Weatherford, TX

Holland Lake Rehabilitation And Wellness Center

5-star overall rating with 5-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

1201 Holland Lake Dr, Weatherford, TX

(817) 598-0160

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

91

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Hmg Healthcare

Operator or chain grouping

Approved since

1996-09-18

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.38

Registered nurse staffing

LPN hours / resident day

1.24

Licensed practical nurse staffing

Aide hours / resident day

2.16

Nurse aide staffing

Weekend hours

3.01

Weekend nurse staffing

RN turnover

46%

Annual RN turnover

Total nurse turnover

36%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	2.1 0.3 pts better	1.9 0.1 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	2.1 0.6 pts better	1.8 0.3 pts better	Long Stay · 20240701-20250630
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
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
Percentage of long-stay residents experiencing one or more falls with major injury	5.0%	3.3% 1.7 pts worse	3.3% 1.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	0.9%	2.7% 1.8 pts better	11.4% 10.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	0.0%	3.3% 3.3 pts better	5.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	5.6%	18.9% 13.3 pts better	19.6% 14 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	0.7%	10.8% 10.1 pts better	16.7% 16 pts better	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened	4.6%	15.4% 10.8 pts better	16.3% 11.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	8.9%	16.1% 7.2 pts better	14.9% 6 pts better	Long Stay · 2024Q4-2025Q3
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
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
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	8.3%	15.0% 6.7 pts better	19.8% 11.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	7.2%	4.2% 3 pts worse	5.1% 2.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.8%	89.7% 10.1 pts better	81.7% 18.1 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	10.0%	12.0% 2 pts better	12.0% 2 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.5% 1.2 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.4%	88.0% 10.4 pts better	79.7% 18.7 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.1%	25.9% 3.8 pts better	23.9% 1.8 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-17 · Fire 2024-10-17

3 health deficiencies

Top issue: Infection Control (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2023-08-31 · Fire 2023-08-31

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-06-30 · Fire 2022-06-30

5 health deficiencies

Top issue: Nutrition and Dietary (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 2024-10-17

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-10-31

F · Potential for more than minimal harm 2024-10-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-10-31

E · Potential for more than minimal harm 2024-10-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-10-31

E · Potential for more than minimal harm 2024-10-17

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-11-04

D · Potential for more than minimal harm 2024-10-17

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-11-04

E · Potential for more than minimal harm 2023-08-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-09-26

E · Potential for more than minimal harm 2023-08-31

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-09-15

D · Potential for more than minimal harm 2023-08-31

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 2023-09-26

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-05

D · Potential for more than minimal harm 2025-03-26

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-03-27

D · Potential for more than minimal harm 2025-01-02

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 2025-01-04

D · Potential for more than minimal harm 2024-10-17

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 2024-10-18

F · Potential for more than minimal harm 2023-08-31

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 2023-09-04

E · Potential for more than minimal harm 2023-08-31

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-09-04

E · Potential for more than minimal harm 2023-08-31

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 2023-09-04

E · Potential for more than minimal harm 2023-08-31

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-09-04

D · Potential for more than minimal harm 2023-08-31

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 2023-09-04

D · Potential for more than minimal harm 2023-08-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-04

E · Potential for more than minimal harm 2022-06-30

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2022-07-01

E · Potential for more than minimal harm 2022-06-30

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2022-07-01

E · Potential for more than minimal harm 2022-06-30

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2022-07-01

E · Potential for more than minimal harm 2022-06-30

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-07-01

E · Potential for more than minimal harm 2022-06-30

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 2022-07-01

Penalties and ownership

What sits behind the stars

Ownership

Winnie-Stowell Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 75 facilities 2021-10-01

Culp, Roland