SNF

Misty Willow Healthcare and Rehabilitation Center

CCN: 676251 · Houston, TX 77070 · Harris County

⚠ SFF Candidate ⚠ Abuse citation flag

Overview

Address
12921 Misty Willow Dr, Houston, TX 77070
Phone
2814697881
Certified beds
124
Avg daily residents
96 (77% of beds filled)
Ownership
For-profit LLC
Provider type
Medicare and Medicaid
Medicare/Medicaid since
2010-04-21
Setting
Urban
1 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 1/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 2/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 3/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 3/5
Short-Stay Quality Measures ★★★★★ 3/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 3.36 3.79 3.42 ≥ 3.48 Below floor
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 0.52 0.66 0.53 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 0.88 0.84 0.89 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 1.96 2.29 2.00 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 1.40 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.20 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
2.83
hrs / resident / day
RN (weekend)
0.41
hrs / resident / day
Total nurse (adjusted, weekend)
2.88
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
58.4%
annual
RN turnover
60.0%
annual
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
1.34
higher acuity than avg
Case-Mix Index Ratio
0.98
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-12-04 15 7 8 827 1 827
Cycle 2/3 (prior) 2024-08-30 16 6 11 88 1 88
Total weighted health score
642.3
lower is better

Deficiencies (31)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

23 D/E/F Actual harm — potential for minor
1 G/H/I Actual harm
7 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2025-12-04 2025-12-06
0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. D 2025-12-04 2025-12-06
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2025-12-04 2025-12-06
0761 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 2025-12-04 2025-12-06
0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. E 2025-12-04 2025-12-06
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F 2025-12-04 2025-12-06
0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. E 2025-12-04 2025-12-06
0564 Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. D 2025-09-24 2025-10-16
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. K 2025-09-24 2025-10-16
0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. K 2025-09-24 2025-10-16
0610 Respond appropriately to all alleged violations. K 2025-09-24 2025-10-16
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. K 2025-09-24 2025-10-16
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. K 2025-03-29 2025-03-31
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. K 2025-03-29 2025-03-31
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. J 2025-03-29 2025-03-31
0583 Keep residents' personal and medical records private and confidential. D 2024-08-30 2024-09-03
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2024-08-30 2024-09-03
0690 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 2024-08-30 2024-09-03
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2024-08-30 2024-09-03
0761 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 2024-08-30 2024-09-03
0880 Provide and implement an infection prevention and control program. E 2024-08-30 2024-09-03
0583 Keep residents' personal and medical records private and confidential. D 2023-06-16 2023-07-14
0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted D 2023-06-16 2023-07-14
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2023-06-16 2023-07-14
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2023-06-16 2023-07-14
0759 Ensure medication error rates are not 5 percent or greater. D 2023-06-16 2023-07-14
0761 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 2023-06-16 2023-07-14
0803 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 2023-06-16 2023-07-14
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2023-04-06 2023-04-14
0880 Provide and implement an infection prevention and control program. D 2023-04-06 2023-04-14
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. G 2023-03-01 2023-03-02

Penalties (2)

Fines issued
2
last 3 years
Total fines
$46,677
Date Type Fine amount
2025-03-29 Fine $15,147
2025-09-24 Fine $31,530

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 8.3% Medicaid 68.5% Other 23.1%

Operating performance

Operating Margin
7.8%
Total Margin
7.8%
Occupancy Rate
70.8%
Cost per Resident Day
$88

Revenue & costs

Net Patient Revenue
$11.5M
Total Costs
$2.8M
Net Income
$906K

Balance sheet

Total Assets
$9.2M
Total Liabilities
$13.4M
Fund Balance
-$4.2M

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: THE ENSIGN GROUP

Chain ID
507
Facilities in chain
329
Legal business name
LIBERTY COUNTY HOSPITAL DISTRICT NO. 1
Chain-average star ratings (for peer context)
Overall
3.2
Health
2.9
Staffing
2.7
QM
4.3

Owner / manager organizations (2)

Organization Role Association
LIBERTY COUNTY HOSPITAL DISTRICT NO. 1 5% OR GREATER DIRECT OWNERSHIP INTEREST since 04/01/2017
MISTY WILLOW HEALTHCARE, INC. OPERATIONAL/MANAGERIAL CONTROL since 04/01/2017

Owner / manager individuals (5)

Name Role Association
ALI, NIDA OPERATIONAL/MANAGERIAL CONTROL since 09/18/2024
FITZGERALD, TAMI OPERATIONAL/MANAGERIAL CONTROL since 04/01/2017
BURNAM, SOON CORPORATE OFFICER since 04/01/2017
KEETCH, CHAD CORPORATE OFFICER since 03/01/2011
STRATTON, CHARLES CORPORATE OFFICER since 02/07/2005

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
None
Sprinkler systems
Yes
Special focus status
SFF Candidate
Abuse citation flag
Yes — last 2 cycles
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 112 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $88 metrics.cost_per_resident_day
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 68.5% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 8.3% metrics.medicare_day_share
Cost Report Net Income ($) $906,123 metrics.net_income
Cost Report Net Patient Revenue ($) $11,540,837 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 70.8% metrics.occupancy_rate
Cost Report Operating Margin (%) 7.8% metrics.operating_margin
Cost Report Total Assets ($) $9,207,975 metrics.total_assets
Cost Report Total Costs ($) $2,819,087 metrics.total_costs
Cost Report Total Fund Balances ($) $-4,227,271 metrics.fund_balance
Cost Report Total Liabilities ($) $13,435,246 metrics.total_liabilities
Cost Report Total Margin (%) 7.8% metrics.total_margin
Provider Information Abuse Icon Y Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.89402 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 1.99843 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.52904 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.42149 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 2.88125 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote — Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 95.8 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.84166 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.28745 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.66341 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.79252 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.34271 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.9 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 3.2 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 4.3 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 2.7 Chain Average Staffing Rating
Provider Information Chain ID 507 Chain ID
Provider Information Chain Name THE ENSIGN GROUP Chain Name
Provider Information City/Town Houston City/Town
Provider Information CMS Certification Number (CCN) 676251 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Harris County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 2010-04-21 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 29.9642 Latitude
Provider Information Legal Business Name LIBERTY COUNTY HOSPITAL DISTRICT NO. 1 Legal Business Name
Provider Information Location 12921 Misty Willow Dr,Houston,TX,77070 Location
Provider Information Long-Stay QM Rating 3 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -95.558 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 124 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 329 Number of Facilities in Chain
Provider Information Number of Fines 2 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.34352 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.97523 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 1 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type For profit - Limited Liability company Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 12921 Misty Willow Dr Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name Misty Willow Healthcare and Rehabilitation Center Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 610 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 3 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 827 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 8 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 7 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-12-04 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 827 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 15 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 6 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2024-08-30 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 88 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 11 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 88 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 16 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.40703 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 60.0 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.39785 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.87818 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 1.96302 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.19744 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.51967 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.36087 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 3 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status SFF Candidate Special Focus Status
Provider Information Staffing Rating 2 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State TX State
Provider Information Telephone Number 2814697881 Telephone Number
Provider Information Total Amount of Fines in Dollars 46677.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 2.83020 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 2 Total Number of Penalties
Provider Information Total nursing staff turnover 58.4 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 642.250 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council None With a Resident and Family Council
Provider Information ZIP Code 77070 ZIP Code