Willow Creek Lodge - 4-Star Rehab Facility in Tomball, TX | Placet0.28h
RN HOURS
per resident/day
4/5
CMS STARS
overall rating
3.9★
TRUST INDEX
Placet score
24.5%
BOUNCE BACK
30-day readmission
Clinical Quality Indicators
Long-stay residents — lower is better
Antipsychotic medication use 11.37%Falls causing major injury 0%Pressure ulcers (high-risk) 0.76%Admissions Contacts
No admissions contacts on file yet.
CMS Star Ratings
Last inspected: Nov 2025 (148 days ago)🔍 Health Inspection
4/5
★★★★☆
📊 Quality Measures
5/5
★★★★★
Are you the administrator of this facility? Claim your listing to update your profile and view referral analytics.
Source: CMS MDS Quality Measures. Updated quarterly.
State avg: 26 min · US avg: 41 min
Total Nurse / Resident / Day
3h 10m
State avg: 3h 24m · US avg: 3h 53m
4 min
State avg: 4 min · US avg: 4 min
75 per 100
State avg: 51 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
Weekend vs. Weekday RN
55%below avg
US avg: 64%
Total Nurse Weekend
2h 25m
Federal Penalties
No federal penalties in the past 3 years.
| Date | Type | Fine | Denial Days |
|---|
| 3/6/2023 | Fine | $4,194 | - |
| 3/6/2023 | Fine | $4,194 | - |
| 3/6/2023 | Fine | $4,194 | - |
| 3/6/2023 | Fine | $4,194 | - |
| 3/6/2023 | Fine | $4,194 | - |
| 3/6/2023 | Fine | $4,194 | - |
| 3/6/2023 | Fine | $4,194 | - |
| 3/6/2023 | Fine | $4,194 | - |
| 3/6/2023 | Fine | $4,194 | - |
Inspection Citations
Survey: November 19, 2025(3 citations)
⚪ MinimalNursing and Physician Services DeficienciesComplaint
⚪ MinimalNursing and Physician Services DeficienciesComplaint
⚪ MinimalNursing and Physician Services DeficienciesComplaint
Survey: July 17, 2025(30 citations)
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
24.5 per 100
State avg: 25.9 · US avg: 23.9
17.4 per 100
State avg: 12.0 · US avg: 12.0
0.0 per 100
State avg: 3.3 · US avg: 3.3
0.8 per 100
State avg: 4.2 · US avg: 5.1
0.0 per 100
State avg: 1.5 · US avg: 1.6
93.8 per 100
State avg: 88.0 · US avg: 79.7
Rates shown per 100 patients · Green = better than average · Amber = average · Red = below average
VBP Performance Score
10/100
Incentive Payment
-1.91% penalty
Healthcare-Assoc. Infections
7.6 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Avg Length of Stay
28.9 days
Avg Payment / Stay
$13,616.95
Patient Complexity
3.15 × avg
Avg LOS 15-30 days is typical for short-term rehab · Patient complexity = HCC risk score (1.0 = national average; higher = sicker patient mix)
🟡 Potential for Harm
Resident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
Survey: July 2, 2025(3 citations)
🟡 Potential for HarmResident Assessment and Care Planning DeficienciesComplaint
🟡 Potential for HarmResident Assessment and Care Planning DeficienciesComplaint
🟡 Potential for HarmResident Assessment and Care Planning DeficienciesComplaint
Survey: June 13, 2024(9 citations)
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmNursing and Physician Services Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmNursing and Physician Services Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmNursing and Physician Services Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
Survey: September 20, 2023(6 citations)
🟡 Potential for HarmResident Rights DeficienciesComplaint
🟡 Potential for HarmPharmacy Service DeficienciesComplaint
🟡 Potential for HarmResident Rights DeficienciesComplaint
🟡 Potential for HarmPharmacy Service DeficienciesComplaint
🟡 Potential for HarmResident Rights DeficienciesComplaint
🟡 Potential for HarmPharmacy Service DeficienciesComplaint
+ 2 more survey(s) not shown in snapshot