Cycle 1
Health 2025-12-19 · Fire 2025-12-19
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Clifton, TX
Willow Park Rehabilitation Health Care Center
1-star overall rating with 1-star inspections with abuse icon flag with $64,431 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1000 Fm 3220, Clifton, TX
(254) 675-2828
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexion Health
Operator or chain grouping
Approved since
1995-09-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 3 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.35
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
0.35
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,868
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.74
Baseline 53.33% · Performance 48.39% · Measure score 3.74 · Achievement 3.74 · Improvement 1.24
Adjusted total nurse staffing
1.34
Baseline 3.65 hours · Performance 3.46 hours · Measure score 1.34 · Achievement 1.34 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 103 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 97 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · 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 | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
97.1%
3.9 pts worse
|
93.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 93.8% · Q3 85.2% · Q4 96.2% · 4Q avg 93.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.2% |
97.9%
4.7 pts worse
|
95.5%
2.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.3%
0.8 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 3.7% · Q4 3.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
3.3%
1.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 0.0% · Q3 3.1% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
18.9%
7.1 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 28.1% · Q3 23.9% · Q4 21.5% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.3% |
10.8%
16.5 pts worse
|
16.7%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 25.6% · Q3 29.3% · Q4 31.1% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 3.7% |
0.0%
3.7 pts worse
|
0.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.7% · Q3 3.7% · Q4 3.8% · 4Q avg 3.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.3% |
15.4%
12.9 pts worse
|
16.3%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 31.5% · Q3 10.1% · Q4 36.2% · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.2% |
16.1%
17.1 pts worse
|
14.9%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 32.0% · Q3 24.1% · Q4 46.3% · 4Q avg 33.2% · 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 | 17.8% |
15.0%
2.8 pts worse
|
19.8%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 16.6% · Q3 18.3% · Q4 17.6% · 4Q avg 17.8% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.2%
2.1 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.8% · Q3 3.9% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.5% |
89.7%
32.2 pts worse
|
81.7%
24.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.0% · Q2 48.8% · Q3 55.0% · Q4 61.4% · 4Q avg 57.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.5%
2 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.1% |
88.0%
28.9 pts worse
|
79.7%
20.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-27 · Fire 2024-09-27
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-07-27 · Fire 2023-07-27
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-10
F · Potential for more than minimal harm
2024-09-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-09-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-28
F · Potential for more than minimal harm
2024-09-27
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-09-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-25
Inspection history
Recent health citations
K · Immediate jeopardy
2025-12-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-20
E · Potential for more than minimal harm
2025-12-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-12-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-12-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-12-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-12-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-12-19
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 2025-12-20
D · Potential for more than minimal harm
2025-12-19
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 2025-12-20
D · Potential for more than minimal harm
2025-12-19
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 2025-12-20
D · Potential for more than minimal harm
2025-12-19
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-12-19
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-12-20
D · Potential for more than minimal harm
2025-12-19
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 2025-12-20
D · Potential for more than minimal harm
2025-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-20
J · Immediate jeopardy
2025-07-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-07-10
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 2025-07-11
D · Potential for more than minimal harm
2024-10-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-10-21
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 2024-10-22
J · Immediate jeopardy
2024-09-27
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-09-28
F · Potential for more than minimal harm
2024-09-27
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 2024-09-28
D · Potential for more than minimal harm
2024-09-27
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 2024-09-28
D · Potential for more than minimal harm
2024-09-27
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 2024-09-28
D · Potential for more than minimal harm
2024-09-27
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 2024-09-28
E · Potential for more than minimal harm
2023-07-27
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 2023-08-04
E · Potential for more than minimal harm
2023-07-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-07-27
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-07-21
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 2023-08-22
Penalties and ownership
What sits behind the stars
$43,670
2025-12-19
Fine
Fine · fine $43,670
Fine
$0
2025-12-19
Payment Denial
Payment Denial · denial start 2026-01-28 · 13 days
13 day denial
$12,740
2025-07-10
Fine
Fine · fine $12,740
Fine
$8,021
2024-09-27
Fine
Fine · fine $8,021
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Fallon, John
Operational/Managerial Control · Individual
Kirley, Francis
Operational/Managerial Control · Individual
Lee, Brian
Operational/Managerial Control · Individual
Mak, David
Corporate Officer · Individual
Munden, Kimberly
Operational/Managerial Control · Individual
Munden, Kimberly
W-2 Managing Employee · Individual
Nexion Health At Clifton, Inc.
Operational/Managerial Control · Organization
Oswald, John
Operational/Managerial Control · Individual
Pierce, Daniel
Corporate Officer · Individual
Riner, Meera
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sunset Home
Clifton, TX
3-star overall rating with 3-star inspections with $14,020 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
The Hilltop On Main
Meridian, TX
2-star overall rating with 3-star inspections with $29,243 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Whitney Nursing And Rehabilitation Center
Whitney, TX
1-star overall rating with 2-star inspections with $45,435 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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