Misty Willow Healthcare and Rehabilitation Center
12921 Misty Willow Dr, Houston, TX 77070
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Follow this homeMisty Willow Healthcare and Rehabilitation Center is a nursing home in Houston, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionDecember 4, 2025 (11 months ago)
- Health citations since June 16, 202330 (Texas average 28)
- Fines in the past three years3, $64,093 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of October 8, 2026
Name
CMS lists a new legal business name for this home.
Fine
CMS changed the fine from March 9, 2026 from $43,770 to $28,451.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of June 24, 2026
Name
CMS lists a new legal business name for this home.
Fine
CMS changed the fine from September 24, 2025 from $31,530 to $20,495.
Fine
CMS changed the fine from March 9, 2026 from $37,720 to $43,770.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on March 9, 2026
2 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
129 of 1,177 Texas homes (11%) got a citation at the immediate jeopardy level in 2026.
CMS fine of $28,451 on March 9, 2026.
Show the 2 citations
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 11, 2026.
CMS has cited this home for F0684 2 times since 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on March 11, 2026.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Fine
CMS changed the fine from March 29, 2025 from $14,901 to $15,147.
CMS update of January 14, 2026
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS added its abuse icon to this home.
Fine
CMS changed the fine from March 29, 2025 from $22,925 to $14,901.
Health inspection on December 4, 2025
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 6, 2025.
Citation F0805. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on December 6, 2025.
Citation F0813. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
CMS lists it as corrected on December 6, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 6, 2025.
CMS has cited this home for F0689 2 times since 2025.
Citation F0694. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
CMS lists it as corrected on December 6, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on December 6, 2025.
CMS has cited this home for F0755 2 times since 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 6, 2025.
CMS has cited this home for F0761 3 times since 2023.
Fire safety inspection on December 4, 2025
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 6, 2025.
Citation K0929. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
CMS lists it as corrected on December 6, 2025.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Name
CMS lists a new legal business name for this home.
Health inspection on September 24, 2025
5 citationsCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $20,495 on September 24, 2025.
Show the 5 citations
Citation F0600. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on October 16, 2025.
Citation F0607. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on October 16, 2025.
Citation F0610. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on October 16, 2025.
Citation F0656. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0656 2 times since 2023.
Citation F0564. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
CMS lists it as corrected on October 16, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Name
CMS lists a new legal business name for this home.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Health inspection on March 29, 2025
3 citationsCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $15,147 on March 29, 2025.
Show the 3 citations
Citation F0684. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 31, 2025.
Citation F0689. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 31, 2025.
Citation F0755. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on March 31, 2025.
Health inspection on August 30, 2024
6 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 6 citations
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 3, 2024.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on September 3, 2024.
CMS has cited this home for F0583 2 times since 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on September 3, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on September 3, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on September 3, 2024.
CMS has cited this home for F0695 2 times since 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 3, 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of February 29, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Health inspection on June 16, 2023
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 14, 2023.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on July 14, 2023.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on July 14, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 14, 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on July 14, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on July 14, 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 14, 2023.
Fire safety inspection on June 16, 2023
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0342. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on June 23, 2023.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 1 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (281) 469-7881
- Last standard health inspection
- December 4, 2025 (11 months ago)
- Certified beds
- 124
- Residents per day, on average
- 78
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Liberty County Hospital District No 1
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
More health citations than the Texas average (30 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- LIBERTY COUNTY HOSPITAL DISTRICT NO 15% or greater direct ownership interest · 100% · since 04/01/2017
- MISTY WILLOW HEALTHCARE, INC.Operational/managerial control · not applicable · since 04/01/2017
- ALI, NIDAOperational/managerial control · not applicable · since 09/18/2024
- FITZGERALD, TAMIOperational/managerial control · not applicable · since 04/01/2017
Questions
When was Misty Willow Healthcare and Rehabilitation Center last inspected?
CMS lists December 4, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Misty Willow Healthcare and Rehabilitation Center have?
CMS lists 30 health citations since June 16, 2023. CMS also calls these deficiencies.
Has Misty Willow Healthcare and Rehabilitation Center been fined?
CMS lists 3 fines in the past three years, $64,093 in total.
What is the CMS star rating of Misty Willow Healthcare and Rehabilitation Center?
Its CMS overall star rating is 1 of 5.
Is Misty Willow Healthcare and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.