Cycle 1
Health 2025-03-27 · Fire 2025-03-27
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Weatherford, TX
College Park Rehabilitation And Care Center
2-star overall rating with 3-star inspections with $233,175 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1715 Martin Dr, Weatherford, TX
(817) 458-3100
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Priority Management
Operator or chain grouping
Approved since
2009-02-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.14
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.05
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.14
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
64%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.52% · Performance 25.14% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.73% · Performance 10.11% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 60.29% · Performance 71.74% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.75 hours · Performance 2.60 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.47% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 182 · Observed rate 10.99% · Lower 95% interval 7.56% |
| Discharge to community | 51.31% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 140 · Observed rate 46.43% · Lower 95% interval 42.4% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.76% |
95.27%
2.5 pts better
|
Numerator 131 · Denominator 134 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 1 · Denominator 134 |
| Discharge self-care score | 61.54% |
53.69%
7.9 pts better
|
Numerator 48 · Denominator 78 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 39 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 0.75% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 134 · Adjusted rate 0.69% |
| Healthcare-associated infections requiring hospitalization | 10.11% |
7.12%
3 pts worse
|
No Different than the National Rate · Eligible stays 116 · Observed rate 13.79% · Lower 95% interval 6.86% |
| Staff COVID-19 vaccination coverage | 1.05% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 95 |
| Staff flu vaccination coverage | 37.69% |
42%
4.3 pts worse
|
Numerator 49 · Denominator 130 |
| Discharge function score | 60.26% |
56.45%
3.8 pts better
|
Numerator 47 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 61 · Denominator 61 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 46 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.7% · Q4 3.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
2.7%
1.2 pts worse
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.4% · Q3 5.4% · Q4 1.6% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
3.3%
3 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 12.0% · Q3 4.0% · Q4 0.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
18.9%
9.9 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 31.5% · Q3 25.5% · Q4 32.1% · 4Q avg 28.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
10.8%
3.9 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.9% · Q3 7.9% · Q4 6.5% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.9% |
15.4%
13.5 pts worse
|
16.3%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 28.7% · Q3 26.0% · Q4 22.0% · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
16.1%
6 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 42.0% · Q3 13.0% · Q4 16.7% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.5% |
15.0%
0.5 pts better
|
19.8%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 20.5% · Q3 8.2% · Q4 14.7% · 4Q avg 14.5% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
4.2%
4 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 7.4% · Q3 11.1% · Q4 5.7% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
89.7%
10.2 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
12.0%
2.9 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.1% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.6% · Q3 0.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
88.0%
5.2 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.2% |
25.9%
7.3 pts worse
|
23.9%
9.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.2% · Observed 33.6% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-20 · Fire 2024-02-20
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-03-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-29
F · Potential for more than minimal harm
2024-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-04-25
J · Immediate jeopardy
2024-02-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-21
J · Immediate jeopardy
2024-02-20
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-02-21
F · Potential for more than minimal harm
2024-02-20
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-02-20
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-02-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-02-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-02-20
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-02-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-21
E · Potential for more than minimal harm
2022-11-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-28
E · Potential for more than minimal harm
2022-11-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-11-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-11-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-11-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-11
Penalties and ownership
What sits behind the stars
$233,175
2024-02-20
Fine
Fine · fine $233,175
Fine
Ownership
Parker County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bacus, Randy
Corporate Director · Individual
Bauder Family Investments, LLC
5% Or Greater Mortgage Interest · Organization
Bauder, Kelly
5% Or Greater Mortgage Interest · Individual
Bauder, Madison
5% Or Greater Mortgage Interest · Individual
Bauder, Parker
5% Or Greater Mortgage Interest · Individual
Bauder, William
Operational/Managerial Control · Individual
Boulware St James LLC
5% Or Greater Mortgage Interest · Organization
Boulware, Sandra
5% Or Greater Mortgage Interest · Individual
Boulware, Steven
Operational/Managerial Control · Individual
Boulware, Thomas
5% Or Greater Mortgage Interest · Individual
Pmg Opco - College Park LLC
Operational/Managerial Control · Organization
Pmg Realco - College Park LLC
5% Or Greater Mortgage Interest · Organization
Steven Boulware Family Investments LLC
5% Or Greater Mortgage Interest · Organization
Wahrman, Chad
Operational/Managerial Control · Individual
Walker, Katie
5% Or Greater Mortgage Interest · Individual
Nearby options
Other facilities in reach
#1
Santa Fe Health & Rehabilitation Center
1205 Santa Fe Dr, TX
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Holland Lake Rehabilitation And Wellness Center
Weatherford, TX
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Hilltop Park Rehabilitation And Care Center
Weatherford, TX
2-star overall rating with 3-star inspections with $102,810 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out