Willow Creek Lodge

Nursing Home · Tomball, TX

CMS overall rating 3/5 For profit - Limited Liability company

CMS certification number676244

Contact & location

11830 Northpointe Boulevard
Tomball, TX 77377
Harris County
Phone
(281) 205-9400
ZIP code
77377 – all care providers

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Facility details

Certified beds
135
Residents per day
81.4 (60% occupied)
Ownership
For profit - Limited Liability company
Legal name
West Coke County Hospital District
Chain
Cross Healthcare Management (6 facilities, avg 2.8★)
Medicare certified since
February 16, 2010
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 3/5
State avg 2.6
Health inspections★★★★★ 4/5
State avg 2.8
Staffing★★★★★ 1/5
State avg 1.9
Quality measures★★★★★ 4/5
State avg 3.7
Long-stay quality★★★★★ 5/5
Short-stay quality★★★★★ 2/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.36 (state 3.39 · U.S. 3.86)
Registered nurses (RN)
0.18 (state 0.43 · U.S. 0.69)
Licensed practical nurses
1.13 (state 0.95 · U.S. 0.86)
Nurse aides
2.05 (state 2.00 · U.S. 2.32)
Weekend total
3.03 (state 2.98 · U.S. 3.42)
Nursing staff turnover
62.5 (state 55.3 · U.S. 45.8)%
RN turnover
72.7 (state 54.6 · U.S. 42.9)%
Administrators who left
0 in the last year

Inspections

Last standard inspection
July 17, 2025
Health deficiencies (last cycle)
11.0 (state 9.3 · U.S. 9.3)
From complaints
2
Infection control citations
2
Citations on record (3 years)
23 health · 10 fire safety
DateCitationSeverityStatus
2025-11-19 Post nurse staffing information every day.
F0732 · Nursing and Physician Services Deficiencies · complaint inspection		 C
No actual harm, potential for minimal harm		 Corrected 2025-11-20
2025-07-17 Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-17 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-17 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-17 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-17 PASARR screening for Mental disorders or Intellectual Disabilities
F0645 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-17 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-17 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-17 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.
F0693 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-17 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.
F0742 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-17 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-29
2025-07-02 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-07-25
2024-06-13 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2024-06-20
2024-06-13 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-20
2024-06-13 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
F0710 · Nursing and Physician Services Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-20
2023-09-20 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.
F0622 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-16
2023-09-20 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-10-16
2023-03-24 Have enough backup water supply for essential areas of the nursing home.
F0922 · Environmental Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2023-04-17
2023-03-24 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-04-05
2023-03-24 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F0582 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-04-10
2023-03-24 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-03-25
2023-03-24 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-03-25
2023-03-24 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-03-25

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

No federal fines or payment denials in the last three years.

Ownership & management

NameRoleSince
Canyonlands Peak Healthcare LLC (organization)Administrator · NOT APPLICABLE
Ensign Services INC (organization)Administrator · NOT APPLICABLE
Grewal, Hermanjeet (individual)Administrator · NOT APPLICABLE
John, Biju (individual)Administrator · NOT APPLICABLE
Northpointe Blvd Health Holdings LLC (organization)Administrator · NOT APPLICABLE
Standard Bearer Healthcare Op, LP (organization)Administrator · NOT APPLICABLE
The Ensign Group INC (organization)Administrator · NOT APPLICABLE
Keetch, Chad (individual)Corporate Officer · NOT APPLICABLE
McGuire, Wesley (individual)Corporate Officer · NOT APPLICABLE
Grewal, Hermanjeet (individual)Managing Control - Governing Body · NOT APPLICABLE
John, Biju (individual)Managing Control - Governing Body · NOT APPLICABLE
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

Frequently asked questions

What is the rating of Willow Creek Lodge?

Willow Creek Lodge has a 3-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.6-star average in Texas.

How many beds does Willow Creek Lodge have?

It has 135 certified beds and cares for about 81 residents per day.

Has Willow Creek Lodge been fined?

CMS lists no federal fines or payment denials in the last three years.

Who owns Willow Creek Lodge?

It is part of Cross Healthcare Management and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Willow Creek Lodge?

(281) 205-9400. The facility is located at 11830 Northpointe Boulevard, Tomball, TX 77377.

Other nursing homes in Tomball

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Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.