For profit - Limited Liability company · 124 certified beds · CMS number 676251
Misty Willow Healthcare and Rehabilitation Center, Houston, TX
CMS records 30 health deficiencies at Misty Willow Healthcare and Rehabilitation Center in Houston, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Dec 4, 2025. The highest severity cited is K (immediate jeopardy to resident health or safety). 8 citations were at the immediate jeopardy level. CMS lists 3 fines totaling $64,093 in the last three years.
- Special Focus Facility candidate (CMS)
- CMS abuse icon
- 8 immediate jeopardy (J/K/L) citations
- A tag cited in 3 inspections
- 30deficiencies, 3 cycles (TX median 25)
- 14in the latest cycle (TX median 8)
- Khighest severity · Immediate jeopardy
- $64,093fines, last 3 years
- 1CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Misty Willow Healthcare and Rehabilitation Center as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Misty Willow Healthcare and Rehabilitation Center may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (14 deficiencies)
Standard inspection Dec 4, 2025. CMS counts 14 health deficiencies and 2 fire safety deficiencies in this cycle.
Mar 9, 2026 · Complaint inspection
2 deficiencies, highest J
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Mar 11, 2026
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 11, 2026
Dec 4, 2025 · Standard inspection
7 deficiencies, highest F
F813 · Food brought in by visitors
Requirement cited (CMS): Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 6, 2025
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Dec 6, 2025
F805 · Food prepared for individual needs
Requirement cited (CMS): Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 6, 2025
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 6, 2025
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 6, 2025
F694 · IV fluid administration
Requirement cited (CMS): Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 6, 2025
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 6, 2025
Sep 24, 2025 · Complaint inspection
5 deficiencies, highest K
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Oct 16, 2025
F610 · Investigating and responding to allegations
Requirement cited (CMS): Respond appropriately to all alleged violations.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Oct 16, 2025
F607 · Abuse prevention policies
Requirement cited (CMS): Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Oct 16, 2025
F600 · Freedom from abuse and neglect
Requirement cited (CMS): Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Oct 16, 2025
F564 · Explaining visitation rights
Requirement cited (CMS): Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 16, 2025
Previous cycle: 9 deficiencies (standard inspection Aug 30, 2024)
Standard inspection Aug 30, 2024. CMS counts 9 health deficiencies and 0 fire safety deficiencies in this cycle.
Mar 29, 2025 · Complaint inspection
3 deficiencies, highest K
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Mar 31, 2025
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Mar 31, 2025
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Mar 31, 2025
Aug 30, 2024 · Standard + complaint inspection
6 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Sep 3, 2024
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 3, 2024
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 3, 2024
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 3, 2024
F686 · Pressure ulcer prevention and care
Requirement cited (CMS): Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 3, 2024
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 3, 2024
Earlier cycle: 7 deficiencies (standard inspection Jun 16, 2023)
Standard inspection Jun 16, 2023. CMS counts 7 health deficiencies and 1 fire safety deficiency in this cycle.
Jun 16, 2023 · Standard inspection
7 deficiencies, highest E
F803 · Menus that meet nutritional needs
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 14, 2023
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 14, 2023
F759 · Medication error rate under 5 percent
Requirement cited (CMS): Ensure medication error rates are not 5 percent or greater.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 14, 2023
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 14, 2023
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 14, 2023
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 14, 2023
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 14, 2023
Tags cited in more than one inspection
7 tags cited on more than one inspection date at Misty Willow Healthcare and Rehabilitation Center; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F761 Drug labeling and secure storage | 3 | Dec 4, 2025; Aug 30, 2024; Jun 16, 2023 |
| F583 Personal privacy and confidential records | 2 | Aug 30, 2024; Jun 16, 2023 |
| F656 Comprehensive person-centered care plan | 2 | Sep 24, 2025; Jun 16, 2023 |
| F684 Quality of care | 2 | Mar 9, 2026; Mar 29, 2025 |
| F689 Accident prevention and supervision | 2 | Dec 4, 2025; Mar 29, 2025 |
| F695 Respiratory and oxygen care | 2 | Aug 30, 2024; Jun 16, 2023 |
| F755 Pharmacy services and a consultant pharmacist | 2 | Dec 4, 2025; Mar 29, 2025 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Mar 9, 2026 | Fine | $28,451 |
| Sep 24, 2025 | Fine | $20,495 |
| Mar 29, 2025 | Fine | $15,147 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.30 h (about the same as the Texas median of 3.27 h)
- RN hours per resident per day
- 0.35 h (below the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.87 h
- Nursing staff turnover
- not reported
- Administrators who left
- not reported
- CMS overall rating
- 1 of 5
- Health inspection rating
- 1 of 5
- Staffing rating
- 2 of 5
- Quality measure rating
- 4 of 5
CMS figures for Misty Willow Healthcare and Rehabilitation Center, copied as published; Texas medians are ours.
Facility details
- Address
- 12921 Misty Willow Dr, Houston, TX 77070
- Phone
- (281) 469-7881
- County
- Harris
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Chain (CMS)
- The Ensign Group
- Certified beds
- 124
- Average residents per day
- 89.8
- In Medicare/Medicaid since
- Apr 21, 2010
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- None
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How are medications stored and secured on each unit? (F761, cited 3 times)
- How do staff protect residents' privacy during bathing, dressing, and treatments? (F583, cited 2 times)
- How are a resident's goals and preferences written into the care plan? (F656, cited 2 times)
- How does the home make sure doctor's orders are followed consistently across shifts? (F684, cited 2 times)
Other nursing homes in Houston and the same chain
- Woodway Nursing & Rehab
Houston · 55 deficiencies - Avir at Houston
Houston · 45 deficiencies - Terra Bella Health and Wellness Suites
Houston · 44 deficiencies - Afton Oaks Nursing and Rehabilitation Center
Houston · 43 deficiencies - Fallbrook Rehabilitation and Care Center
Houston · 43 deficiencies - Paradigm at Westbury
Houston · 42 deficiencies - The Eden of Las Colinas
Irving · 65 deficiencies - Northeast Rehabilitation and Healthcare Center
San Antonio · 57 deficiencies - Westpark Rehabilitation and Living
Euless · 54 deficiencies - Park Village Healthcare and Rehabilitation
DeSoto · 52 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.