need to be discharged . He said after the incident, he would keep his hands to himself in the common areas and would sit on the patio. He said he was not aware of the incident that happened in May 2025 but if he had he would have reported it to HHSC and completed an investigation. He said when another incident occurred in July 2025, they tried to give CR #1's family member the final call on locating another facility for him. He said CR #1 could propel himself in his wheelchair and they monitored him but also wanted to protect his privacy. He said the last two sexual abuse incidents occurred in a resident's room. He said they were trying to balance supervision and privacy. He said the incidents were surprising and there were no signs or indications that he would act again. He said he told CR #1 that his behavior was inappropriate. He said CR #2 and Resident #5 had poor cognition and did not approach the point of assessing their ability to consent. In a telephone interview on 9/19/25 at 11:21am, the Former DON said that she worked at the facility until 7/8/25. She said CR #1 had no sexual behaviors prior to the first sexual abuse incident in April 2025. She said after the incident, he was on psychology services, increased monitoring, and believed they updated his care plan. She said she was not aware of the incident that occurred in May 2025. She said care plan revisions were a collaborative effort but was mostly completed by the MDS nurse. She said she could not recall who was responsible for care planning between April 2025 and July 2025 since they had some turnover in the role. In an interview on 9/20/25 at 12:25pm, after reviewing CR #1's care plan for sexually inappropriate behaviors, the DON said she would like to see that care plans are revised after each incident to include what new interventions were implemented. She said there should be more interventions listed for CR #1. This was determined to be an Immediate Jeopardy (IJ) on 9/19/25 at 4:52pm. The Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of Removal F656: Care PlansThe Facility failed to develop and implement a comprehensive person-centered care plan for Resident#3 when he sexually abused Residents #1 and #2 and had one sexual inappropriate behavior within a 4-month period. The facility failed to ensure nursing staff were aware of interventions that would prevent further sexual abuse from occurring. 1. The medical director was notified of the IJ on 09/19/2025 at 4:50 pm by the Administrator.2. Abuse, Neglect and Exploitation Policy reviewed by Medical Director and clinical resource with no changes made on 09/19/25. 3. MDS, LVN, Resource conducted a 1-on-1 education and training on the MDS coordinators audit was performed on 09/19/2025 to identify any other residents demonstrating sexually inappropriate behaviors. No other residents were identified.5. Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 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 by 09/20/25. Any remaining staff member(s) pending Training and knowledge check will complete the Training and Knowledge Check prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan, as additional intervention tool to 676251 Page 30 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some ensure timely interventions/investigation(s) are implemented.6. 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, clinical resource/ designee will be responsible that all staff are trained before working. To validate the knowledge check for Licensed Nurses and CNA's, the DON/Designee will quiz 5 random Nursing and CNA staff daily x 1week, then twice a week x 2 weeks and once a week x 2 weeks, or until substantial compliance has been achieved. Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents.7. If in the future, a resident demonstrates sexually inappropriate behavior, it will be added to the resident care profile which will be visible to the nurses. 8. MDS/ designee will be responsible for updating the care plans.9. An ad hoc (a non-scheduled QA meeting) meeting will be called regarding items in the IJ templates and will be completed on 09/20/25. Attendees will include the DON, Administrator, Medical Director, ADON, Clinical Resource which will include the plan of removal items and interventions.10. DON/ designee will educate all nurses by 09/20/25 regarding resident care profile and CNAs regarding Kardex to identify residents for sexually inappropriate behaviors. Any remaining Licensed Nurses and CNAs staff member(s) pending Education/Training checks will complete the Training/Education prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training/education.11. Safe-Surveys were conducted on 09/19/25 by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident(s). Interviewable resident(s) were included in the Safe-Surveys. The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility to report any abuse. & who is the Abuse Coordinator for facility/ who to report for alleged abuse. Interviewed residents were able to answer for who to report at facility for any alleged abuse.12. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 09/19/25 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Record review of the facilities IJ Template revealed it was signed by the Medical Director (undated). Record review of a Grievance Log and Incident Log dated May 2025 to September 2025 revealed the DON reviewed both and signed her name on the documents. Record review of Safe Survey Questionnaires for Alleged Abuse conducted by the Social Worker revealed she interviewed 18 residents. All residents stated they would speak to SW or administrator if abuse occurred, all satisfied with care, no problems with other residents, staff. RR of In-service attendance records dated 9/19/25 revealed the DON presented in-services to all staff, including administrative staff and nursing staff, therapy, housekeeping, maintenance. Topics included: - Abuse prevention, freedom from abuse and neglect.Reporting alleged violations of abuse, neglect, exploitation and mistreatment.- Reporting suspicion of a crime, freedom from abuse, neglect and exploitation. Record review of an In-Service Attendance Record dated 9/20/25 at 11:00am revealed the Clinical Resource provided education to the Administrator, DON and Social Worker on the topic of conducting abuse and incident investigations/interviews which included the following: Define types of incidents requiring an investigation and reporting to appropriate agencies; Initiated the investigation and preparing for the interview- Includes review of medical records and assessment findings physical, psychological impact, personnel files, training records, policies, equipment, scene of the incident, staff schedules and assignments; Techniques for completing a successful and 676251 Page 31 of 32 676251 09/24/2025 Misty Willow Healthcare and Rehabilitation Center 12921 Misty Willow Dr Houston, TX 77070

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some through interview; Analyze findings from investigation and interviews; Develop plan to prevent future occurrences and care plan updates; Maintaining investigation files and completing final report to appropriate agencies; Evaluation used scenario-based presentations with learner replies demonstrating learned techniques. Interviews with CNA D, MA A, CNA E, LVN F, CNA F, CNA G, LVN G and LVN H on 9/21/25 between 5:37am and 3:31pm revealed they could reiterate the in-services they received, including a resident's right to be free from sexual abuse, their responsibility regarding incidents of abuse, abuse prevention, behaviors that could lead to abuse and identifying and locating care plan areas and interventions. Interviews with the Social Worker, Administrator, DON and ADON on 9/21/25 between 1:57pm and 2:34pm revealed they could reiterate he in-services the received, including their responsibility regarding the abuse policy, abuse investigation, abuse prevention and care plan revisions. In an interview on 9/21/25 at 2:01pm, the MDS Coordinator said she had worked at the facility for one month. She said they audited all resident's care plans to ensure there were current. She said she was responsible for care planning. She said she was informed of incidents by attending morning meetings and reviewing falls and changes of condition. On 9/21/25 at 3:37pm, the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. 676251 Page 32 of 32