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
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing
LPN hours / resident day
0.94
Licensed practical nurse staffing
Aide hours / resident day
1.94
Nurse aide staffing
Weekend hours
2.83
Weekend nurse staffing
RN turnover
70%
Annual RN turnover
Total nurse turnover
75%
Annual nurse turnover
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 |
| 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 |
| 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 | 86.2% |
97.9%
11.7 pts worse
|
95.5%
9.3 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 4.1% |
15.4%
11.3 pts better
|
16.3%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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