Misty Willow Healthcare and Rehabilitation Center
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 119 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Special Focus Facility (under heightened CMS scrutiny)
- Abuse citation on record
- Low overall rating (1/5 stars)
- Low staffing rating (2/5 stars)
- Above-median deficiencies (15 vs median 8.0)
- High staff turnover (58%)
- High RN turnover (60%)
Bottom 25% in Texas · Below recommended RN staffing · Worst in THE ENSIGN GROUP chain · $46,677 in fines · Special Focus Facility (CMS) · Abuse citation
What this means for your family
This facility offers excellent rehabilitation services and a very clean, pleasant environment that many families find comforting. However, you must be extremely vigilant regarding hygiene care and response times to call lights, as multiple families have reported serious instances of neglect and delayed medical attention.
Google Reviews
Google Reviews
119 reviews on Google“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
- Clean and well-maintained facility
- Effective physical and occupational therapy
- Professional and welcoming administrative staff
- Pleasant and fresh-smelling environment
Concerns
- Neglect regarding hygiene and incontinence care (mentioned by 4 reviewers)
- Slow response times to call lights/emergency buttons (mentioned by 4 reviewers)
- Delays in medication administration (mentioned by 2 reviewers)
- Poor food quality and lack of dietary options (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 104 analyzed
How They Respond to Reviews
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.
Questions for Your Tour
- 1I noticed many people mention how clean and pleasant the facility smells; how does your housekeeping team ensure that level of care is maintained throughout the day?
- 2With the focus on physical and occupational therapy being a strength here, how do you coordinate therapy schedules with a resident's daily routine?
- 3How does the nursing team manage call light responses and ensure that residents' needs are met promptly, especially during busy shift changes?
- 4Could you tell me more about the meal service, specifically regarding how you handle dietary restrictions and the variety of options available for different nutritional needs?
- 5What specific protocols are in place to ensure medication is administered accurately and on a consistent schedule?
- 6How does the staff approach personal hygiene and incontinence care to ensure every resident feels dignified and comfortable?
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.”
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
10
measures
2
measures
5
measures
Residents on antipsychotic medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents needing more daily help over time
Residents on anti-anxiety or sleep medication
Residents vaccinated for pneumonia
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
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
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.
Mar 9, 2026Complaint2
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.
Dec 4, 2025Routine9
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.
Sep 24, 2025Complaint5
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.
Mar 29, 2025Complaint3
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.
Aug 30, 2024Complaint1
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Aug 30, 2024Routine5
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
$37,720
Fine
Sep 24, 2025
$31,530
Fine
Mar 29, 2025
$15,147
Ownership & Operations
Who Operates This Facility
Kirbyville I Enterprises, LLC
for profit
MISTY WILLOW HEALTHCARE INC
NARINDERPAL GILL
Chain Affiliation
The Ensign Group
338 facilities nationwide
Chain avg rating: 2.9/5 · Rank 79 of 84 (Worst)
Ownership & Management
Owners
Liberty County Hospital District no. 1
Owner · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
119 reviews from families & visitors
Official Website
Visit mistywillowhealthcare.com
Medicare data downloads
Original nursing home datasets
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