Willow Creek Lodge
Grade B — 81/100 composite score
CMS Star Ratings
Certified Beds
135
Ownership
For profit - Limited Liability company
Total Fines
$4,194
Last Survey
N/A
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Staffing Hours & Turnover
Hours per Resident per Day (PBJ)
Turnover Rates
Ownership
WEST COKE COUNTY HOSPITAL DISTRICT
100%
WILLOW CREEK OPCO LLC
LOCKHART, CHRISTOPHER
MARTIN, CHRISTOPHER
RANKIN, DEREK
MCGUIRE, WESLEY
11830NPB, LLC
KTFW-TX LLC
Penalties & Fines (1)
| Date | Type | Description | Amount |
|---|---|---|---|
| Mar 6, 2023 | Fine | — | $4,194 |
Health Inspection Deficiencies (25)
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
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
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies
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
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
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
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
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
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
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
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
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Nursing and Physician Services Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
Have enough backup water supply for essential areas of the nursing home.
Environmental Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
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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.