Cycle 1
Health 2025-09-04 · Fire 2025-09-04
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Weatherford, TX
Hilltop Park Rehabilitation And Care Center
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
970 Hilltop Dr, Weatherford, TX
(817) 599-0000
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
132
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Priority Management
Operator or chain grouping
Approved since
2003-08-13
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
0.25
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,847
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.04
Baseline 22.27% · Performance 19.89% · Measure score 4.04 · Achievement 3.32 · Improvement 4.04
Healthcare-associated infections
0
Baseline 7.75% · Performance 7.87% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 69.15% · Performance 69.91% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.27 hours · Performance 3.09 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 11.63% · Lower 95% interval 7.42% |
| Discharge to community | 51.65% |
50.57%
1.1 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 43.75% · Lower 95% interval 41.97% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 89.41% |
95.27%
5.9 pts worse
|
Numerator 76 · Denominator 85 |
| Falls with major injury | 1.18% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 85 |
| Discharge self-care score | 38% |
53.69%
15.7 pts worse
|
Numerator 19 · Denominator 50 |
| Discharge mobility score | 52% |
50.94%
1.1 pts better
|
Numerator 26 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 2.35% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 85 · Adjusted rate 1.74% |
| Healthcare-associated infections requiring hospitalization | 7.87% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 9.3% · Lower 95% interval 4.73% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 126 |
| Staff flu vaccination coverage | 75.37% |
42%
33.4 pts better
|
Numerator 101 · Denominator 134 |
| Discharge function score | 56% |
56.45%
0.5 pts worse
|
Numerator 28 · Denominator 50 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 29 · Denominator 30 |
| Transfer of health information to patient | 96.88% |
96.28%
0.6 pts better
|
Numerator 31 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 2.7% |
25.2%
22.5 pts worse
|
Numerator 1 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.3 · 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 | 98.8% |
97.9%
0.9 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.7% · Q3 2.7% · Q4 1.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.6% |
2.7%
6.9 pts worse
|
11.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 9.9% · Q3 4.2% · Q4 5.1% · 4Q avg 9.6% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
3.3%
1 pts worse
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 4.3% · Q3 3.9% · Q4 3.4% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.5% |
18.9%
2.6 pts worse
|
19.6%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 20.8% · Q3 23.1% · Q4 18.3% · 4Q avg 21.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
10.8%
2.2 pts worse
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 19.4% · Q3 15.4% · Q4 4.5% · 4Q avg 13.0% · 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 | 15.1% |
15.4%
0.3 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 28.9% · Q3 8.6% · Q4 13.4% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.8% |
16.1%
13.7 pts worse
|
14.9%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 38.3% · Q3 23.5% · Q4 21.4% · 4Q avg 29.8% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 17.2% |
15.0%
2.2 pts worse
|
19.8%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 22.3% · Q3 23.5% · Q4 6.5% · 4Q avg 17.2% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.2%
0.9 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 3.0% · Q4 4.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
89.7%
8.5 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
12.0%
4.5 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.4% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
88.0%
2.6 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
25.9%
0.8 pts better
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 26.1% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-22 · Fire 2024-08-22
13 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-14 · Fire 2023-07-14
4 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
2025-09-04
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-09-04
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-09-04
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-09-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-22
E · Potential for more than minimal harm
2025-09-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-09-22
E · Potential for more than minimal harm
2025-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-22
F · Potential for more than minimal harm
2024-08-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-08-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-08-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-25
E · Potential for more than minimal harm
2024-08-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-04
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 2025-09-22
E · Potential for more than minimal harm
2025-09-04
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 2025-09-22
K · Immediate jeopardy
2025-02-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-15
K · Immediate jeopardy
2025-02-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-15
D · Potential for more than minimal harm
2025-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-15
F · Potential for more than minimal harm
2024-08-22
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 2024-09-09
E · Potential for more than minimal harm
2024-08-22
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 2024-09-09
D · Potential for more than minimal harm
2024-08-22
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-22
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-09
C · Minimal harm
2024-08-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-05-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-22
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 2024-06-21
D · Potential for more than minimal harm
2024-05-22
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 2024-06-21
C · Minimal harm
2024-05-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-02-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-07-14
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 2023-08-14
D · Potential for more than minimal harm
2023-07-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-14
Penalties and ownership
What sits behind the stars
$102,810
2025-02-14
Fine
Fine · fine $102,810
Fine
Ownership
Parker County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bacus, Randy
Corporate Officer · 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
Bauder, William
5% Or Greater Mortgage Interest · Individual
Boulware St James LLC
5% Or Greater Mortgage Interest · Organization
Boulware, Douglas
5% Or Greater Mortgage Interest · Individual
Boulware, Sandra
5% Or Greater Mortgage Interest · Individual
Boulware, Steven
Operational/Managerial Control · Individual
Boulware, Steven
5% Or Greater Mortgage Interest · Individual
Boulware, Thomas
5% Or Greater Mortgage Interest · Individual
Pmg Opco - Hilltop LLC
Operational/Managerial Control · Organization
Pmg Realco-Hilltop, LLC
5% Or Greater Mortgage Interest · Organization
Steven Boulware Family Investments LLC
5% Or Greater Mortgage Interest · Organization
Walker, Katie
5% Or Greater Mortgage Interest · Individual
Nearby options
Other facilities in reach
#1
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
#2
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
#3
College Park Rehabilitation And Care Center
Weatherford, TX
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
Jump out