Cycle 1
Health 2024-10-07 · Fire 2024-10-07
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Lawton, OK
Willow Park Health Care Center
1-star overall rating with 1-star inspections with $58,171 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
7019 Northwest Cache Road, Lawton, OK
(580) 536-1279
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
151
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Southwest Ltc
Operator or chain grouping
Approved since
2003-04-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 4 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
0.20
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.01
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.23
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
60%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,582
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.40
Baseline 24.90% · Performance 23.40% · Measure score 1.40 · Achievement 0 · Improvement 1.40
Healthcare-associated infections
1.97
Baseline 9.30% · Performance 8.24% · Measure score 1.97 · Achievement 0 · Improvement 1.97
Total nurse turnover
0
Baseline 79.31% · Performance 78.99% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.26
Baseline 3.35 hours · Performance 3.44 hours · Measure score 1.26 · Achievement 1.26 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.83% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 15.79% · Lower 95% interval 8.13% |
| Discharge to community | 46.39% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 38.3% · Lower 95% interval 35.51% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 83.64% |
95.27%
11.6 pts worse
|
Numerator 46 · Denominator 55 |
| Falls with major injury | 5.45% |
0.77%
4.7 pts worse
|
Numerator 3 · Denominator 55 |
| Discharge self-care score | 51.85% |
53.69%
1.8 pts worse
|
Numerator 14 · Denominator 27 |
| Discharge mobility score | 40.74% |
50.94%
10.2 pts worse
|
Numerator 11 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 55 · Adjusted rate 1.56% |
| Healthcare-associated infections requiring hospitalization | 8.24% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 14.71% · Lower 95% interval 4.97% |
| Staff COVID-19 vaccination coverage | 15.13% |
8.2%
6.9 pts better
|
Numerator 18 · Denominator 119 |
| Staff flu vaccination coverage | 0.65% |
42%
41.4 pts worse
|
Numerator 1 · Denominator 155 |
| Discharge function score | 37.04% |
56.45%
19.4 pts worse
|
Numerator 10 · Denominator 27 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.3
About the same
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 3.3 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
2.9
0.4 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 4.3 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 52.9% |
90.3%
37.4 pts worse
|
93.4%
40.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 36.8% · Q3 59.1% · Q4 91.3% · 4Q avg 52.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.3% |
94.6%
6.3 pts worse
|
95.5%
7.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
4.5%
1.3 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.9% · Q3 1.5% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
3.3%
3.3 pts worse
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 1.6% · Q3 4.9% · Q4 12.5% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
3.6%
0.4 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.8% · Q3 3.9% · Q4 1.9% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
25.3%
3.5 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 25.0% · Q3 31.5% · Q4 33.3% · 4Q avg 28.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
18.6%
0.2 pts better
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 17.1% · Q3 16.1% · Q4 15.6% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
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 | 23.6% |
15.5%
8.1 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 29.0% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
14.1%
3.3 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 18.5% · Q3 21.7% · Q4 13.5% · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
2.1%
0.3 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.9% · Q3 1.3% · Q4 3.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.8%
0.6 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.1% · Q3 3.2% · Q4 1.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
17.8%
0.2 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 23.5% · Q3 6.8% · Q4 14.4% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.1%
0.1 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.4% · Q3 6.4% · Q4 6.5% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.2% |
75.0%
27.8 pts worse
|
81.7%
34.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 57.1% · Q2 40.6% · Q3 38.8% · Q4 57.1% · 4Q avg 47.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
17.1%
1.9 pts better
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 21.9% · Expected 16.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.9%
0.8 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 4.2% · Q4 4.8% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.5% |
74.0%
19.5 pts worse
|
79.7%
25.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
27.0%
0.2 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 37.5% · Expected 32.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-08 · Fire 2023-08-08
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-18 · Fire 2022-11-18
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-14
E · Potential for more than minimal harm
2022-11-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-11-18
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2022-12-26
C · Minimal harm
2022-11-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-12-26
C · Minimal harm
2022-11-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-26
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-22
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 2026-01-23
J · Immediate jeopardy
2026-01-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-05-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-15
J · Immediate jeopardy
2024-10-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-10-07
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-10-07
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 2024-10-14
E · Potential for more than minimal harm
2024-10-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-10-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-11
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-09-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-07
E · Potential for more than minimal harm
2023-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-08
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-08
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-08
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 2023-09-25
D · Potential for more than minimal harm
2023-08-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-08
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-09-25
E · Potential for more than minimal harm
2022-11-18
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 2022-12-26
E · Potential for more than minimal harm
2022-11-18
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 2022-12-26
E · Potential for more than minimal harm
2022-11-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-12-26
Penalties and ownership
What sits behind the stars
$17,630
2026-01-22
Fine
Fine · fine $17,630
Fine
$40,541
2024-09-11
Fine
Fine · fine $40,541
Fine
Ownership
Southwest Ltc Oklahoma Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Brashier, Craig
5% Or Greater Indirect Ownership Interest · Individual
Payne, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Payne, Ronald
Operational/Managerial Control · Individual
Quality Care Givers Inc
5% Or Greater Indirect Ownership Interest · Organization
Ronald R Payne Pc
5% Or Greater Direct Ownership Interest · Organization
Ronald R Payne Pc
5% Or Greater Indirect Ownership Interest · Organization
Ronald R Payne Pc
Operational/Managerial Control · Organization
Southwest Ltc Management Services, LLC
Operational/Managerial Control · Organization
Southwest Ltc, Ltd
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Montevista Rehabilitation And Skilled Care
Lawton, OK
1-star overall rating with 2-star inspections with $27,782 in total fines with 8 recent health deficiencies
#2
Mcmahon-Tomlinson Nursing Center
Lawton, OK
1-star overall rating with 2-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Lawton Post Acute & Rehab
Lawton, OK
1-star overall rating with 1-star inspections with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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