F55

MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER

Grade F 55/100 composite score

For profit - Limited Liability companySFF CandidateAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
3/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

124

Ownership

For profit - Limited Liability company

Total Fines

$22,802

Last Survey

N/A

12921 MISTY WILLOW DR, HOUSTON, TX 77070
2814697881

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.53h
LPN
0.89h
CNA
2.00h
Total
3.42h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

LIBERTY COUNTY HOSPITAL DISTRICT NO. 1

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince May 2016

100%

MISTY WILLOW HEALTHCARE, INC.

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2017

BURNAM, SOON

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2016

FITZGERALD, TAMI

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2017

STRATTON, CHARLES

IndividualCORPORATE OFFICERSince Feb 2005

Penalties & Fines (2)

$22,802total fines
DateTypeDescriptionAmount
Mar 29, 2025Fine$14,901
Mar 1, 2023Fine$7,901

Health Inspection Deficiencies (24)

September 24, 2025Health5 deficiencies4 severe
0564DMinimal harm, Isolated

Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.

Resident Rights Deficiencies

Corrected Oct 16, 2025
0600KImmediate jeopardy, Pattern

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Oct 16, 2025
0607KImmediate jeopardy, Pattern

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Oct 16, 2025
0610KImmediate jeopardy, Pattern

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Oct 16, 2025
0656KImmediate jeopardy, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 16, 2025
March 29, 2025Health3 deficiencies3 severe
0684KImmediate jeopardy, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Mar 31, 2025
0689KImmediate jeopardy, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Mar 31, 2025
0755JImmediate jeopardy, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Mar 31, 2025
August 30, 2024Health6 deficiencies
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Sep 3, 2024
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Sep 3, 2024
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Sep 3, 2024
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Sep 3, 2024
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Sep 3, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Sep 3, 2024
June 16, 2023Health7 deficiencies
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Jul 14, 2023
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Jul 14, 2023
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 14, 2023
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Jul 14, 2023
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Jul 14, 2023
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Jul 14, 2023
0803EMinimal harm, Pattern

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.

Nutrition and Dietary Deficiencies

Corrected Jul 14, 2023
April 6, 2023Health2 deficiencies
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Apr 14, 2023
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 14, 2023
March 1, 2023Health1 deficiency1 severe
0684GActual harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Mar 2, 2023

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Frequently Asked Questions

What is the CareGrader rating for MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER?

MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER in HOUSTON, Texas has a CareGrader grade of F (Poor), with a composite score of 55.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER?

MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER have?

MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER has 24 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER been fined?

Yes. MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER has $22,802 in total fines from CMS enforcement actions across 2 penalties.

How many beds does MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER have?

MISTY WILLOW HEALTHCARE AND REHABILITATION CENTER has 124 certified beds with approximately 95 current residents (77% occupancy). The facility is located at 12921 MISTY WILLOW DR, HOUSTON, Texas 77070. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.