Misty Willow Healthcare and Rehabilitation Center
12921 Misty Willow Dr · Houston, TX · 77070 · 2814697881
124 certified beds For profit - Limited Liability company Chain: The Ensign Group
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (5 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
5 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
3 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$79,412 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 3 · $79,412 |
Inspection citations (30 in the current record)
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Immediate jeopardy · J March 9, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 11, 2026 · Quality of Life and Care
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Potential for harm · D March 9, 2026 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 11, 2026 · Resident Rights
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Potential for harm · D December 4, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 6, 2025 · Quality of Life and Care
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Potential for harm · D December 4, 2025
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected December 6, 2025 · Quality of Life and Care
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Potential for harm · D December 4, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 6, 2025 · Pharmacy Service
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Potential for harm · D December 4, 2025
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.
Corrected December 6, 2025 · Pharmacy Service
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Potential for harm · E December 4, 2025
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected December 6, 2025 · Nutrition and Dietary
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Potential for harm · F December 4, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 6, 2025 · Nutrition and Dietary
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Potential for harm · E December 4, 2025
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected December 6, 2025 · Nutrition and Dietary
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Immediate jeopardy · K September 24, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 16, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K September 24, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected October 16, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K September 24, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected October 16, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K September 24, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected October 16, 2025 · Resident Assessment and Care Planning
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Potential for harm · D September 24, 2025 · found via complaint
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
Corrected October 16, 2025 · Resident Rights
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Immediate jeopardy · K March 29, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 31, 2025 · Quality of Life and Care
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Immediate jeopardy · K March 29, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 31, 2025 · Quality of Life and Care
-
Immediate jeopardy · J March 29, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 31, 2025 · Pharmacy Service
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Potential for harm · D August 30, 2024
Keep residents' personal and medical records private and confidential.
Corrected September 3, 2024 · Resident Rights
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Potential for harm · D August 30, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected September 3, 2024 · Quality of Life and Care
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Potential for harm · D August 30, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected September 3, 2024 · Quality of Life and Care
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Potential for harm · D August 30, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected September 3, 2024 · Quality of Life and Care
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Potential for harm · D August 30, 2024
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.
Corrected September 3, 2024 · Pharmacy Service
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Potential for harm · E August 30, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected September 3, 2024 · Infection Control
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Potential for harm · D June 16, 2023 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected July 14, 2023 · Resident Rights
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Potential for harm · D June 16, 2023 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected July 14, 2023 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 9, 2026 | Fine | $43,770 |
| September 24, 2025 | Fine | $20,495 |
| March 29, 2025 | Fine | $15,147 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676251 · certified since April 21, 2010. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.