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Willow Creek Lodge
11830 Northpointe Boulevard, Tomball, TX 77377 · CMS Certification Number (CCN) 676244
At a glance
- CMS overall rating
- ★★★☆☆ 3 of 5
- Health inspection citations
- 23 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 4 from complaints)
- Fire safety citations
- 10
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- July 17, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★☆☆ 3 of 5 | 2.7 | 3 |
| Health inspections | ★★★★☆ 4 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★☆ 4 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | July 17, 2025 | 11 | 10 | 2 |
| Cycle 2 | June 13, 2024 | 5 | 3 | 2 |
CMS weighted health inspection score: 44 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: 2. How to read these citations
23 health citations across 6 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
November 19, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| C | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/20/2025 |
July 17, 2025: 10 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
| D | F-0742 | 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 | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
| D | F-0693 | 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 | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
| E | F-0656 | 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 | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
| D | F-0655 | 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 | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
| E | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
| D | F-0580 | 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 | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
| D | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/29/2025 |
July 2, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0656 | 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 | Complaint | Deficient, Provider has date of correction Corrected 07/25/2025 |
June 13, 2024: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/20/2024 |
| D | F-0710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/20/2024 |
| D | F-0656 | 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 | Standard | Deficient, Provider has date of correction Corrected 06/20/2024 |
September 20, 2023: 2 citations (Complaint + Infection control)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint + Infection control | Deficient, Provider has date of correction Corrected 10/16/2023 |
| D | F-0622 | 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 | Complaint + Infection control | Deficient, Provider has date of correction Corrected 10/16/2023 |
March 24, 2023: 6 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0922 | Have enough backup water supply for essential areas of the nursing home. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/17/2023 |
| D | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/25/2023 |
| D | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/25/2023 |
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/25/2023 |
| E | F-0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/05/2023 |
| D | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/10/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
10 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 07/17/2025 | E | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 08/29/2025 |
| 07/17/2025 | F | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies | Deficient, Provider has date of correction Corrected 08/29/2025 |
| 07/17/2025 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 08/29/2025 |
| 07/17/2025 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 08/29/2025 |
| 07/17/2025 | E | K-0281 | Install proper backup exit lighting. Egress Deficiencies | Deficient, Provider has date of correction Corrected 08/29/2025 |
| 06/13/2024 | E | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/18/2024 |
| 06/13/2024 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/20/2024 |
| 06/13/2024 | E | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 06/20/2024 |
| 03/24/2023 | E | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2023 |
| 03/24/2023 | F | K-0222 | 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. Egress Deficiencies | Deficient, Provider has date of correction Corrected 03/24/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.36 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.18 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 1.13 | Not published | Not published |
| Nurse aide hours per resident per day | 2.05 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.03 | Not published | Not published |
| RN hours per resident per day, weekends | 0.12 | Not published | Not published |
| Total nursing staff turnover (%) | 62.5 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 72.7 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- West Coke County Hospital District
- Ownership type
- For profit - Limited Liability company
- Chain
- Cross Healthcare Management (6 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 135
- Average residents per day
- 81.4
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- February 16, 2010
- County/parish
- Harris
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
15 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| GREWAL, HERMANJEET | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JOHN, BIJU | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KEETCH, CHAD | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCGUIRE, WESLEY | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CANYONLANDS PEAK HEALTHCARE LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BURNAM, SOON | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GREWAL, HERMANJEET | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JOHN, BIJU | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CANYONLANDS PEAK HEALTHCARE LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| ENSIGN SERVICES INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| NORTHPOINTE BLVD HEALTH HOLDINGS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| STANDARD BEARER HEALTHCARE OP, LP | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| THE ENSIGN GROUP INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| GREWAL, HERMANJEET | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JOHN, BIJU | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Willow Creek Lodge. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.