Willow Creek Lodge
11830 Northpointe Boulevard, Tomball, TX 77377
Willow Creek Lodge, a 135-bed for profit - limited liability company nursing facility in Tomball, TX, holds a 3-star CMS overall rating - right around the 3.0-star national average, ranking #414 of 1,165 rated homes in TX on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. No recent finding reached the actual-harm level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 2812059400
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- 3 / 5
- Average · CMS overall · nat'l 3.0
- #414 of 1,165
- In-state rank among rated TX homes
- 3.36
- Below average · nurse hrs/day · nat'l 3.86
- 23
- Inspection findings
The verdict
Willow Creek Lodge, a 135-bed for profit - limited liability company nursing facility in Tomball, TX, holds a 3-star CMS overall rating - right around the 3.0-star national average, ranking #414 of 1,165 rated homes in TX on CMS overall stars (with health+staffing+quality tie-breaks), with nurse staffing below the national norm. No recent finding reached the actual-harm level.
- 3 / 5
- CMS overall · national 3.0
- #414 of 1,165
- In-state rank among rated TX homes
- 3.36
- Nurse hrs/resident-day · national 3.86
- 23
- Inspection findings on file
CMS force-curves overall stars within each state; read health, staffing, and quality sub-ratings alongside the headline.
In-state ownership mix · peer inventory
How 1,177 TX nursing homes split by ownership sector
This facility is recorded as For profit - Limited Liability company. Sector buckets collapse CMS ownership_type into For-profit, Nonprofit, and Government, orthogonal to the RN/LPN/CNA hour bar below.
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 676244
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 135
- Residents
- 81
- In Hospital
- No
- County
- Harris
- Last Inspection
- Jul 17, 2025
Staffing Data
How the 3.36 total nursing hours per resident-day are staffed:
- RN Hours
- 0.18 (nat'l avg: 0.69)
- LPN Hours
- 1.13
- CNA Hours
- 2.05
- Total Nursing Hours
- 3.36 (nat'l avg: 3.86)
- PT Hours
- 0.11
- Nursing Turnover
- 62.5%
- RN Turnover
- 72.7%
What the CMS Record Reveals About Willow Creek Lodge
According to CMS Nursing Home Compare, Willow Creek Lodge ranks #414 of 1,165 rated nursing homes in TX on overall stars (tie-broken by health+staffing+quality, then fewer fines). Willow Creek Lodge operates 135 certified beds in Tomball, TX with approximately 81 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars (health inspection 4★ · staffing 1★ · quality 4★).
The inspection file contains 23 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider. Staffing is reported at 3.36 total nursing hours per resident day (national average 3.86), with RN coverage at 0.18 per resident day.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, Willow Creek Lodge falls into a category where comparative context matters. Reported nursing staff turnover at this facility is 62.5% (CMS payroll-based measure).
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify the same record on Medicare.gov Care Compare and with the facility or your state survey agency before making placement decisions.
Deficiency History (23 most recent)
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Nov 20, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 29, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 29, 2025
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.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 29, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 29, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 29, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 29, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Aug 29, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Aug 29, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 29, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 29, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 25, 2025
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Category: Nursing and Physician Services Deficiencies
Corrected: Jun 20, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 20, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 20, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Oct 16, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Oct 16, 2023
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Mar 25, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 25, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 25, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Apr 10, 2023
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 5, 2023
Have enough backup water supply for essential areas of the nursing home.
Category: Environmental Deficiencies
Corrected: Apr 17, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 6.3% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 6.6% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 1.1% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 11.0% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.2% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 5.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.7% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 36.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 86.2% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 23.5% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 98.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 93.8% | No |
Penalty History
No penalties on record.
Nationwide facilities with similar scale or staffing
Two data-derived peer sets for Willow Creek Lodge, both outside TX so the neighborhoods are not the same-state geography list below.
Similar bed count
Nearest CMS certified bed counts outside TX (135 beds here).
Similar staffing hours
Nearest CMS adjusted total nurse hours per resident day outside TX (3.65 here).
Nearby Nursing Homes in TX
1,176 other nursing homes are on record in TX; 6 are shown here.
600 Maple Ave.
Burleson, TX
Accel at College Station
College Station, TX
Accel at Willow Bend
Plano, TX
Advanced Health & Rehab Center of Garland
Garland, TX
Advanced Rehabilitation & Healthcare of Burleson
Burleson, TX
Advanced Rehabilitation & Healthcare of Live Oak
Live Oak, TX
Understanding Nursing Home Data
What the CMS records show for Willow Creek Lodge
The health, staffing, and quality sub-ratings above often diverge from the CMS overall headline. Use those components and the inspection findings to read the full file, not the overall star alone.
- The TX registry aggregates state averages and the highest-rated homes in this cohort. View TX registry
- Peer homes near 135 beds show how CMS stars vary at a similar scale in TX. Compare a similar-size peer
- CMS publishes separate fields for inspections, nurse staffing hours, and quality measures; the guide explains how each star is computed. How CMS ratings work
CMS refreshes Nursing Home Compare quarterly (current extract: August 2026). PlainNursing describes published records; it does not establish suitability, availability, admissions, or individual outcomes.
Frequently Asked Questions
What is the overall CMS rating for Willow Creek Lodge?
Where does Willow Creek Lodge rank among nursing homes in TX?
What are the staffing levels at Willow Creek Lodge?
How many beds does Willow Creek Lodge have?
Does Willow Creek Lodge have any deficiencies on record?
Has Willow Creek Lodge received any fines or penalties?
Who owns Willow Creek Lodge?
When was Willow Creek Lodge last inspected?
What quality measures are tracked for Willow Creek Lodge?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Verify the same CCN on Medicare.gov Care Compare and with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
