Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willis Nursing And Rehabilitation Lp during CMS and state inspections, most recent first.
A nurse failed to wear a gown while providing wound care to a resident on Enhanced Barrier Precautions, despite facility policy and physician orders requiring both gown and gloves for residents with wounds and indwelling devices. The resident had multiple invasive devices and wounds, and the nurse acknowledged forgetting to use the required PPE. Interviews and policy review confirmed that staff were trained on EBP requirements, but the observed lapse resulted in a breach of infection control protocols.
A resident with COPD, CHF, and dementia did not receive oxygen therapy at the physician-ordered rate of 2L/min, as observations showed oxygen was administered at higher rates. Nursing staff were unclear about the correct order and did not consistently verify or maintain the prescribed oxygen flow, despite facility policy requiring such checks.
The facility failed to implement a pest control program to prevent or address issues with mice, insects, or other pests. The report does not specify the number of residents affected or provide further details about individual cases.
The facility failed to properly label and store food in the unit refrigerator, as observed with multiple unlabeled and undated items, including pudding, chips, dips, and a cupcake. Interviews revealed confusion over responsibility for maintaining the refrigerator, with staff acknowledging the importance of labeling to prevent illness. The facility's policy required proper labeling and dating, but this was not adhered to, leading to the deficiency.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to wear appropriate personal protective equipment (PPE) while performing wound care on a resident who was under Enhanced Barrier Precautions (EBP). During the observation, the LVN was seen providing wound care with only gloves and without a gown, despite the presence of an EBP sign and a PPE cart outside the resident's room. The LVN later acknowledged that both a gown and gloves were required for such procedures under EBP and admitted to forgetting to wear the gown. The resident involved had multiple complex medical conditions, including sepsis, urinary tract infection, neurogenic bladder dysfunction, atrial fibrillation, and acute embolism and thrombosis of the lower extremity. The resident had several invasive devices, such as a PICC line, Foley catheter, and colostomy, and was receiving wound care for multiple wounds, including those on the sacrum, buttocks, and right foot. Physician orders and the facility's policy required EBP, which mandates the use of gown and gloves during high-contact care activities like wound care for residents with indwelling medical devices or wounds. Interviews with the LVN and the Director of Nursing (DON) confirmed that staff were trained to use gowns and gloves for residents on EBP during treatments. The facility's policy on EBP, reviewed by surveyors, specified that enhanced barrier precautions are to be implemented for residents with wounds or indwelling medical devices and that adherence is monitored by the Infection Preventionist. Despite these requirements, the observed failure to use the required PPE during wound care constituted a breach of the facility's infection prevention and control program.
Failure to Administer Oxygen Therapy at Physician-Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received oxygen therapy at the rate ordered by the physician. The resident, who had diagnoses including COPD, CHF, metabolic encephalopathy, and dementia, had a physician's order for continuous oxygen at 2L/min via nasal cannula. However, observations on multiple occasions revealed that the resident was receiving oxygen at higher rates, specifically 3.5L/min and 4L/min, rather than the ordered 2L/min. Nursing staff interviews confirmed that the oxygen settings were not consistently checked or maintained at the prescribed rate, and there was confusion among staff regarding the correct order, with one nurse incorrectly stating the order was for 2-3L/min. Record reviews showed that the oxygen therapy was documented as administered according to the order, but direct observation contradicted these records. The facility's policy required nurses to verify physician orders for oxygen flow rate and route, but this was not consistently followed. Staff interviews indicated a lack of awareness regarding the specific reasons for the oxygen order and the importance of adhering to the prescribed rate. The Director of Nursing acknowledged that orders must be followed and expected nurses to check oxygen settings at least once per shift, but this expectation was not met in practice.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified during the survey, but the report does not specify the number of residents affected or provide details about any specific incidents involving residents. No additional information about the medical history or condition of residents at the time of the deficiency is provided in the report.
Failure to Properly Label and Store Food in Unit Refrigerator
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the unit refrigerator located in the medication room. Observations revealed multiple food items, including a clear plastic container with pudding, a plastic bag of chips and dips, a Whataburger cup with a dark liquid, and a plastic container with a frosted chocolate cupcake, all of which were unlabeled and undated. This lack of labeling and dating could potentially lead to cross-contamination or spoilage, posing a risk of foodborne illness to residents consuming these items. Interviews with staff, including an LVN and the ADON, highlighted a lack of clarity regarding responsibility for maintaining the refrigerator. The LVN expressed embarrassment over the state of the refrigerator and acknowledged the importance of labeling to prevent illness. The ADON stated that charge nurses were responsible for checking labels and dates, and that personal items should not be stored in the unit refrigerator. The Administrator confirmed that medication aides and nurses, who have access to the room, were responsible for labeling and discarding outdated items. The facility's policy required proper labeling and dating of refrigerated foods, but this was not followed, leading to the observed deficiencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Willis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Conroe Health Care Center | 7.1 mi | ★★★★★ | 0 | 0 |
| Woodland Manor Nursing And Rehabilitation | 7.9 mi | ★★★★★ | 10 | 3 |
| The Brightpointe | 10.5 mi | ★★★★★ | 0 | 0 |
| Park Manor Of Conroe | 10.6 mi | ★★★★★ | 3 | 0 |
| Park Manor Of The Woodlands | 15.6 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.