Misty Willow Healthcare And Rehabilitation Center

Penalties

• Mar 9, 2026 — Fine ($43,770)
• Sep 24, 2025 — Fine ($20,495)
• Mar 29, 2025 — Fine ($15,147)

Inspection findings

1. Mar 9, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Mar 11, 2026 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Mar 11, 2026 · CMS health inspection

2. Dec 4, 2025 Health · 9 findings
   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Dec 6, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0694 Quality of Life and Care Deficiencies

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

     Corrected Dec 6, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

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

     Corrected Dec 6, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected Dec 6, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0805 Nutrition and Dietary Deficiencies

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

     Corrected Dec 6, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Dec 6, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0813 Nutrition and Dietary Deficiencies

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

     Corrected Dec 6, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Dec 6, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

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

     Corrected Dec 6, 2025 · CMS fire safety

3. Sep 24, 2025 Health · 5 findings
   • Not serious Scope/severity D Complaint

     F0564 Resident Rights Deficiencies

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

     Corrected Oct 16, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0600 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.

     Corrected Oct 16, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Oct 16, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Oct 16, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0656 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.

     Corrected Oct 16, 2025 · CMS health inspection

4. Mar 29, 2025 Health · 3 findings
   • Serious Scope/severity K Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Mar 31, 2025 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Mar 31, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0755 Pharmacy Service Deficiencies

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

     Corrected Mar 31, 2025 · CMS health inspection

5. Aug 30, 2024 Health · 6 findings
   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Sep 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Sep 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 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.

     Corrected Sep 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Sep 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected Sep 3, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 3, 2024 · CMS health inspection

6. Jun 16, 2023 Health · 8 findings
   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jul 14, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

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

     Corrected Jul 14, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0656 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.

     Corrected Jul 14, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Jul 14, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jul 14, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected Jul 14, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0803 Nutrition and Dietary Deficiencies

     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 Jul 14, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0342 Smoke Deficiencies

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

     Corrected Jun 23, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ALI, NIDA — managing control - governing body, NOT APPLICABLE, since 09/18/2024
• ALI, NIDA — adp of the snf, NOT APPLICABLE, since 09/18/2024
• ALI, NIDA — operational/managerial control, NOT APPLICABLE, since 09/18/2024
• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 04/01/2017
• FITZGERALD, TAMI — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• FITZGERALD, TAMI — managing control - governing body, NOT APPLICABLE, since 04/01/2017
• FITZGERALD, TAMI — adp of the snf, NOT APPLICABLE, since 04/01/2017
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• STRATTON, CHARLES — corporate officer, NOT APPLICABLE, since 02/07/2005
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 05/01/2016
• LIBERTY COUNTY HOSPITAL DISTRICT NO 1 — 5% or greater direct ownership interest, 100%, since 04/01/2017
• MISTY WILLOW HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 11/03/2025
• MISTY WILLOW HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• NATIONAL HEALTH INVESTORS, INC. — adp of the snf, NOT APPLICABLE, since 04/01/2017
• TEXAS NHI INVESTORS, LLC — adp of the snf, NOT APPLICABLE, since 04/01/2017