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

Chain footprint

33 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 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

0.38

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.24

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.16

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.79

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.62

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.01

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.31

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.41

CMS adjusted RN staffing hours

Adjusted total hours

4.09

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

36%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,483

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

29.61

Composite VBP score used to determine payment impact.

Payment multiplier

0.9855

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.24

Baseline 22.03% · Performance 21.16% · Measure score 1.24 · Achievement 0.58 · Improvement 1.24

Healthcare-associated infections

2.39

Baseline 5.20% · Performance 7.12% · Measure score 2.39 · Achievement 2.39 · Improvement 0

Total nurse turnover

5.18

Baseline 63.79% · Performance 42.50% · Measure score 5.18 · Achievement 5.18 · Improvement 4.97

Adjusted total nurse staffing

3.02

Baseline 3.11 hours · Performance 3.94 hours · Measure score 3.02 · Achievement 3.02 · Improvement 2.60

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.72%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 192 · Observed rate 8.85% · Lower 95% interval 7.53%
Discharge to community	57.06%	50.57% 6.5 pts better	Better than the National Rate · Eligible stays 176 · Observed rate 52.27% · Lower 95% interval 51%
Medicare spending per beneficiary	0.93	1.02 0.1 pts better
Drug regimen review with follow-up	94.24%	95.27% 1 pts worse	Numerator 131 · Denominator 139
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 139
Discharge self-care score	58.25%	53.69% 4.6 pts better	Numerator 60 · Denominator 103
Discharge mobility score	45.63%	50.94% 5.3 pts worse	Numerator 47 · Denominator 103
Pressure ulcers or injuries, new or worsened	5.04%	2.29% 2.8 pts worse	Numerator 7 · Denominator 139 · Adjusted rate 4.81%
Healthcare-associated infections requiring hospitalization	7.12%	7.12% About the same	No Different than the National Rate · Eligible stays 119 · Observed rate 6.72% · Lower 95% interval 4.09%
Staff COVID-19 vaccination coverage	92.31%	8.2% 84.1 pts better	Numerator 72 · Denominator 78
Staff flu vaccination coverage	88.96%	42% 47 pts better	Numerator 145 · Denominator 163
Discharge function score	44.66%	56.45% 11.8 pts worse	Numerator 46 · Denominator 103
Transfer of health information to provider	95.16%	95.95% 0.8 pts worse	Numerator 59 · Denominator 62
Transfer of health information to patient	98.33%	96.28% 2 pts better	Numerator 59 · Denominator 60
Resident COVID-19 vaccinations up to date	3.95%	25.2% 21.2 pts worse	Numerator 3 · Denominator 76

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 · Adjusted 1.8 · Observed 1.5 · Expected 1.6 · Used in QM five-star
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 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · 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	5.0%	3.3% 1.7 pts worse	3.3% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.5% · Q3 6.6% · Q4 4.8% · 4Q avg 5.0% · Used in QM five-star
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 · Q1 0.0% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9%
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · Q1 6.0% · Q2 4.2% · Q3 6.1% · Q4 5.9% · 4Q avg 5.6%
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 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 0.7% · 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	4.6%	15.4% 10.8 pts better	16.3% 11.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 4.6% · Used in QM five-star
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 · Q1 21.7% · Q2 10.6% · Q3 0.0% · Q4 4.0% · 4Q avg 8.9% · 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 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star
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 · Q1 11.2% · Q2 7.4% · Q3 10.1% · Q4 4.7% · 4Q avg 8.3%
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 · Q1 7.6% · Q2 7.8% · Q3 9.1% · Q4 4.4% · 4Q avg 7.2% · Used in QM five-star
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 · Q1 99.5% · Q2 99.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8%
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 · Adjusted 10.0% · Observed 10.1% · Expected 11.4% · Used in QM five-star
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 · Q1 0.7% · Q2 0.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
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 · 4Q avg 98.4%
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 · Adjusted 22.1% · Observed 23.0% · Expected 24.7% · Used in QM five-star

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