Houston, TX

Misty Willow Healthcare and Rehabilitation Center

1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $46,677 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

12921 Misty Willow Dr, Houston, TX

(281) 469-7881

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

124

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

2010-04-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.52

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.88

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.96

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.36

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.40

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.83

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.41

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.20

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.53

CMS adjusted RN staffing hours

Adjusted total hours

3.42

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

58%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,031

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

28.02

Composite VBP score used to determine payment impact.

Payment multiplier

0.9848

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.05

Baseline 20.72% · Performance 20.02% · Measure score 3.05 · Achievement 3.05 · Improvement 1.41

Healthcare-associated infections

5.26

Baseline 8.06% · Performance 6.30% · Measure score 5.26 · Achievement 5.15 · Improvement 5.26

Total nurse turnover

1.71

Baseline 65.79% · Performance 56.76% · Measure score 1.71 · Achievement 1.69 · Improvement 1.71

Adjusted total nurse staffing

1.19

Baseline 2.91 hours · Performance 3.39 hours · Measure score 1.19 · Achievement 1.11 · Improvement 1.19

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.35%	10.72% 0.4 pts better	No Different than the National Rate · Eligible stays 89 · Observed rate 11.24% · Lower 95% interval 7.86%
Discharge to community	51.85%	50.57% 1.3 pts better	No Different than the National Rate · Eligible stays 79 · Observed rate 44.3% · Lower 95% interval 42.26%
Medicare spending per beneficiary	1.12	1.02 0.1 pts worse
Drug regimen review with follow-up	95.35%	95.27% 0.1 pts better	Numerator 41 · Denominator 43
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 43
Discharge self-care score	60.71%	53.69% 7 pts better	Numerator 17 · Denominator 28
Discharge mobility score	46.43%	50.94% 4.5 pts worse	Numerator 13 · Denominator 28
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 43 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.3%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 33 · Observed rate 3.03% · Lower 95% interval 3.09%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 149
Staff flu vaccination coverage	44.28%	42% 2.3 pts better	Numerator 89 · Denominator 201
Discharge function score	53.57%	56.45% 2.9 pts worse	Numerator 15 · Denominator 28
Transfer of health information to provider	96.55%	95.95% 0.6 pts better	Numerator 28 · Denominator 29
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	14.29%	25.2% 10.9 pts worse	Numerator 3 · Denominator 21

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.7%	97.1% 1.6 pts better	93.4% 5.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 100.0% · Q4 96.2% · 4Q avg 98.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.8%	97.9% 0.9 pts better	95.5% 3.3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8%
Percentage of long-stay residents experiencing one or more falls with major injury	3.2%	3.3% 0.1 pts better	3.3% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 5.0% · Q4 2.5% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.9%	2.7% 0.2 pts worse	11.4% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 7.4% · Q4 0.0% · 4Q avg 2.9%
Percentage of long-stay residents who lose too much weight	2.0%	3.3% 1.3 pts better	5.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.9% · Q3 2.6% · Q4 1.3% · 4Q avg 2.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.3%	18.9% 6.6 pts better	19.6% 7.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 11.7% · Q3 14.3% · Q4 12.0% · 4Q avg 12.3%
Percentage of long-stay residents who received an antipsychotic medication	3.9%	10.8% 6.9 pts better	16.7% 12.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.9% · Q3 4.5% · Q4 4.5% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	27.4%	15.4% 12 pts worse	16.3% 11.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 50.9% · Q2 25.6% · Q3 17.2% · Q4 15.7% · 4Q avg 27.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	27.4%	16.1% 11.3 pts worse	14.9% 12.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 34.8% · Q3 14.5% · Q4 18.0% · 4Q avg 27.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	0.8% 0.5 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.0%	15.0% 3 pts worse	19.8% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 20.0% · Q3 9.9% · Q4 16.4% · 4Q avg 18.0%
Percentage of long-stay residents with pressure ulcers	5.4%	4.2% 1.2 pts worse	5.1% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.7% · Q3 5.8% · Q4 4.5% · 4Q avg 5.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.0%	89.7% 0.7 pts worse	81.7% 7.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 91.1% · Q3 80.7% · Q4 84.5% · 4Q avg 89.0%
Percentage of short-stay residents who had an outpatient emergency department visit	17.2%	12.0% 5.2 pts worse	12.0% 5.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 21.2% · Expected 13.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	88.5%	88.0% 0.5 pts better	79.7% 8.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 88.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.4%	25.9% 0.5 pts worse	23.9% 2.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 33.3% · Expected 30.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-04 · Fire 2025-12-04

15 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2024-08-30 · Fire 2024-08-30

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-06-16 · Fire 2023-06-16

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-12-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-12-06

E · Potential for more than minimal harm 2025-12-04

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2025-12-06

E · Potential for more than minimal harm 2023-06-16

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2023-06-23

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-12-04

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-12-06

E · Potential for more than minimal harm 2025-12-04

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2025-12-06

E · Potential for more than minimal harm 2025-12-04

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2025-12-06

D · Potential for more than minimal harm 2025-12-04

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-12-06

D · Potential for more than minimal harm 2025-12-04

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-12-06

D · Potential for more than minimal harm 2025-12-04

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-12-06

D · Potential for more than minimal harm 2025-12-04

F761 · Pharmacy Service Deficiencies

Health

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 2025-12-06

K · Immediate jeopardy 2025-09-24

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-10-16

K · Immediate jeopardy 2025-09-24

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2025-10-16

K · Immediate jeopardy 2025-09-24

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-10-16

K · Immediate jeopardy 2025-09-24

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-10-16

D · Potential for more than minimal harm 2025-09-24

F564 · Resident Rights Deficiencies

Health

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

Corrected 2025-10-16

K · Immediate jeopardy 2025-03-29

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-31

K · Immediate jeopardy 2025-03-29

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-31

J · Immediate jeopardy 2025-03-29

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-03-31

E · Potential for more than minimal harm 2024-08-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-30

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-30

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-30

F690 · Quality of Life and Care Deficiencies

Health

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 2024-09-03

D · Potential for more than minimal harm 2024-08-30

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-09-03

D · Potential for more than minimal harm 2024-08-30

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-09-03

E · Potential for more than minimal harm 2023-06-16

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2023-07-14