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Misty Willow Healthcare and Rehabilitation Center
12921 Misty Willow Dr, Houston, TX 77070 · CMS Certification Number (CCN) 676251
Special Focus Facility candidate CMS abuse icon
CMS shows the abuse icon when a nursing home was cited for abuse or neglect at the harm level or above (scope/severity G or higher) on its most recent inspection cycle, or at the potential-harm level (D or higher) on both of its two most recent cycles. CMS data dictionary
CMS lists this home in its data as a candidate for the Special Focus Facility (SFF) program, which CMS describes as for homes with a history of serious quality issues. CMS Technical Users’ Guide
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 30 in the last 3 inspection cycles (8 immediate jeopardy, 0 actual harm, 11 from complaints)
- Fire safety citations
- 3
- Fines (last 3 years)
- 3 fines, total $64,093
- Payment denials
- 0
- Most recent standard inspection
- December 4, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★☆☆☆☆ 1 of 5 | 2.8 | 2.8 |
| Staffing | ★★☆☆☆ 2 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | December 4, 2025 | 14 | 7 | 7 |
| Cycle 2 | August 30, 2024 | 9 | 6 | 4 |
CMS weighted health inspection score: 536.5 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
30 health citations across 6 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
March 9, 2026: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/11/2026 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/11/2026 |
December 4, 2025: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0813 | Have a policy regarding use and storage of foods brought to residents by family and other visitors. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/06/2025 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/06/2025 |
| E | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/06/2025 |
| D | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/06/2025 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/06/2025 |
| D | F-0694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/06/2025 |
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/06/2025 |
September 24, 2025: 5 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| K | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/16/2025 |
| K | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/16/2025 |
| K | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/16/2025 |
| K | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/16/2025 |
| D | F-0564 | Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 10/16/2025 |
March 29, 2025: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/31/2025 |
| K | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/31/2025 |
| K | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/31/2025 |
August 30, 2024: 6 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 09/03/2024 |
| D | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/03/2024 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/03/2024 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/03/2024 |
| D | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/03/2024 |
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/03/2024 |
June 16, 2023: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/14/2023 |
| D | F-0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/14/2023 |
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/14/2023 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/14/2023 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/14/2023 |
| D | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/14/2023 |
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/14/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
3 fire safety citations across 2 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 12/04/2025 | E | K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 12/06/2025 |
| 12/04/2025 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/06/2025 |
| 06/16/2023 | E | K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/23/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| March 9, 2026 | Fine | $28,451 | — |
| September 24, 2025 | Fine | $20,495 | — |
| March 29, 2025 | Fine | $15,147 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.3 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.35 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.01 | Not published | Not published |
| Nurse aide hours per resident per day | 1.94 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.87 | Not published | Not published |
| RN hours per resident per day, weekends | 0.29 | Not published | Not published |
| Total nursing staff turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | 55.3 | 45.8 |
| Registered nurse turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
| Administrators who have left | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Liberty County Hospital District No 1
- Ownership type
- For profit - Limited Liability company
- Chain
- The Ensign Group (344 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 124
- Average residents per day
- 89.8
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- None
- First approved for Medicare/Medicaid
- April 21, 2010
- County/parish
- Harris
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
15 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| LIBERTY COUNTY HOSPITAL DISTRICT NO 1 | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| ALI, NIDA | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FITZGERALD, TAMI | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BURNAM, SOON | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KEETCH, CHAD | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STRATTON, CHARLES | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MISTY WILLOW HEALTHCARE, INC. | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ALI, NIDA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FITZGERALD, TAMI | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| ENSIGN SERVICES INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MISTY WILLOW HEALTHCARE, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| NATIONAL HEALTH INVESTORS, INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| TEXAS NHI INVESTORS, LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ALI, NIDA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FITZGERALD, TAMI | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Misty Willow Healthcare and Rehabilitation Center. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.