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On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 120 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Medicare Special Focus status indicates a history of serious quality problems and heightened oversight. Review the latest inspection records, ask what corrective actions remain open, and visit in person before deciding.
Families considering Misty Willow should be aware of a significant divide in experiences. While many reviewers praise the facility for its cleanliness, professional rehabilitation therapy, and welcoming atmosphere, there are serious, recurring allegations regarding resident neglect, delayed medication administration, and unresponsive call lights.
Quality Themes
Tap a score for detailsStrengths
Concerns
Rating Trends
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Distribution · 106 analyzed
The owner provides highly personalized responses that frequently use the reviewer's name and reference specific staff members or facility details mentioned in the review. For negative reviews, the owner maintains a professional and empathetic tone, consistently inviting the reviewer to contact management directly for resolution.
Personalized based on this facility's data
Key Review Excerpts
“The team of nurses,PTand OT were great on helping my mom stay comfortable, the social worker was very nice and pleasant on helping with my mom's concerns.”
“My mother was told they were not allowed to help her to the restroom and that she would have to go to the restroom in a diaper and then they would come and clean her up.”
“There was a night nurse, Katrina W., who would take 1-2 hours to give me my pain meds. Once, Katrena claimed that she couldn’t find the key to the controlled substance box.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
10
measures
2
measures
5
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents whose walking got worse
Residents vaccinated for pneumonia
Residents whose bladder or bowel control got worse
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Families have repeatedly filed complaints against this facility, triggering 19 of 34 total deficiencies across 7 surveys, including serious concerns about abuse protection, medication management, and resident care quality. The most recent complaints in September 2024 involved failures to protect residents from abuse and properly investigate violations. While all deficiencies show correction dates, the recurring pattern of family complaints about fundamental care areas suggests ongoing operational challenges that warrant careful consideration.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
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.
Resident Rights Deficiencies
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
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.
Federal Penalties
Fine
Mar 9, 2026
$43,770
Fine
Sep 24, 2025
$20,495
Fine
Mar 29, 2025
$15,147
Kirbyville I Enterprises, LLC
for profit
MISTY WILLOW HEALTHCARE INC
NARINDERPAL GILL
The Ensign Group
342 facilities nationwide
Chain avg rating: 2.9/5 · Rank 79 of 84 (Lowest rating)
Owners
Liberty County Hospital District no 1
Owner · Organization
Key personnel
Contact this facility directly and verify the details that matter most to your family.
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
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Google Reviews
120 reviews from families & visitors
Official Website
Visit mistywillowhealthcare.com
Medicare data downloads
Original nursing home datasets
EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
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