For profit - Limited Liability company · 135 certified beds · CMS number 676244
Willow Creek Lodge, Tomball, TX
CMS records 23 health deficiencies at Willow Creek Lodge in Tomball, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Jul 17, 2025. The highest severity cited is F (no actual harm, potential for more than minimal harm). CMS lists no fines or payment denials in the last three years.
- 23deficiencies, 3 cycles (TX median 25)
- 11in the latest cycle (TX median 8)
- Fhighest severity · Potential for harm
- $0fines, last 3 years
- 3CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Willow Creek Lodge as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Willow Creek Lodge may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (11 deficiencies)
Standard inspection Jul 17, 2025. CMS counts 11 health deficiencies and 5 fire safety deficiencies in this cycle.
Nov 19, 2025 · Complaint inspection
1 deficiency, highest C
F732 · Daily posting of nurse staffing
Requirement cited (CMS): Post nurse staffing information every day.
- Severity
- C No actual harm, potential for minimal harm, widespread
- Status
- Correction date Nov 20, 2025
Jul 17, 2025 · Standard inspection
10 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 29, 2025
F742 · Treatment for mental health and trauma
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 29, 2025
F693 · Feeding tube use and care
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 29, 2025
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 29, 2025
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Aug 29, 2025
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 29, 2025
F645 · Pre-admission screening for mental disorder or intellectual disability
Requirement cited (CMS): PASARR screening for Mental disorders or Intellectual Disabilities
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 29, 2025
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Aug 29, 2025
F580 · Telling residents and families about changes
Requirement cited (CMS): Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 29, 2025
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 29, 2025
Previous cycle: 4 deficiencies (standard inspection Jun 13, 2024)
Standard inspection Jun 13, 2024. CMS counts 4 health deficiencies and 3 fire safety deficiencies in this cycle.
Jul 2, 2025 · Complaint inspection
1 deficiency, highest E
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 25, 2025
Jun 13, 2024 · Standard inspection
3 deficiencies, highest F
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Jun 20, 2024
F710 · Physician approval and supervision
Requirement cited (CMS): Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 20, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 20, 2024
Earlier cycle: 8 deficiencies (standard inspection Mar 24, 2023)
Standard inspection Mar 24, 2023. CMS counts 8 health deficiencies and 2 fire safety deficiencies in this cycle.
Sep 20, 2023 · Complaint inspection
2 deficiencies, highest D
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 16, 2023
- Found in
- infection control inspection
F622 · Permitted reasons for transfer or discharge
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Oct 16, 2023
- Found in
- infection control inspection
Mar 24, 2023 · Standard inspection
6 deficiencies, highest F
F922 · Backup water supply
Requirement cited (CMS): Have enough backup water supply for essential areas of the nursing home.
- Severity
- F No actual harm, potential for more than minimal harm, widespread
- Status
- Correction date Apr 17, 2023
F759 · Medication error rate under 5 percent
Requirement cited (CMS): Ensure medication error rates are not 5 percent or greater.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 25, 2023
F692 · Nutrition and hydration
Requirement cited (CMS): Provide enough food/fluids to maintain a resident's health.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 25, 2023
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 25, 2023
F607 · Abuse prevention policies
Requirement cited (CMS): Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 5, 2023
F582 · Notice of covered and extra charges
Requirement cited (CMS): Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 10, 2023
Tags cited in more than one inspection
1 tag cited on more than one inspection date at Willow Creek Lodge; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F656 Comprehensive person-centered care plan | 3 | Jul 17, 2025; Jul 2, 2025; Jun 13, 2024 |
Fines and payment denials
CMS lists no fines or payment denials for this nursing home in the last three years.
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.36 h (about the same as the Texas median of 3.27 h)
- RN hours per resident per day
- 0.18 h (below the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 3.03 h
- Nursing staff turnover
- 62.5% (Texas median 52.1%)
- Administrators who left
- 0
- CMS overall rating
- 3 of 5
- Health inspection rating
- 4 of 5
- Staffing rating
- 1 of 5
- Quality measure rating
- 4 of 5
CMS figures for Willow Creek Lodge, copied as published; Texas medians are ours.
Facility details
- Address
- 11830 Northpointe Boulevard, Tomball, TX 77377
- Phone
- (281) 205-9400
- County
- Harris
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Chain (CMS)
- Cross Healthcare Management
- Certified beds
- 135
- Average residents per day
- 81.4
- In Medicare/Medicaid since
- Feb 16, 2010
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How are a resident's goals and preferences written into the care plan? (F656, cited 3 times)
- How do staff learn about and respect each resident's personal routines and choices? (F550, cited 1 time)
- How quickly is the family called if a resident falls or their condition changes? (F580, cited 1 time)
- Which services and supplies are included in the daily rate, and which are billed separately? (F582, cited 1 time)
Other nursing homes in Tomball and the same chain
- Park Manor of Tomball
Tomball · 28 deficiencies - Tomball Rehab & Nursing
Tomball · 26 deficiencies - Lawrence Street Health Care Center
Tomball · 13 deficiencies - The Heights of Tomball
Tomball · 10 deficiencies - Hilltop Village Nursing and Rehabilitation
Kerrville · 51 deficiencies - Falcon Point Post Acute
Katy · 31 deficiencies - Eagle Crest Rapid Recovery
Houston · 29 deficiencies - Parks Health Center
Odessa · 15 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.