Willow Creek Lodge

Name: Willow Creek Lodge
Address: 11830 Northpointe Boulevard, Tomball, TX, 77377, US
Telephone: 2812059400

11830 Northpointe Boulevard, Tomball, TX 77377 · Harris County · 135 certified beds · avg 81 residents/day · certified since Feb 16, 2010

Part of chain: CROSS HEALTHCARE MANAGEMENT (6 facilities, chain avg rating 2.8★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.65

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (23)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Nov 19, 2025	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint
Jul 17, 2025	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jul 17, 2025	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jul 17, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jul 17, 2025	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jul 17, 2025	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Jul 17, 2025	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Jul 17, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jul 17, 2025	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Jul 17, 2025	D · Potential for harm, one-off	The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Jul 17, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 2, 2025	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jun 13, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 13, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 13, 2024	D · Potential for harm, one-off	The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care.
Sep 20, 2023	D · Potential for harm, one-off	The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint
Sep 20, 2023	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Mar 24, 2023	F · Potential for harm, facility-wide	The facility did not have enough backup water supply for essential areas of the building.
Mar 24, 2023	E · Potential for harm, repeated	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Mar 24, 2023	D · Potential for harm, one-off	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Mar 24, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Mar 24, 2023	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 24, 2023	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 10).

Year	Citations	Worst severity that year
2023	8	F
2024	3	F
2025	12	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.65	3.46	3.95	top 28% in Texas; bottom 44% in the U.S.
Registered Nurse hours	0.20	0.44	0.69	bottom 7% in Texas; bottom 2% in the U.S.
Weekend total nurse staffing	3.29	3.04	3.50	top 24% in Texas; bottom 46% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.12	0.34	0.48	bottom 5% in Texas; bottom 3% in the U.S.
Total nursing staff turnover (%)	62.5	55.3	45.8	bottom 28% in Texas; bottom 13% in the U.S.
RN turnover (%)	72.7	54.6	42.9	bottom 26% in Texas; bottom 9% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.36, RN 0.18, weekend 3.03. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 2/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2026
Canyonlands Peak Healthcare LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	05/01/2026
Canyonlands Peak Healthcare LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/10/2026
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	02/11/2026
Grewal, Hermanjeet	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/01/2026
Grewal, Hermanjeet	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2026
Grewal, Hermanjeet	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2026
John, Biju	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/01/2026
John, Biju	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2026
John, Biju	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2026
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
McGuire, Wesley	Individual	Corporate Officer	NOT APPLICABLE	05/01/2023
Northpointe Blvd Health Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2026
Standard Bearer Healthcare Op, LP	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2026
The Ensign Group INC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2026

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Where do you post your daily staffing numbers, and can I see today's?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"If my family member falls or their condition changes, exactly when and how will I be notified?"
"How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
The Heights of Tomball	3.5 mi	Tomball, TX	★★★★☆	4/5
Park Manor of Tomball	4.1 mi	Tomball, TX	★★☆☆☆	2/5
Lawrence Street Health Care Center	4.2 mi	Tomball, TX	★★★★☆	4/5
Cypress Creek Rehabilitation and Healthcare Center	5.3 mi	Cypress, TX	★★☆☆☆	3/5
Tomball Rehab & Nursing	5.4 mi	Tomball, TX	★☆☆☆☆	2/5
North Houston Transitional Care	6.2 mi	Houston, TX	★★★☆☆	3/5
Misty Willow Healthcare and Rehabilitation Center	6.6 mi	Houston, TX	★☆☆☆☆	1/5	abuseSFF
Champions Healthcare at Willowbrook	7.0 mi	Houston, TX	★★☆☆☆	2/5	abuse
Fallbrook Rehabilitation and Care Center	7.8 mi	Houston, TX	★☆☆☆☆	1/5	SFF
Park Manor of Cyfair	7.8 mi	Houston, TX	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Tomball →

Facility data as of CMS processing date 2026-08-01. CCN 676244.

The Care File

Visit checklist — Willow Creek Lodge

11830 Northpointe Boulevard, Tomball, TX 77377 · 2812059400

Health inspection rating 4/5 · CMS overall 3/5· Fines (3y): $0

Questions for the administrator:

☐ "Where do you post your daily staffing numbers, and can I see today's?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 676244 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)