B+
82/100Willis Nursing and Rehabilitation Inspection Report, Violations & Safety Grade (WILLIS, Texas)
3000 N. Danville St., WILLIS, Texas 77378
Phone: 9368564312
CMS Overall:4/5
Overview & Bed Count
Certified Beds
114
Avg Residents/Day
48.7
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Montgomery
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health5/5
Staffing1/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.36 | 0.44 | -0.08 |
| Total Nurse Hours per Resident per Day | 2.96 | 3.42 | -0.45 |
| CMS Staffing Rating | 1/5 | 1.9/5 | - |
| Nursing Staff Turnover | 50.0% | 50.8% | - |
Health Citation History
13 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-03 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-08-21 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-08-21 | Environmental Deficiencies | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | D – Moderate Harm Potential |
| 2024-06-28 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2023-10-20 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2023-10-20 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-10-19 | Resident Rights Deficiencies | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D – Moderate Harm Potential |
| 2023-10-19 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-10-19 | 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. | D – Moderate Harm Potential |
| 2023-10-19 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2023-05-11 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E – Moderate Harm Potential |
| 2023-05-11 | Resident Rights Deficiencies | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | E – Moderate Harm Potential |
| 2023-05-11 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
Fire Safety Citation History
8 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-08-21 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | F – Moderate Harm Potential |
| 2025-08-21 | Smoke Deficiencies | Install an approved automatic sprinkler system. | D – Moderate Harm Potential |
| 2025-08-21 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | C – Minimal Harm Potential |
| 2024-06-28 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
| 2024-06-28 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | C – Minimal Harm Potential |
| 2023-05-11 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D – Moderate Harm Potential |
| 2023-05-11 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | C – Minimal Harm Potential |
| 2023-05-11 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | C – Minimal Harm Potential |
Total Penalties & Fines
$7,443
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2023-10-19 | Fine | $7,443 | - |
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WILLIS area at no cost.
Find Safe, Vetted Facilities Near WILLIS
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WILLIS area at no cost.
Find Safe, Vetted Facilities Near WILLIS
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.