Find a nursing home

Home / Texas / Kilgore

Willow Rehab & Nursing

1901 Whippoorwill, Kilgore, TX 75662 · Gregg County · (903) 983-7775

118 certified beds, about 93 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2004

Inside a hospital Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
2 of 5
Staffing
2 of 5
Quality measures
5 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 676007 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on April 1, 2026, inspectors cited 5 health deficiencies (the Texas average is 9.4, the national average 9.2).

Of 33 health citations since October 2023, 3 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).

CMS lists 2 fines totaling $219,229 in the last three years; the largest was $201,884, and the latest is dated June 13, 2025.

Nurses and nurse aides worked 3.16 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.30 of those hours.

43.8% of nursing staff left within the year CMS measured (Texas average 55.3%).

CMS links it to Advanced Healthcare Solutions, an affiliated group of 28 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 33 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
1K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
9E
2F
Potential for minimal harm
0A
0B
0C
April 1, 2026Standard inspection · 5 citations
  1. E
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 6, 2026
    Inspectors wroteBased on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 4 of 21 residents reviewed. (Resident #24, Resident #27, Resident #33, and Resident #91)1. The facility failed to securely store over the counter medications (hemorrhoid cream) for Resident #24.2. The facility failed to securely store over the counter medication, ear relief ear drops for Resident #27.3. The facility failed to securely store prescribed medication, (Nystatin Topical Cream) for Resident #33.4. The facility failed to securely store prescribed medication, Breyna (budesonide and formoterol fumarate dihydrate) inhalation aerosol for Resident #91. This failure could place residents at risk for adverse reactions.
  2. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 6, 2026
    Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 20 (Resident #73) residents reviewed for call lights. The facility failed to ensure Resident #73 had a call light with reach. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.
  3. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 6, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 19 residents (Resident #31) reviewed for accidents and supervision. The facility failed to ensure an oxygen cylinder found in Resident #31's room was properly stored. This deficient practice could place residents at risk of injury.
  4. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 6, 2026
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 20 residents reviewed for respiratory care. (Resident #37) The facility failed to ensure Resident #37's oxygen concentrator had a clean filter. This failure could place residents at risk of respiratory complications or respiratory infection.
  5. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 6, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 20 residents reviewed for infection control practices (Resident #9). The facility failed to ensure CNA A changed her gloves and performed hand hygiene appropriately after taking Resident #9's pants off and before performing indwelling catheter care. CNA A also failed to change her gloves and perform hand hygiene prior to touching disposable bags, some containing clean wipes. CNA A placed the dirty and clean disposable bags on Resident #9's bed side table beside his water cup while providing catheter care to Resident #9. [...]
June 13, 2025Complaint inspection · 1 citation
  1. J
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 30, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needs respiratory care, is provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure that CNA B effectively communicated to RN A that Resident #1 requested a nurse. The facility failed to ensure that CNA B recognized a change of condition in Resident #1 that needed to be emergently communicated to RN A. The facility failed to ensure CNA C reported Resident #1's change of condition to RN A. [...]
January 30, 2025Standard inspection, Complaint inspection · 12 citations
  1. E
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 6 residents reviewed for misappropriation of resident property. (Resident # 85) CNA T used Resident #85's debit/credit card for her personal use on various dates. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.
  2. E
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 3 of 5 residents (Resident #20, Resident #76, Resident #5) reviewed for quality of care. The facility failed to prevent Resident #20 from having rubbing alcohol in his room. The facility failed to ensure Resident #76 did not have 5 razors in his room. The facility failed to ensure Resident #5's fall mat was beside his bed on 01/28/25 and 01/29/25. This failure could place residents at risk for injury, harm, and impairment.
  3. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed for food safety requirements. The facility failed to prepare fried eggs with pasteurized eggs. The facility failed to ensure the kitchen staff had an operable paper towel dispenser to wash their hands instead of placing the paper towel roll on the clean dish rack. The facility failed to ensure the Dietary Manager in training and the [NAME] Helper properly performed hand hygiene while assisting with preparing resident meals in the kitchen. These failures could place residents at risk for foodborne illness.
  4. E
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    F813 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 3 of 8 resident personal refrigerators reviewed for food safety (Resident #62, Resident #61, and Resident #56). 1. The facility failed to ensure the refrigerator for Resident #62 did not contain expired milk. 2. The facility failed to ensure the refrigerator in Resident #61's room did not contain expired strawberry yogurt. 3. The facility failed to ensure the refrigerator for Resident #56 did not contain expired baked beans and expired macaroni and cheese. This failure could place resident at risk for food borne illnesses.
  5. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 20 residents (Resident #47, Resident #5, and Resident #54) reviewed for infection control practices. The facility failed to ensure latex gloves, resident's clothes, briefs, and wet clothes were not left on the floor of the resident #47's room . The facility failed to ensure Resident #54's gastrostomy tube piston syringe was properly changed out and covered in the provided plastic bag on 01/27/25 and 01/28/25. [...]
  6. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 6 (Resident #72) residents reviewed for call lights. The facility failed to ensure Resident #72's call button was within reach while Resident #72 was in her bed. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.
  7. D
    PASARR screening for Mental disorders or Intellectual Disabilities
    F645 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #32) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #32. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses (major depressive disorder and post-traumatic stress disorder) were present upon Resident #32's admission date on 04/21/22. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.
  8. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 1 of 6 residents (Residents #74) reviewed for ADL care. The facility failed to ensure Resident #74 was showered on 01/01/25, 01/06/25, 01/13/25, 01/15/25 and 01/20/25. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.
  9. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 5 residents (Resident's #27 and Resident #290) reviewed for respiratory care. 1. The facility failed to ensure staff followed the policy for dating the oxygen tubing and bagging the CPAP (a machine that uses mild air pressure to keep breathing airways open while you sleep) on 01/27/25 and 01/28/25 for Resident #27. 2. The facility failed to ensure staff followed the policy for bagging and dating Resident #290's Handheld nebulizer on 01/27/25 and 01/29/25. [...]
  10. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 5.56%, based on 2 errors out of 36 opportunities, which involved 2 of 6 residents (Resident #37 and Resident #80) reviewed for medication administration. 1. The facility failed to administer Resident #37's eye drops ophthalmic solution 0.05% Tetrahydrozoline HCL medication (used for temporary treatment of eye redness and irritation.) as ordered. 2. The facility failed to administer Resident #80's Aspirin chewable 81mg medication (used to help prevent a heart attack or clot-related stroke) as ordered. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.
  11. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 1 of 21 residents (Resident #56) reviewed for storage of medication. The facility failed to securely store medications, Resident #56 had a white cream and green powder substances found at her bedside inside medicine cups. These failures could place residents at risk for adverse reactions to medications or overdose.
  12. D
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    F849 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 28, 2025
    Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 5 residents (Resident #54) reviewed for hospice services. The facility failed to obtain Resident #54's most recent updated hospice medication profile to indicate Resident #54 was taking Lorazepam (an antianxiety medication) 1mg tab scheduled every 12 hours scheduled instead of every 4 hours as needed. [...]
December 12, 2024Complaint inspection · 2 citations
  1. K
    Prepare residents for a safe transfer or discharge from the nursing home.
    F624 · Resident Rights · Immediate jeopardy to resident health or safety, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2024
    Inspectors wroteBased on record review, and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 2 of 5 residents (Resident #1 and Resident #2) reviewed for discharge rights, in that: The facility failed to ensure Resident #1 had a safe and orderly discharge to a home environment on 9/12/2024. Resident #1 was discharged from the facility with no place to go and made to sit outside and found approximately 7 hours later on the ground behind the facility and transported to the hospital with A-fib and high blood pressure. The facility failed to ensure Resident #2 had a safe and orderly discharge to a home environment on 11/14/2024. Resident #2 who needed supervision and assistance with some ADL's and was a moderate fall risk was discharged to a motel and had multiple falls. [...]
  2. J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 13, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #3) residents reviewed for supervision. The facility failed to respond to door alarm that resulted in Resident #3 elopement on 9/20/2024. Resident #3, who had dementia, left the facility through an alarmed door on 9/20/2024 at 5:05 PM. The resident wandered approximately 200 yards down the road from the facility driveway and was intercepted by Medical Records and returned to the facility. An IJ was identified on 12/11/2024. The IJ template was provided to the facility on [DATE] at 1:55 PM. [...]
December 12, 2023Standard inspection · 10 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Potatoes were stored on the floor. 2. Food items were not labeled and dated. These failures could place residents who received meals from the kitchen at risk for food borne illness.
  2. F
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    F851 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information. (Quarter 3 2023) The facility failed to submit staffing information to CMS for the 3rd quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feeling of well-being within their living environment.
  3. E
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 9 days out of 90 days reviewed for RN coverage. The facility failed to have an RN coverage for 8 consecutive hours 7 days a week on September 4,2023, September 5,2023, September 9,2023, October 2, 2023, October 3, 2023, October 4, 2023, October 12, 2023, October 13, 2023, and October 18, 2023. These failures could place all residents at risk for their clinical needs not being met.
  4. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 resident (Resident #70) reviewed for resident rights. The facility failed to ensure CNA D treated Resident #70 with respect and dignity when CNA D told her What ya'll need?, What, Are you going to stay up until we get off of work?, and I don't know if we going to do all that. The facility failed to ensure CNA E treated Resident #70 with respect and dignity when CNA E told her From here on out, if you want to get up, you are going to have to get up earlier than this. This ain't going to cut it. It is too close to supper. These failures could place residents at risk for diminished quality of life, loss of dignity, and self-worth.
  5. D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 4 Residents (Resident #35) reviewed for PASSAR (Preadmission Screening and Resident Review Services) in that: Resident #35 did not have a PASSR level II evaluation with diagnosis of PTSD (post-traumatic stress disorder). The Social Worker failed to refer Resident #35 for a resident review after being diagnosed with PTSD on 2/23/2021 until after surveyor entrance on 12/10/23. These failures could place residents at risk of not receiving the needed PASRR services to meet their individual needs and could result in a decrease quality of life.
  6. D
    PASARR screening for Mental disorders or Intellectual Disabilities
    F645 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 4 residents (Resident #18) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #18. The PASRR 1 Level screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.
  7. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 21 residents reviewed for ADLs (Residents # 8) The facility did not trim Resident # 8's fingernails. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.
  8. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained free of accident hazards for 1 of 5 residents (Resident #30) reviewed for accident hazards. The facility failed to ensure an oxygen cylinder found in Resident #30's room was properly stored. This failure could place residents at risk of injury.
  9. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 4 residents (Resident #35) and reviewed for pharmacy services. The facility failed to ensure Resident #35's Diphenhydramine Cream 2% was available to be administered. The facility did not ensure medications were properly administered to Resident #35 on 12/11/23. LVN F signed the medication administration record that she had administered Resident #35's Diphenhydramine Cream 2% when the medication was not in the facility. These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and not receiving the intended therapeutic benefit of the medications.
  10. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 11, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #39) reviewed for infection control practices. The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #39. These failures could place residents and staff at risk for cross contamination and the spread of infection.
October 16, 2023Complaint inspection · 3 citations
  1. E
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 17, 2023
    Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 3 residents (Resident #1) reviewed for pain management. The facility failed to perform and document a pain assessment with the administration of Resident #1's prn (as needed) pain medication. The facility failed to perform a follow up pain assessment after administering Resident #1's prn pain medication. This failure could place residents at risk for incomplete pain relief, discomfort and decreased quality of life. Findings Included: [...]
  2. E
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 17, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 1 of 3 residents (Resident #1) reviewed for medical records. The facility failed to ensure the documentation of Resident #1's prn (as needed) pain medication was documented in the MAR. This failure could place residents at risk of delayed pain medication administration, or over medication.
  3. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 17, 2023
    Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident for 1 of 3 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to implement the care plan intervention to monitor and document Resident #1's output. This failure could place residents at risk of unmet care needs.

Fire safety inspections

8 fire safety citations on file: 2 on April 1, 2026, 4 on January 30, 2025, 2 on December 12, 2023.

Every fire safety citation8 citations
  1. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · April 1, 2026 · Corrected (the home has a date of correction)
  2. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · April 1, 2026 · Corrected (the home has a date of correction)
  3. F
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · January 30, 2025 · Corrected (the home has a date of correction)
  4. E
    Provide properly protected cooking facilities.
    K 324 · January 30, 2025 · Corrected (the home has a date of correction)
  5. E
    Install an approved automatic sprinkler system.
    K 351 · January 30, 2025 · Corrected (the home has a date of correction)
  6. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · January 30, 2025 · Corrected (the home has a date of correction)
  7. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · December 12, 2023 · Corrected (the home has a date of correction)
  8. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · December 12, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
June 13, 2025Fine $17,345
December 12, 2024Fine $201,884

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeTexasUnited States
All nursing staff (RN, LPN and aides)3.163.393.86
Registered nurses0.300.430.69
All nursing staff on weekends2.812.983.42
Nurse aides2.03
Licensed practical nurses0.83
Nursing staff turnover (share who left in a year)43.8%55.3%45.8%
Registered nurse turnover44.4%54.6%42.9%
Administrators who left0

CMS expects 3.51 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.30 on weekdays and 2.81 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.97 in April to June 2025 to 3.16 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.160.303.302.81 0.0%0 of 9093
Oct to Dec 20252.980.303.082.72 0.0%2 of 9293
Jul to Sep 20253.000.323.112.72 0.0%0 of 9291
Apr to Jun 20252.970.333.072.72 0.0%0 of 9188
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Texas, Jan to Mar 20263.330.403.502.932.2%0.7% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Texas

JobMedianMiddle halfEmployed
Texas, all employers
CNAs (nursing assistants)$18.03$16.97 to $20.7188,680
LPNs and LVNs$29.92$27.46 to $32.8957,560
Registered nurses$46.14$38.06 to $50.53271,380
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeTexasUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
9.815.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.30.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.90.81.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
3.03.33.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.01.51.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
7.714.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
4.03.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
2.49.615.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
32.025.723.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
5.512.312.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.72.21.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.62.11.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Willow Rehab & Nursing's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (47.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

47.7% this home

No different from the national rate

US median of homes 51.5% · Texas: 116 better, 50 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 30 eligible stays.

Potentially preventable readmissions

9.9% this home

No different from the national rate

US median of homes 10.7% · Texas: 0 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 58 eligible stays.

Infections that led to a hospital stay

8.4% this home

No different from the national rate

US median of homes 7.1% · Texas: 4 better, 11 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 27 eligible stays.

Self-care and mobility at discharge

82.3% this home

Median of homes: Texas57.3% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 34 residents counted.

Falls with major injury

0.0% this home

Median of homes: Texas0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 46 residents counted.

New or worsened pressure ulcers

1.7% this home

Median of homes: Texas1.3% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 46 residents counted.

Medication list given at discharge

Not reported

CMS note: Newly certified nursing home with less than 12-15 months of data available or the nursing opened less than 6 months ago, and there were no data to submit or claims for this measure.

Median of homes: Texas98.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: HAMILTON COUNTY HOSPITAL DISTRICT. CMS links this home to Advanced Healthcare Solutions, a group of 28 nursing homes averaging 2.9 stars overall.

NameRoleTypeShareSince
Hooper, GradyCorporate officerIndividual03/01/2024
Scheiner, EliezerOperational/managerial controlIndividual02/29/2024
Silberstein, AriOperational/managerial controlIndividual02/29/2024
Gold Tx TrustAdp of the SNFOrganization01/03/2025
Red Brass Holdco LLCAdp of the SNFOrganization01/03/2025
Silver Tx TrustAdp of the SNFOrganization01/03/2025
Willow Hc LLCAdp of the SNFOrganization01/03/2025
Faulkner, GarrelAdp of the SNFIndividual01/03/2025
Jensen, KevinAdp of the SNFIndividual01/03/2025

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 10 problems in this area, most recently on April 1, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
  2. When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on January 30, 2025: "PASARR screening for Mental disorders or Intellectual Disabilities"
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 4 problems in this area, most recently on April 1, 2026: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs."
  4. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 4 problems in this area, most recently on April 1, 2026: "Reasonably accommodate the needs and preferences of each resident."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.81 hours per resident per day, below the Texas average of 2.98.

Other nursing homes nearby

Texas contacts for a concern about a nursing home

These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.

Common questions

What is Willow Rehab & Nursing's Medicare star rating?
CMS rates Willow Rehab & Nursing 3 out of 5 stars overall, with 2 for health inspections, 2 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Willow Rehab & Nursing get at its last inspection?
5 health deficiencies at the standard inspection on April 1, 2026. The Texas average is 9.4.
Has Willow Rehab & Nursing been fined?
Yes. CMS lists 2 fines totaling $219,229 in the last three years.
Does Willow Rehab & Nursing accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Willow Rehab & Nursing?
CMS lists 9 owners and managers, and links the home to Advanced Healthcare Solutions. Legal business name: HAMILTON COUNTY HOSPITAL DISTRICT.

Sources

Find a nursing home Read an inspection