Cycle 1
Health 2025-04-09 · Fire 2025-04-09
8 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Willow Park, TX
Willow Park Rehabilitation And Care Center
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
300 Crowne Point Blvd, Willow Park, TX
(817) 757-1200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2014-09-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
2.21
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
0.77
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.61
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.51
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
2.00
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
2.20
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
80%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,527
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.09% · Performance 23.74% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.62
Baseline 7.44% · Performance 7.35% · Measure score 1.62 · Achievement 1.62 · Improvement 0
Total nurse turnover
0
Baseline 71.91% · Performance 73.33% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.09 hours · Performance 3.02 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 9.35% · Lower 95% interval 6.76% |
| Discharge to community | 48.85% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 43.59% · Lower 95% interval 40.9% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.33% |
95.27%
1.9 pts worse
|
Numerator 84 · Denominator 90 |
| Falls with major injury | 1.11% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 90 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 25 · Denominator 50 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 30 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 8.89% |
2.29%
6.6 pts worse
|
Numerator 8 · Denominator 90 · Adjusted rate 8.64% |
| Healthcare-associated infections requiring hospitalization | 7.35% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 7.69% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 8.93% |
8.2%
0.7 pts better
|
Numerator 10 · Denominator 112 |
| Staff flu vaccination coverage | 3.7% |
42%
38.3 pts worse
|
Numerator 5 · Denominator 135 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 32 · Denominator 50 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 31 · Denominator 32 |
| Transfer of health information to patient | 96.67% |
96.28%
0.4 pts better
|
Numerator 29 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 53.85% |
25.2%
28.7 pts better
|
Numerator 14 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
97.1%
1.5 pts worse
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 95.6% · Q3 100.0% · Q4 100.0% · 4Q avg 95.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
97.9%
0.8 pts worse
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.3%
0.1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 7.9% · Q4 3.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
2.7%
0.2 pts worse
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.0% · Q3 3.2% · Q4 3.6% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
3.3%
2.9 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 10.5% · Q3 5.8% · Q4 4.0% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.8% |
18.9%
20.9 pts worse
|
19.6%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.6% · Q2 46.6% · Q3 38.9% · Q4 33.3% · 4Q avg 39.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
10.8%
0.9 pts worse
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 12.1% · Q3 11.1% · Q4 15.2% · 4Q avg 11.7% · 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 | 27.2% |
15.4%
11.8 pts worse
|
16.3%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.6% |
16.1%
20.5 pts worse
|
14.9%
21.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 35.6% · Q3 58.3% · Q4 22.7% · 4Q avg 36.6% · 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 | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.2% |
15.0%
2.8 pts better
|
19.8%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 18.9% · Q3 4.9% · Q4 4.7% · 4Q avg 12.2% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.2%
0.3 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 2.2% · Q3 3.5% · Q4 2.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.4% |
89.7%
17.3 pts worse
|
81.7%
9.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 66.3% · Q3 91.5% · Q4 95.3% · 4Q avg 72.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
12.0%
3.1 pts worse
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 14.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.4% |
88.0%
28.6 pts worse
|
79.7%
20.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
25.9%
4.2 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 22.2% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
10 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-12-15 · Fire 2022-12-15
6 health deficiencies
Top issue: Nursing and Physician Services (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
2025-04-09
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-20
F · Potential for more than minimal harm
2024-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-15
F · Potential for more than minimal harm
2024-02-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-15
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-03-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
F · Potential for more than minimal harm
2025-05-23
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-05-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-22
D · Potential for more than minimal harm
2025-04-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
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 2025-05-09
D · Potential for more than minimal harm
2024-10-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-29
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-29
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-12-10
B · Minimal harm
2024-10-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-02-15
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-15
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 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
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 2024-03-15
E · Potential for more than minimal harm
2023-09-07
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 2023-10-13
F · Potential for more than minimal harm
2022-12-15
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 2023-01-20
E · Potential for more than minimal harm
2022-12-15
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-15
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-15
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2023-01-20
C · Minimal harm
2022-12-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-20
Penalties and ownership
What sits behind the stars
Ownership
Bacus, Randy
Corporate Officer · Individual
Parker County Hospital District
Operational/Managerial Control · Organization
Ticknor Enterprises Willow Park LLC
Operational/Managerial Control · Organization
Ticknor, Gregory
Operational/Managerial Control · Individual
Wahrman, Chad
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
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
#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
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
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