Willow Creek Lodge

11830 Northpointe Boulevard
Tomball, TX, 77377
2812059400
CCN: 676244
4
Overall
4
Health
1
Staffing
5
Quality
ChainCROSS HEALTHCARE MANAGEMENT
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
WEST COKE COUNTY HOSPITAL DISTRICT5% OR GREATER DIRECT OWNERSHIP INTEREST100%
KTFW-TX LLC5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE
11830NPB, LLC5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE
MCGUIRE, WESLEYCORPORATE OFFICERNOT APPLICABLE
MARTIN, CHRISTOPHEROPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
RANKIN, DEREKOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
WILLOW CREEK OPCO LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LOCKHART, CHRISTOPHEROPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Health Deficiencies (23)
2025-11-19 · Health
C
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
2025-07-17 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F742 · 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.
D
F693 · 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.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
E
F656 · 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.
D
F655 · 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
D
F645 · Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
E
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F580 · 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.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2025-07-02 · Health
E
F656 · 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.
2024-06-13 · Health
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F710 · Nursing and Physician Services Deficiencies
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
D
F656 · 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.
2023-09-20 · Health
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F622 · Resident Rights 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.
2023-03-24 · Health
F
F922 · Environmental Deficiencies
Have enough backup water supply for essential areas of the nursing home.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
D
F582 · Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.17
3.68
RN Hrs/Resident/Day
0.28
0.54
LPN Hrs/Resident/Day
0.94
0.81
CNA Hrs/Resident/Day
1.94
2.33
PT Hrs/Resident/Day
0.07
0.12
Data as of 2026-03-01