D
46/100Misty Willow Healthcare and Rehabilitation Center Inspection Report, Violations & Safety Grade (Houston, Texas)
12921 Misty Willow Dr, Houston, Texas 77070
Phone: 2814697881
CMS Overall:1/5
Overview & Bed Count
Certified Beds
124
Avg Residents/Day
78
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Harris
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing1/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.27 | 0.44 | -0.17 |
| Total Nurse Hours per Resident per Day | 3.32 | 3.42 | -0.10 |
| CMS Staffing Rating | 1/5 | 1.9/5 | - |
| Nursing Staff Turnover | N/A | 50.8% | - |
Health Citation History
30 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-03-09 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J – Immediate Jeopardy |
| 2026-03-09 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-12-04 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-12-04 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | E – Moderate Harm Potential |
| 2025-12-04 | Nutrition and Dietary Deficiencies | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | E – Moderate Harm Potential |
| 2025-12-04 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-12-04 | Quality of Life and Care Deficiencies | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D – Moderate Harm Potential |
| 2025-12-04 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-12-04 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-09-24 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | K – Immediate Jeopardy |
| 2025-09-24 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | K – Immediate Jeopardy |
| 2025-09-24 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | K – Immediate Jeopardy |
| 2025-09-24 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | K – Immediate Jeopardy |
| 2025-09-24 | Resident Rights Deficiencies | Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | D – Moderate Harm Potential |
| 2025-03-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2025-03-29 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K – Immediate Jeopardy |
| 2025-03-29 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | J – Immediate Jeopardy |
| 2024-08-30 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-08-30 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2024-08-30 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2024-08-30 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2024-08-30 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-08-30 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-06-16 | Nutrition and Dietary Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-06-16 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2023-06-16 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2023-06-16 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2023-06-16 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2023-06-16 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2023-06-16 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
Fire Safety Citation History
3 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-04 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2025-12-04 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | E – Moderate Harm Potential |
| 2023-06-16 | Smoke Deficiencies | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | E – Moderate Harm Potential |
Total Penalties & Fines
$64,093
Total Fine Amount (CMS)
3
Number of Fines
3
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-03-09 | Fine | $28,451 | - |
| 2025-09-24 | Fine | $20,495 | - |
| 2025-03-29 | Fine | $15,147 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Houston area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.