Misty Willow Healthcare and Rehabilitation Center
12921 Misty Willow Dr, Houston, TX 770702814697881124 certified beds · 90 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
6
since 2023
Deficiencies
30
● 0● 22● 8
Penalties · 3 yrs
$79,412
3 fines
Last survey
2026-03-09
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 1
Staffing 2
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-03-09 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2025-12-04 | Standard | 070 | CMS-2567 (Care Compare) | — |
| 2025-09-24 | Complaint | 014 | CMS-2567 (Care Compare) | — |
| 2025-03-29 | Complaint | 003 | CMS-2567 (Care Compare) | — |
| 2024-08-30 | Standard | 060 | CMS-2567 (Care Compare) | — |
| 2023-06-16 | Standard | 070 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2026-03-11Record 676251-20260309-F684
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-11Record 676251-20260309-F550
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-06Record 676251-20251204-F689
F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-06Record 676251-20251204-F694
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-06Record 676251-20251204-F755
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-06Record 676251-20251204-F761
F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-06Record 676251-20251204-F805
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-12-06Record 676251-20251204-F812
F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-06Record 676251-20251204-F813
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-10-16Record 676251-20250924-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-10-16Record 676251-20250924-F607
F610Respond appropriately to all alleged violations.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-10-16Record 676251-20250924-F610
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity KHarm
Care planningRecords
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-10-16Record 676251-20250924-F656
F564Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-16Record 676251-20250924-F564
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-03-31Record 676251-20250329-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity KHarm
Care planningFalls
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-03-31Record 676251-20250329-F689
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity JHarm
Medication
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-03-31Record 676251-20250329-F755
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-03Record 676251-20240830-F583
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-03Record 676251-20240830-F686
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-03Record 676251-20240830-F690
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-03Record 676251-20240830-F695
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-03Record 676251-20240830-F761
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-03Record 676251-20240830-F880
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-14Record 676251-20230616-F583
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-14Record 676251-20230616-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-14Record 676251-20230616-F656
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-14Record 676251-20230616-F695
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-14Record 676251-20230616-F759
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-14Record 676251-20230616-F761
F803Ensure 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.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-14Record 676251-20230616-F803
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2026-03-09 | Civil money penalty | $43,770 | CMS · Penalties |
| 2025-09-24 | Civil money penalty | $20,495 | CMS · Penalties |
| 2025-03-29 | Civil money penalty | $15,147 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.35
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day3.30
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours2.87
Facility
Texas
National
Texas 2.98 · National 3.42
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 3.9% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 3.5% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 4.9% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.0% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 14.9% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 3.9% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 12.4% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Liberty County Hospital District No 1 Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Ali, Nida Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Fitzgerald, Tami Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Misty Willow Healthcare, Inc. Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Ali, Nida Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Ali, Nida Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Burnam, Soon Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Ensign Services Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Fitzgerald, Tami Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Fitzgerald, Tami Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Keetch, Chad Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Misty Willow Healthcare, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| National Health Investors, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Stratton, Charles Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Texas Nhi Investors, LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
The Ensign Group — 342 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Harris.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| North Houston Transitional Care Houston | 0.4 mi | 2026-05-21 | 062 |
| Champions Healthcare at Willowbrook Houston | 1.0 mi | 2026-04-23 | 0153 |
| Fallbrook Rehabilitation and Care Center Houston | 3.0 mi | 2026-04-29 | 0308 |
| Park Manor Of Cyfair Houston | 3.0 mi | 2026-05-01 | 030 |
| Legend Oaks Healthcare And Rehabilitation Center - Houston | 4.3 mi | 2025-12-01 | 1142 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |