Willowbrook Nursing Center
227 Russell Blvd, Nacogdoches, TX 75965 · Nacogdoches County · 166 certified beds · avg 102 residents/day · certified since Apr 28, 1987
Part of chain: HMG HEALTHCARE (31 facilities, chain avg rating 3.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · 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.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Mar 19, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 20, 2025 (Deficient, Provider has date of correction)
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 |
|---|---|---|
| Jul 9, 2025 | E · Potential for harm, repeated | 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. · from a complaint |
| Jul 9, 2025 | E · Potential for harm, repeated | 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 9, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 9, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 9, 2025 | 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. |
| Jul 9, 2025 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| May 28, 2025 | 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 19, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 19, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jun 19, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 19, 2024 | E · Potential for harm, repeated | 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 19, 2024 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Jun 19, 2024 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Jun 19, 2024 | 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. |
| Jun 19, 2024 | 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. |
| Jun 19, 2024 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint |
| Jun 19, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Jun 19, 2024 | 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 |
| Apr 19, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 19, 2023 | E · Potential for harm, repeated | 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. |
| Apr 19, 2023 | E · Potential for harm, repeated | The facility did not have policies on smoking. |
| Apr 19, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 19, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (10 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | E |
| 2024 | 10 | 0 | E |
| 2025 | 8 | 1 | J ▲ |
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)
1 fine totaling $153,439.
| Date | Type | Amount / length |
|---|---|---|
| Mar 19, 2025 | Fine | $153,439 |
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) | 3.29 | 3.46 | 3.95 | bottom 48% in Texas; bottom 26% in the U.S. |
| Registered Nurse hours | 0.27 | 0.44 | 0.69 | bottom 20% in Texas; bottom 7% in the U.S. |
| Weekend total nurse staffing | 2.87 | 3.04 | 3.50 | bottom 45% in Texas; bottom 24% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.20 | 0.34 | 0.48 | bottom 22% in Texas; bottom 12% in the U.S. |
| Total nursing staff turnover (%) | 52.0 | 55.3 | 45.8 | top 50% in Texas; bottom 32% in the U.S. |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
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 3.21, RN 0.26, weekend 2.79. 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: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Cibc Bank USA | Organization | 5% or Greater Direct Ownership Interest | — | 04/01/2018 |
| Forvis Mazars LLP | Organization | 5% or Greater Direct Ownership Interest | — | 04/01/2018 |
| Zions Bancorporation | Organization | 5% or Greater Direct Ownership Interest | — | 04/01/2018 |
| Balsamo, Krystal | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2018 |
| Balsamo, Krystal | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2018 |
| Benavides, Rhonda | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/20/2001 |
| Benavides, Rhonda | Individual | ADP of the SNF | NOT APPLICABLE | 08/20/2001 |
| Casper, Andrea | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/30/2022 |
| Casper, Andrea | Individual | ADP of the SNF | NOT APPLICABLE | 08/30/2022 |
| Cibc Bank USA | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2021 |
| Cibc Bank USA | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2018 |
| Culp, Roland | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2018 |
| Culp, Roland | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2018 |
| Daspit, Laurence | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2018 |
| Daspit, Laurence | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2018 |
| Dohn, William | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2018 |
| Dohn, William | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2018 |
| Forvis Mazars LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2018 |
| Forvis Mazars LLP | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2018 |
| HMG Park Manor of Willowbrook LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "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 |
|---|---|---|---|---|---|
| Stallings Court Nursing and Rehabilitation | 0.4 mi | Nacogdoches, TX | ★★★★★ | 4/5 | |
| Westward Trails Nursing and Rehabilitation | 2.1 mi | Nacogdoches, TX | ★★★☆☆ | 4/5 | |
| Garrison Nursing Home & Rehabilitation Center | 15.1 mi | Garrison, TX | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
All facilities in Nacogdoches →
Facility data as of CMS processing date 2026-08-01. CCN 455700.