Misty Willow Healthcare and Rehabilitation Center
12921 Misty Willow Dr, Houston, TX 77070 · CCN 676251
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Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★☆☆☆☆ 1
- Quality measures
- ★★★☆☆ 3
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 124
- Avg residents/day
- 95.8
- Phone
- 2814697881
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-12-04 | 15 | 9.1 | 9.5 | +5.9 worse |
| 2 | 2024-08-30 | 6 | 9.4 | 9.8 | -3.4 better |
| 3 | 2023-06-16 | 10 | 8.1 | 9.3 | +1.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Abuse, neglect, exploitation | 3 |
| Quality of life and care | 4 |
| Resident assessment and care planning | 1 |
| Resident rights | 1 |
| Nutrition and dietary | 3 |
| Pharmacy service | 3 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.36 | 58.4% |
| RN staffing (reported) | 0.52 | 60.0% |
| Total nurse staffing (adjusted) | 3.42 | — |
Fines & penalties
- Total fines
- $46,677
- Number of fines
- 2
- Number of penalties
- 2
- Payment denials
- 0
Chain
- Chain
- THE ENSIGN GROUP
- Facilities in chain
- 329
- Chain avg overall
- 3.20 / 5
Inspection citations (31)7 immediate jeopardy1 actual harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-12-04 · Health · corrected 2025-12-06
Potential for more than minimal harm
- DF0694Provide for the safe, appropriate administration of IV fluids for a resident when needed.2025-12-04 · Health · corrected 2025-12-06
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-12-04 · Health · corrected 2025-12-06
Potential for more than minimal harm
- DF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2025-12-04 · Health · corrected 2025-12-06
Potential for more than minimal harm
- EF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2025-12-04 · Health · corrected 2025-12-06
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-12-04 · Health · corrected 2025-12-06
Potential for more than minimal harm
- EF0813Have a policy regarding use and storage of foods brought to residents by family and other visitors.2025-12-04 · Health · corrected 2025-12-06
Potential for more than minimal harm
- DF0564Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.2025-09-24 · Health · corrected 2025-10-16
Potential for more than minimal harm
- KF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-09-24 · Health · corrected 2025-10-16
Immediate jeopardy
- KF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2025-09-24 · Health · corrected 2025-10-16
Immediate jeopardy
- KF0610Respond appropriately to all alleged violations.2025-09-24 · Health · corrected 2025-10-16
Immediate jeopardy
- KF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-09-24 · Health · corrected 2025-10-16
Immediate jeopardy
- KF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-03-29 · Health · corrected 2025-03-31
Immediate jeopardy
- KF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-03-29 · Health · corrected 2025-03-31
Immediate jeopardy
- JF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-03-29 · Health · corrected 2025-03-31
Immediate jeopardy
- DF0583Keep residents' personal and medical records private and confidential.2024-08-30 · Health · corrected 2024-09-03
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-08-30 · Health · corrected 2024-09-03
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-08-30 · Health · corrected 2024-09-03
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-08-30 · Health · corrected 2024-09-03
Potential for more than minimal harm
- DF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2024-08-30 · Health · corrected 2024-09-03
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2024-08-30 · Health · corrected 2024-09-03
Potential for more than minimal harm
- DF0583Keep residents' personal and medical records private and confidential.2023-06-16 · Health · corrected 2023-07-14
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2023-06-16 · Health · corrected 2023-07-14
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-06-16 · Health · corrected 2023-07-14
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2023-06-16 · Health · corrected 2023-07-14
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2023-06-16 · Health · corrected 2023-07-14
Potential for more than minimal harm
- DF0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.2023-06-16 · Health · corrected 2023-07-14
Potential for more than minimal harm
- EF0803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.2023-06-16 · Health · corrected 2023-07-14
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-04-06 · Health · corrected 2023-04-14
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2023-04-06 · Health · corrected 2023-04-14
Potential for more than minimal harm
- GF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-03-01 · Health · corrected 2023-03-02
Actual harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| LIBERTY COUNTY HOSPITAL DISTRICT NO. 1 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2017-04-01 |
| MISTY WILLOW HEALTHCARE, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-04-01 |
| ALI, NIDA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-09-18 |
| FITZGERALD, TAMI | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2017-04-01 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | — | 2017-04-01 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | — | 2011-03-01 |
| STRATTON, CHARLES | Individual | CORPORATE OFFICER | — | 2005-02-07 |
Other facilities in Houston
| Name | Overall | Beds |
|---|---|---|
| Treemont Health Care Center | ★★★★★ | 70 |
| ST DOMINIC VILLAGE REHABILITATION AND NURSING CENT | ★★★★★ | 158 |
| Sharpville Residence and Rehabilitation Center | ★★★★☆ | 134 |
| Ashford Gardens | ★★★★☆ | 202 |
| Caraday of Houston | ★★★★☆ | 150 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.