B81

Willow Creek Lodge

Grade B 81/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
4/5
Health Insp.
4/5
Quality
5/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

135

Ownership

For profit - Limited Liability company

Total Fines

$4,194

Last Survey

N/A

11830 Northpointe Boulevard, Tomball, TX 77377
2812059400

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.31h
LPN
1.03h
CNA
2.13h
Total
3.48h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

WEST COKE COUNTY HOSPITAL DISTRICT

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince May 2023

100%

WILLOW CREEK OPCO LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince May 2022

LOCKHART, CHRISTOPHER

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2023

MARTIN, CHRISTOPHER

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2023

RANKIN, DEREK

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2023

MCGUIRE, WESLEY

IndividualCORPORATE OFFICERSince May 2023

11830NPB, LLC

Organization5% OR GREATER MORTGAGE INTERESTSince May 2023

KTFW-TX LLC

Organization5% OR GREATER MORTGAGE INTERESTSince May 2023

Penalties & Fines (1)

$4,194total fines
DateTypeDescriptionAmount
Mar 6, 2023Fine$4,194

Health Inspection Deficiencies (25)

November 19, 2025Health1 deficiency
0732CNo harm, Widespread

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

July 17, 2025Health10 deficiencies
0550DMinimal harm, Isolated

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

Resident Rights Deficiencies

Corrected Aug 29, 2025
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Aug 29, 2025
0641EMinimal harm, Pattern

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 29, 2025
0645DMinimal harm, Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Aug 29, 2025
0655DMinimal harm, Isolated

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

Resident Assessment and Care Planning Deficiencies

Corrected Aug 29, 2025
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 29, 2025
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Aug 29, 2025
0693DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected Aug 29, 2025
0742DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected Aug 29, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 29, 2025
July 2, 2025Health1 deficiency
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 25, 2025
June 13, 2024Health3 deficiencies
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 20, 2024
0710DMinimal harm, Isolated

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Nursing and Physician Services Deficiencies

Corrected Jun 20, 2024
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Jun 20, 2024
September 20, 2023Health2 deficiencies
0622DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Oct 16, 2023
0755DMinimal harm, Isolated

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

Pharmacy Service Deficiencies

Corrected Oct 16, 2023
March 24, 2023Health6 deficiencies
0582DMinimal harm, Isolated

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies

Corrected Apr 10, 2023
0689DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 25, 2023
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Mar 25, 2023
0922FMinimal harm, Widespread

Have enough backup water supply for essential areas of the nursing home.

Environmental Deficiencies

Corrected Apr 17, 2023
0607EMinimal harm, Pattern

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

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 5, 2023
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Mar 25, 2023
January 30, 2023Health2 deficiencies
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 20, 2023
0755DMinimal harm, Isolated

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

Pharmacy Service Deficiencies

Corrected Feb 20, 2023

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Frequently Asked Questions

What is the CareGrader rating for Willow Creek Lodge?

Willow Creek Lodge in Tomball, Texas has a CareGrader grade of B (Good), with a composite score of 80.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Willow Creek Lodge?

Willow Creek Lodge has an overall CMS star rating of 4 out of 5, a health inspection rating of 4/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Willow Creek Lodge have?

Willow Creek Lodge has 25 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has Willow Creek Lodge been fined?

Yes. Willow Creek Lodge has $4,194 in total fines from CMS enforcement actions across 1 penalty.

How many beds does Willow Creek Lodge have?

Willow Creek Lodge has 135 certified beds with approximately 87 current residents (64% occupancy). The facility is located at 11830 Northpointe Boulevard, Tomball, Texas 77377. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.