Cycle 1
Health 2025-07-17 · Fire 2025-07-17
12 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Tomball, TX
Willow Creek Lodge
4-star overall rating with 4-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
11830 Northpointe Boulevard, Tomball, TX
(281) 205-9400
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
135
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cross Healthcare Management
Operator or chain grouping
Approved since
2010-02-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 1 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.17
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.22
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
0.16
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,793
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.04
Baseline 21.02% · Performance 20.48% · Measure score 2.04 · Achievement 2.04 · Improvement 0.83
Healthcare-associated infections
0.76
Baseline 6.14% · Performance 7.61% · Measure score 0.76 · Achievement 0.76 · Improvement 0
Total nurse turnover
0
Baseline 54.93% · Performance 68.23% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.36
Baseline 3.61 hours · Performance 3.47 hours · Measure score 1.36 · Achievement 1.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.66% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 7.69% · Lower 95% interval 6.89% |
| Discharge to community | 54.92% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 41.67% · Lower 95% interval 42.57% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 15.25% |
95.27%
80 pts worse
|
Numerator 9 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 39.53% |
53.69%
14.2 pts worse
|
Numerator 17 · Denominator 43 |
| Discharge mobility score | 41.86% |
50.94%
9.1 pts worse
|
Numerator 18 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 1.69% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 59 · Adjusted rate 1.41% |
| Healthcare-associated infections requiring hospitalization | 7.61% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 11.36% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 53.98% |
8.2%
45.8 pts better
|
Numerator 61 · Denominator 113 |
| Staff flu vaccination coverage | 12.09% |
42%
29.9 pts worse
|
Numerator 22 · Denominator 182 |
| Discharge function score | 53.49% |
56.45%
3 pts worse
|
Numerator 23 · Denominator 43 |
| Transfer of health information to provider | 20% |
95.95%
76 pts worse
|
Numerator 4 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 65.52% |
25.2%
40.3 pts better
|
Numerator 19 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.2% |
97.9%
11.7 pts worse
|
95.5%
9.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 5.2% |
2.7%
2.5 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.0% · Q3 4.1% · Q4 9.9% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
3.3%
1.5 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 4.2% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.1% |
18.9%
17.2 pts worse
|
19.6%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 41.3% · Q3 38.4% · Q4 32.9% · 4Q avg 36.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
10.8%
0.6 pts worse
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.1% · Q3 9.4% · Q4 11.5% · 4Q avg 11.4% · 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 | 4.1% |
15.4%
11.3 pts better
|
16.3%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 0.0% · Q4 12.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
16.1%
11.1 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.9% · Q3 7.5% · Q4 6.1% · 4Q avg 5.0% · 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 | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
15.0%
3.7 pts worse
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 21.0% · Q3 16.6% · Q4 14.7% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
4.2%
3.4 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.7%
9.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.7% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.4% |
12.0%
5.4 pts worse
|
12.0%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 17.3% · Expected 11.1% · 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 | 93.8% |
88.0%
5.8 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
25.9%
1.4 pts better
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 25.0% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-24 · Fire 2023-03-24
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-07-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-29
F · Potential for more than minimal harm
2024-06-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-20
E · Potential for more than minimal harm
2024-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-20
E · Potential for more than minimal harm
2024-06-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-18
F · Potential for more than minimal harm
2023-03-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-03-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-24
Inspection history
Recent health citations
C · Minimal harm
2025-11-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Not marked corrected
E · Potential for more than minimal harm
2025-07-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-17
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 2025-08-29
D · Potential for more than minimal harm
2025-07-17
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 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
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 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-02
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 2025-07-25
F · Potential for more than minimal harm
2024-06-13
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 2024-06-20
D · Potential for more than minimal harm
2024-06-13
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 2024-06-20
D · Potential for more than minimal harm
2024-06-13
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-06-20
D · Potential for more than minimal harm
2023-09-20
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-20
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 2023-10-16
F · Potential for more than minimal harm
2023-03-24
F922 · Environmental Deficiencies
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-03-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-03-24
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-03-24
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 2023-03-25
D · Potential for more than minimal harm
2023-03-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-25
D · Potential for more than minimal harm
2023-03-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-25
Penalties and ownership
What sits behind the stars
Ownership
West Coke County Hospital District
5% Or Greater Direct Ownership Interest · Organization
11830npb, LLC
5% Or Greater Mortgage Interest · Organization
Ktfw-Tx LLC
5% Or Greater Mortgage Interest · Organization
Lockhart, Christopher
Operational/Managerial Control · Individual
Martin, Christopher
Operational/Managerial Control · Individual
Mcguire, Wesley
Corporate Officer · Individual
Rankin, Derek
Operational/Managerial Control · Individual
Willow Creek Opco LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
The Heights Of Tomball
Tomball, TX
3-star overall rating with 3-star inspections with $21,908 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Park Manor Of Tomball
Tomball, TX
1-star overall rating with 2-star inspections with $21,645 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Lawrence Street Health Care Center
Tomball, TX
4-star overall rating with 4-star inspections with $12,740 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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