Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Willow Creek Lodge during CMS and state inspections, most recent first.
The facility did not ensure daily Direct Care Staffing Numbers were posted and accessible, as required. On the day of surveyor observation, the designated posting area was empty, and staff interviews revealed confusion about who was responsible for the task, especially in the absence of the DON. The Staffing Coordinator was new and untrained for this duty, and the ADON was unaware of the gap, resulting in the posting not being completed.
Two residents did not have their care plans updated to address new or existing medical needs, including a new diagnosis of CKD, a lactose allergy, and a recent fall with injury. Despite documentation and discussion of these issues, care plans lacked measurable goals and interventions as required by facility policy.
The facility failed to maintain proper chemical concentration levels of the sanitizer solution during the dishwasher's wash cycle, as observed in the kitchen. Staff A, the Dietary Supervisor, relied solely on logs maintained by her staff and did not perform random strip tests herself. Staff B admitted to not logging testing results due to being in a hurry. The Administrator was unaware of the malfunction until informed by the surveyor. This failure could affect all residents by placing them at risk for food-borne illness.
A resident with severe cognitive impairment and a diagnosis related to an indwelling urethral catheter did not have their care plan updated to include necessary urinary catheter care. Despite staff understanding the importance of comprehensive care plans, the omission was identified during a record review. The facility's policy requires timely development of care plans, but this was not followed, placing the resident at risk of inadequate care.
A facility failed to ensure physician supervision for a resident with an indwelling urethral catheter, resulting in a deficiency. The resident, with severe cognitive impairment, had no physician orders for catheter care despite a diagnosis of infection and inflammatory reaction. Staff interviews revealed a lack of adherence to protocol for reviewing and obtaining physician orders, potentially leading to inappropriate care and harm.
Failure to Post Daily Direct Care Staffing Numbers
Penalty
Summary
The facility failed to ensure that the daily Direct Care Staffing Numbers were posted and readily accessible for review, as required. On the day of surveyor observation, the placard at the front entrance, which is designated for staffing postings, was found empty during two separate checks in the morning. Interviews with facility staff revealed confusion regarding responsibility for the posting. The Staffing Coordinator, who was new and still in training, stated he was not responsible for the posting and had not been trained to complete it. The DON, who typically handled the posting, was on leave, and there was no clear delegation of the task in her absence. The Administrator was unaware of the specific regulations and did not know why the posting was not completed that day. The ADON believed the Staffing Coordinator was responsible but was unaware he had not been trained, resulting in the posting not being completed. Record review indicated that facility policy requires direct care daily staffing numbers to be posted for every shift by 10 am daily. However, the Administrator confirmed there was no specific policy on posting the Direct Care Daily Staffing Numbers, and the ADON stated she had been updating the posting daily since the DON went on leave, typically arriving between 7:45 and 8:00 am. On the day in question, the posting was not completed due to a lack of training and clear assignment of responsibility, leading to the deficiency.
Failure to Update Care Plans After Significant Changes and Events
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents following significant changes in their medical conditions and events. For one resident, after returning from a hospital stay with a new diagnosis of chronic kidney disease (CKD) stage 4 and an order for Furosemide, the care plan did not address the CKD diagnosis, nor were any goals or interventions related to this condition included. This omission occurred despite documentation in the resident's hospital records and active physician orders indicating the presence and management of CKD. For another resident, the care plan did not address a known allergy to lactose or a recent fall that resulted in injury. The resident had a documented mild intolerance to lactose and continued to receive dairy products, with no care plan interventions to prevent complications from this allergy. Additionally, after experiencing a fall that led to a hospital visit and documented injuries, the care plan was not updated to include goals or interventions to prevent future falls or injuries, despite the incident being discussed in risk management meetings. Interviews with facility staff, including the MDS nurse and DON, confirmed that these omissions were oversights and not in accordance with facility policy, which requires care plans to be updated following significant changes in condition, new diagnoses, or incidents such as falls. The facility's own policies emphasize the need for measurable objectives and timetables in care plans, as well as the inclusion of interventions based on comprehensive assessments and ongoing changes in residents' conditions.
Failure to Maintain Proper Sanitizer Levels in Dishwasher
Penalty
Summary
The facility failed to maintain the correct chemical concentration of the sanitizer solution during the dishwasher's wash cycle, as observed in the kitchen. The deficiency was identified when a strip test performed by Staff A, the Dietary Supervisor, did not change color after five attempts, indicating lower than the minimum required PPM levels of sanitizer solution. This issue was observed with the facility's only low-temperature dishwasher in use at the time. Staff A admitted to relying solely on the logs maintained by her staff and did not perform random strip tests herself. She acknowledged that the residents would be at risk for cross-contamination and diseases if there was a malfunction in the dishwasher. Further interviews revealed that Staff B did not log testing results prior to the observation because he was in a hurry and did not test sanitation levels during the wash. The Administrator was unaware of the dishwasher's malfunction until informed by the surveyor's observation. He confirmed that the facility's policy required kitchen staff to log concentration levels of sanitizing solution using testing strips each shift during wash cycles. The failure to adhere to this policy could potentially affect all residents by placing them at risk for food-borne illness.
Failure to Update Care Plan for Urinary Catheter Care
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, specifically neglecting to include the necessary urinary catheter care. This oversight was identified during a review of the resident's records, which showed that the care plan did not address the resident's need for urethral catheter care, despite the resident having a diagnosis related to an indwelling urethral catheter. The resident, a male with severe cognitive impairment, was observed with a urinary catheter in place, yet the care plan lacked any mention of this critical aspect of his care. Interviews with various staff members, including CNAs, RNs, LVNs, the DON, and the Administrator, revealed a consistent understanding that care plans should be initiated upon a resident's admission and updated regularly to reflect any changes in the resident's condition. Staff members acknowledged the importance of care plans in ensuring that all caregivers are informed about the necessary care and monitoring required for each resident. However, despite this understanding, the care plan for the resident in question was not updated to include urinary catheter care, which is a significant omission given the resident's medical condition. The facility's policy on care plans emphasizes the need for comprehensive, person-centered plans that include measurable objectives and timetables to meet residents' needs. The policy specifies that care plans should be developed within a specific timeframe following the completion of the MDS assessment. Despite these guidelines, the facility did not adhere to its policy in the case of this resident, resulting in a deficiency that placed the resident at risk of not receiving adequate care.
Lack of Physician Supervision for Resident's Catheter Care
Penalty
Summary
The facility failed to ensure that a physician supervised the care of a resident with an indwelling urethral catheter, leading to a deficiency in physician services. The resident, an 85-year-old male with severe impaired cognition, was diagnosed with an infection and inflammatory reaction due to the catheter. Despite this diagnosis, there were no physician orders for the care of the catheter, as confirmed by a review of the resident's records. Observations noted the resident in bed with a urinary catheter, but without specific physician instructions for its management. Interviews with facility staff, including CNAs, RNs, LVNs, the DON, and the Administrator, revealed a lack of adherence to protocol regarding the review and implementation of physician orders. Staff members acknowledged that physician orders should be reviewed before performing care and that they rely on these orders to guide treatment. However, it was noted that the resident did not have the necessary orders, and staff were not proactive in obtaining them. This oversight could lead to inappropriate care and potential harm to the resident, as highlighted by the staff's concerns about the risks of not having proper medical directives in place.
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What surveyors actually found near you
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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 Tomball
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights Of Tomball | 3.5 mi | ★★★★★ | 0 | 0 |
| Park Manor Of Tomball | 4.1 mi | ★★★★★ | 13 | 0 |
| Lawrence Street Health Care Center | 4.2 mi | ★★★★★ | 9 | 1 |
| Cypress Creek Rehabilitation And Healthcare Center | 5.3 mi | ★★★★★ | 4 | 0 |
| Tomball Rehab & Nursing | 5.4 mi | ★★★★★ | 10 | 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.