01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-17 | 11 | 2025-07-17 | 5 |
| Cycle 2 | 2024-06-13 | 4 | 2024-06-13 | 3 |
| Cycle 3 | 2023-03-24 | 8 | 2023-03-24 | 2 |
CMS CCN 6762442026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Willow Creek Lodge
11830 Northpointe Boulevard · Tomball, TX 77377 · Harris County
Certified beds135CMS provider file
Recent citation rows33current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
33 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-11-19 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-11-20 · complaint2025-07-17 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · HEALTHF0742Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · FIREK0281Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Install proper backup exit lighting.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · FIREK0511Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-17 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-02 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-07-25 · complaint2024-06-13 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-06-13 · HEALTHF0710Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-06-13 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-06-13 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-06-13 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-06-13 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-06-182023-09-20 · HEALTHF0622Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-10-16 · complaint · infection control03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- GREWAL, HERMANJEETIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2026
- JOHN, BIJUIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2026
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- MCGUIRE, WESLEYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/01/2023
- CANYONLANDS PEAK HEALTHCARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2026
- BURNAM, SOONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2026
- GREWAL, HERMANJEETIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2026
- JOHN, BIJUIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2026
- CANYONLANDS PEAK HEALTHCARE LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/10/2026
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 02/11/2026
- NORTHPOINTE BLVD HEALTH HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2026
- STANDARD BEARER HEALTHCARE OP, LPOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2026
- THE ENSIGN GROUP INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 05/01/2026
- GREWAL, HERMANJEETIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2026
- JOHN, BIJUIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2026
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.36per resident day
RN hours0.18per resident day
Weekend nurse hours3.03per resident day
Staff turnover62.5%CMS reported field
06 / LOCAL RECORDS
Open the Tomball ledger →