Misty Willow Healthcare and Rehabilitation Center

Nursing Home · Houston, TX

CMS overall rating 1/5 SFF candidate Abuse citation For profit - Limited Liability company

CMS certification number676251
CMS lists this nursing home as a Special Focus Facility candidate – one of the lowest-performing nursing homes in its state based on inspection history.
This facility was cited for abuse, neglect or exploitation in a recent inspection (CMS abuse icon).

Contact & location

12921 Misty Willow Dr
Houston, TX 77070
Harris County
Phone
(281) 469-7881
ZIP code
77070 – all care providers

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Facility details

Certified beds
124
Residents per day
89.8 (72% occupied)
Ownership
For profit - Limited Liability company
Legal name
Liberty County Hospital District No 1
Chain
The Ensign Group (342 facilities, avg 3.2★)
Medicare certified since
April 21, 2010
Participates in
Medicare and Medicaid

CMS star ratings

Overall★★★★★ 1/5
State avg 2.6
Health inspections★★★★★ 1/5
State avg 2.8
Staffing★★★★★ 2/5
State avg 1.9
Quality measures★★★★★ 4/5
State avg 3.7
Long-stay quality★★★★★ 4/5
Short-stay quality★★★★★ 4/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.30 (state 3.39 · U.S. 3.86)
Registered nurses (RN)
0.35 (state 0.43 · U.S. 0.69)
Licensed practical nurses
1.01 (state 0.95 · U.S. 0.86)
Nurse aides
1.94 (state 2.00 · U.S. 2.32)
Weekend total
2.87 (state 2.98 · U.S. 3.42)
Nursing staff turnover
—
RN turnover
—

Inspections

Last standard inspection
December 4, 2025
Health deficiencies (last cycle)
14.0 (state 9.3 · U.S. 9.3)
From complaints
7
Citations on record (3 years)
30 health · 3 fire safety · includes immediate jeopardy
DateCitationSeverityStatus
2026-03-09 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2026-03-11
2026-03-09 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-03-11
2025-12-04 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-12-06
2025-12-04 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F0805 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-12-06
2025-12-04 Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F0813 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-12-06
2025-12-04 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-06
2025-12-04 Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F0694 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-06
2025-12-04 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-06
2025-12-04 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-06
2025-09-24 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 K
Immediate jeopardy to resident health or safety		 Corrected 2025-10-16
2025-09-24 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 K
Immediate jeopardy to resident health or safety		 Corrected 2025-10-16
2025-09-24 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 K
Immediate jeopardy to resident health or safety		 Corrected 2025-10-16
2025-09-24 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 K
Immediate jeopardy to resident health or safety		 Corrected 2025-10-16
2025-09-24 Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
F0564 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-10-16
2025-03-29 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 K
Immediate jeopardy to resident health or safety		 Corrected 2025-03-31
2025-03-29 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 K
Immediate jeopardy to resident health or safety		 Corrected 2025-03-31
2025-03-29 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2025-03-31
2024-08-30 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-09-03
2024-08-30 Keep residents' personal and medical records private and confidential.
F0583 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-03
2024-08-30 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-03
2024-08-30 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-03
2024-08-30 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-03
2024-08-30 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-03
2023-06-16 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.
F0803 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-07-14
2023-06-16 Keep residents' personal and medical records private and confidential.
F0583 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-14
2023-06-16 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-14
2023-06-16 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-14
2023-06-16 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-14
2023-06-16 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-14
2023-06-16 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-07-14

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

3 penalties in the last three years, including $79,412 in fines.

DateTypeAmount
2026-03-09Fine$43,770
2025-09-24Fine$20,495
2025-03-29Fine$15,147

Ownership & management

NameRoleSince
Liberty County Hospital District No 1 (organization)5%+ Direct Ownership Interest · 100%
Ali, Nida (individual)Administrator · NOT APPLICABLE
Ensign Services INC (organization)Administrator · NOT APPLICABLE
Fitzgerald, Tami (individual)Administrator · NOT APPLICABLE
Misty Willow Healthcare, INC. (organization)Administrator · NOT APPLICABLE
National Health Investors, INC. (organization)Administrator · NOT APPLICABLE
Texas Nhi Investors, LLC (organization)Administrator · NOT APPLICABLE
Burnam, Soon (individual)Corporate Officer · NOT APPLICABLE
Keetch, Chad (individual)Corporate Officer · NOT APPLICABLE
Stratton, Charles (individual)Corporate Officer · NOT APPLICABLE
Ali, Nida (individual)Managing Control - Governing Body · NOT APPLICABLE
Fitzgerald, Tami (individual)Managing Control - Governing Body · NOT APPLICABLE
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

Frequently asked questions

What is the rating of Misty Willow Healthcare and Rehabilitation Center?

Misty Willow Healthcare and Rehabilitation Center has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.6-star average in Texas.

How many beds does Misty Willow Healthcare and Rehabilitation Center have?

It has 124 certified beds and cares for about 90 residents per day.

Has Misty Willow Healthcare and Rehabilitation Center been fined?

Yes. CMS lists 3 penalties totaling $79,412 in the last three years.

Who owns Misty Willow Healthcare and Rehabilitation Center?

It is part of The Ensign Group and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Misty Willow Healthcare and Rehabilitation Center?

(281) 469-7881. The facility is located at 12921 Misty Willow Dr, Houston, TX 77070.

Other nursing homes in Houston

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Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.