Cycle 1
Health 2025-08-21 · Fire 2025-08-21
3 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Willis, TX
Willis Nursing And Rehabilitation LP
5-star overall rating with 5-star inspections with $7,443 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3000 N Danville St, Willis, TX
(936) 856-4312
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Slp Operations
Operator or chain grouping
Approved since
1994-02-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing
LPN hours / resident day
1.22
Licensed practical nurse staffing
Aide hours / resident day
1.48
Nurse aide staffing
Weekend hours
2.54
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.3%
3.5 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.5% |
3.3%
1.2 pts worse
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
18.9%
1.5 pts worse
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
10.8%
4 pts worse
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.4% |
15.4%
3 pts worse
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
16.1%
1.9 pts better
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.6% |
15.0%
4.4 pts better
|
19.8%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.2%
2.2 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
12.0%
12 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.3% |
1.5%
2.8 pts worse
|
1.6%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
25.9%
3.2 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-28 · Fire 2024-06-28
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-09-18
C · Minimal harm
2025-08-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-18
D · Potential for more than minimal harm
2024-06-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-09
C · Minimal harm
2024-06-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-09
D · Potential for more than minimal harm
2023-05-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-06-22
C · Minimal harm
2023-05-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-22
C · Minimal harm
2023-05-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-08-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-09-18
E · Potential for more than minimal harm
2024-06-28
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 2024-07-23
G · Actual harm
2023-10-20
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 2023-10-20
D · Potential for more than minimal harm
2023-10-20
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 2023-11-30
D · Potential for more than minimal harm
2023-10-19
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-19
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-10-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-05-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-22
E · Potential for more than minimal harm
2023-05-11
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-22
Penalties and ownership
What sits behind the stars
$7,443
2023-10-19
Fine
Fine · fine $7,443
Fine
Ownership
Slp Omega Operations, LLC
5% Or Greater Direct Ownership Interest · Organization
Boswell, Darren
5% Or Greater Indirect Ownership Interest · Individual
Eden, James
5% Or Greater Indirect Ownership Interest · Individual
Guerrero, Milton
Operational/Managerial Control · Individual
Leonard, Joshua
Operational/Managerial Control · Individual
Leonard, Joshua
Corporate Officer · Individual
Senior Living Properties LLC
5% Or Greater Indirect Ownership Interest · Organization
Slp Management Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Slp Operations, LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitworth, Gary
5% Or Greater Indirect Ownership Interest · Individual
Willis Texas Aviv LLC
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Conroe Health Care Center
Conroe, TX
2-star overall rating with 2-star inspections with $12,860 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Woodland Manor Nursing and Rehabilitation
Conroe, TX
1-star overall rating with 2-star inspections with $21,530 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Brightpointe
Conroe, TX
3-star overall rating with 3-star inspections with $21,037 in total fines with 8 fire-safety deficiencies in the latest cycle
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