Nursing homeActive
Willow Creek Lodge
11830 Northpointe Boulevard, Tomball, TX 773772812059400135 certified beds · 81 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
6
since 2023
Deficiencies
23
● 1● 22● 0
Penalties · 3 yrs
—
none on file
Last survey
2025-11-19
Complaint
CMS overall
3 / 5
stars as published by CMS
CMS overall 3/5
Health 4
Staffing 1
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2025-11-19 | Complaint | 100 | CMS-2567 (Care Compare) | — |
| 2025-07-17 | Standard | 0100 | CMS-2567 (Care Compare) | — |
| 2025-07-02 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-06-13 | Standard | 030 | CMS-2567 (Care Compare) | — |
| 2023-09-20 | Infection control | 020 | CMS-2567 (Care Compare) | — |
| 2023-03-24 | Standard | 060 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2025-11-20Record 676244-20251119-F732
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F550
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F580
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F641
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F645
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F656
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F684
F693Ensure 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F693
F742Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F742
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-29Record 676244-20250717-F880
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-07-25Record 676244-20250702-F656
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-20Record 676244-20240613-F656
F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-20Record 676244-20240613-F710
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-06-20Record 676244-20240613-F812
F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-16Record 676244-20230920-F622
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-16Record 676244-20230920-F755
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-04-10Record 676244-20230324-F582
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-04-05Record 676244-20230324-F607
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-25Record 676244-20230324-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-25Record 676244-20230324-F692
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-03-25Record 676244-20230324-F759
F922Have enough backup water supply for essential areas of the nursing home.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-04-17Record 676244-20230324-F922
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.18
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day3.36
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours3.03
Facility
Texas
National
Texas 2.98 · National 3.42
Total nursing staff turnover63%
Facility
Texas
National
Texas 55% · National 46%
Registered nurse turnover73%
Facility
Texas
National
Texas 55% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 1.1% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 0.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 11.0% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.7% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 6.3% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 2.2% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 36.7% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Burnam, Soon Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Canyonlands Peak Healthcare LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Grewal, Hermanjeet Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| John, Biju Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Canyonlands Peak Healthcare LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Ensign Services Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Grewal, Hermanjeet Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Grewal, Hermanjeet Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| John, Biju Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| John, Biju Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Keetch, Chad Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Mcguire, Wesley Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Northpointe Blvd Health Holdings LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Standard Bearer Healthcare Op, LP Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| The Ensign Group Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Cross Healthcare Management — 6 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Harris.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| The Heights Of Tomball Tomball | 3.5 mi | 2025-05-12 | 022 |
| Park Manor Of Tomball Tomball | 4.1 mi | 2026-03-26 | 2242 |
| Lawrence Street Health Care Center Tomball | 4.2 mi | 2026-06-16 | 081 |
| Cypress Creek Rehabilitation and Healthcare Center Cypress | 5.3 mi | 2026-04-30 | 0122 |
| Tomball Rehab & Nursing Tomball | 5.4 mi | 2026-04-10 | 0192 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |