SNF
Willow Creek Lodge
CCN: 676244 · Tomball, TX 77377 · Harris County
Overview
- Address
- 11830 Northpointe Boulevard, Tomball, TX 77377
- Phone
- 2812059400
- Certified beds
- 135
- Avg daily residents
- 87 (65% of beds filled)
- Ownership
- For-profit LLC
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 2010-02-16
- Setting
- Urban
4 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 3.17 | 3.52 | 3.48 | ≥ 3.48 | Below floor |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.28 | 0.61 | 0.31 | ≥ 0.55 | Below floor |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.94 | 0.78 | 1.03 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 1.94 | 2.12 | 2.13 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.22 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.07 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
2.83
hrs / resident / day
RN (weekend)
0.16
hrs / resident / day
Total nurse (adjusted, weekend)
3.11
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
74.5%
annual
RN turnover
70.0%
annual
Administrators departed
0
last 12 months
Resident acuity
Nursing Case-Mix Index
1.25
higher acuity than avg
Case-Mix Index Ratio
0.90
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-07-17 | 11 | 10 | 2 | 48 | 1 | 48 |
| Cycle 2/3 (prior) | 2024-06-13 | 7 | 3 | 4 | 44 | 1 | 44 |
Total weighted health score
47.0
lower is better
Infection-control citations
2
last cycle
Deficiencies (23)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
1 A/B/C No actual harm — minor
22 D/E/F Actual harm — potential for minor
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0732 | Post nurse staffing information every day. | C | 2025-11-19 | — |
| 0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | 2025-07-17 | 2025-08-29 |
| 0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | 2025-07-17 | 2025-08-29 |
| 0641 | Ensure each resident receives an accurate assessment. | E | 2025-07-17 | 2025-08-29 |
| 0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | 2025-07-17 | 2025-08-29 |
| 0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | 2025-07-17 | 2025-08-29 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | 2025-07-17 | 2025-08-29 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2025-07-17 | 2025-08-29 |
| 0693 | 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. | D | 2025-07-17 | 2025-08-29 |
| 0742 | 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. | D | 2025-07-17 | 2025-08-29 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2025-07-17 | 2025-08-29 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | 2025-07-02 | 2025-07-25 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2024-06-13 | 2024-06-20 |
| 0710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | D | 2024-06-13 | 2024-06-20 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | 2024-06-13 | 2024-06-20 |
| 0622 | 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. | D | 2023-09-20 | 2023-10-16 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2023-09-20 | 2023-10-16 |
| 0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D | 2023-03-24 | 2023-04-10 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2023-03-24 | 2023-03-25 |
| 0759 | Ensure medication error rates are not 5 percent or greater. | D | 2023-03-24 | 2023-03-25 |
| 0922 | Have enough backup water supply for essential areas of the nursing home. | F | 2023-03-24 | 2023-04-17 |
| 0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | E | 2023-03-24 | 2023-04-05 |
| 0692 | Provide enough food/fluids to maintain a resident's health. | D | 2023-03-24 | 2023-03-25 |
Financial Health (FY 2023)
Payer mix (share of resident days)
Medicare 4.7% Medicaid 80.2% Other 15.1%
Operating performance
Operating Margin
-5.0%
Total Margin
-4.8%
Occupancy Rate
52.5%
Cost per Resident Day
$62
Revenue & costs
Net Patient Revenue
$4.9M
Total Costs
$1.1M
Net Income
-$237K
Balance sheet
Total Assets
$745K
Total Liabilities
$860K
Fund Balance
-$115K
Current Ratio
0.89
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: CROSS HEALTHCARE MANAGEMENT
- Chain ID
751- Facilities in chain
- 6
- Legal business name
- WEST COKE COUNTY HOSPITAL DISTRICT
Chain-average star ratings (for peer context)
Overall
3.0
Health
3.2
Staffing
1.3
QM
4.2
Owner / manager organizations (4)
| Organization | Role | Association |
|---|---|---|
| WEST COKE COUNTY HOSPITAL DISTRICT | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 05/01/2023 |
| WILLOW CREEK OPCO LLC | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2022 |
| 11830NPB, LLC | 5% OR GREATER MORTGAGE INTEREST | since 05/01/2023 |
| KTFW-TX LLC | 5% OR GREATER MORTGAGE INTEREST | since 05/01/2023 |
Owner / manager individuals (4)
| Name | Role | Association |
|---|---|---|
| LOCKHART, CHRISTOPHER | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2023 |
| MARTIN, CHRISTOPHER | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2023 |
| RANKIN, DEREK | OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2023 |
| MCGUIRE, WESLEY | CORPORATE OFFICER | since 05/01/2023 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 113 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $62 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 0.89 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 80.2% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 4.7% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $-237,044 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $4,898,725 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 52.5% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | -5.0% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $745,146 | metrics.total_assets |
| Cost Report | Total Costs ($) | $1,078,145 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $-115,279 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $860,425 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | -4.8% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 1.02990 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 2.13425 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.31217 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 3.47631 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 3.10736 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 87.3 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.78015 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.12026 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.61493 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.51534 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.09840 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 3.2 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 3.0 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 4.2 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 1.3 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 751 | Chain ID |
| Provider Information | Chain Name | CROSS HEALTHCARE MANAGEMENT | Chain Name |
| Provider Information | City/Town | Tomball | City/Town |
| Provider Information | CMS Certification Number (CCN) | 676244 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Harris | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 2010-02-16 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 4 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 30.0284 | Latitude |
| Provider Information | Legal Business Name | WEST COKE COUNTY HOSPITAL DISTRICT | Legal Business Name |
| Provider Information | Location | 11830 Northpointe Boulevard,Tomball,TX,77377 | Location |
| Provider Information | Long-Stay QM Rating | 5 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -95.639 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 0 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 135 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | 2 | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 6 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.24533 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.90395 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 4 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | For profit - Limited Liability company | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 11830 Northpointe Boulevard | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | Willow Creek Lodge | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 610 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 48 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 2 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 10 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-07-17 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 48 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 11 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 3 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2024-06-13 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 44 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 4 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 44 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 7 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.16004 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 70.0 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.22194 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.93771 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 1.94321 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.07217 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.28422 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 3.16515 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 3 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 1 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | TX | State |
| Provider Information | Telephone Number | 2812059400 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 2.82922 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 74.5 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 47.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 77377 | ZIP Code |