Cycle 1
Health 2025-02-27 · Fire 2025-02-27
11 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Abilene, TX
Willowcreek Rehab And Nursing
2-star overall rating with 2-star inspections with $23,744 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4934 S 7th St, Abilene, TX
(325) 692-2172
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
68
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-05-20
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
0.51
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.69
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.71
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.43
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,936
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
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
4.40
Baseline 74.14% · Performance 50.00% · Measure score 4.40 · Achievement 3.35 · Improvement 4.40
Adjusted total nurse staffing
0
Baseline 3.50 hours · Performance 2.93 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.12% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 7.32% · Lower 95% interval 6.98% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.83% |
95.27%
0.6 pts better
|
Numerator 46 · Denominator 48 |
| Falls with major injury | 2.08% |
0.77%
1.3 pts worse
|
Numerator 1 · Denominator 48 |
| Discharge self-care score | 51.85% |
53.69%
1.8 pts worse
|
Numerator 14 · Denominator 27 |
| Discharge mobility score | 37.04% |
50.94%
13.9 pts worse
|
Numerator 10 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 48 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.54% |
8.2%
6.7 pts worse
|
Numerator 1 · Denominator 65 |
| Staff flu vaccination coverage | 61.36% |
42%
19.4 pts better
|
Numerator 54 · Denominator 88 |
| Discharge function score | 48.15% |
56.45%
8.3 pts worse
|
Numerator 13 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 7 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.6 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.0 · 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 | 5.1% |
3.3%
1.8 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 3.3% · Q3 5.5% · Q4 4.9% · 4Q avg 5.1% · 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 1.8% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
3.3%
1.3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
18.9%
4.7 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 11.8% · Q3 13.5% · Q4 17.5% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
10.8%
4.7 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.3% · Q3 7.1% · Q4 6.5% · 4Q avg 6.1% · 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 | 12.2% |
15.4%
3.2 pts better
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 4.9% · Q3 12.6% · Q4 15.5% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
16.1%
0.5 pts better
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 17.4% · Q3 12.0% · Q4 18.2% · 4Q avg 15.6% · 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 | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
15.0%
4.4 pts worse
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 26.2% · Q3 12.1% · Q4 14.1% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.2%
0.9 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.9% · Q3 4.7% · Q4 4.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
89.7%
4.5 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 88.2% · Q4 94.4% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
12.0%
6.6 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 6.4% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
88.0%
5.8 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
25.9%
1.8 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 27.7% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-10 · Fire 2024-01-10
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-11-10 · Fire 2022-11-10
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-27
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-03-07
F · Potential for more than minimal harm
2025-02-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-02-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-02-27
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 2025-03-07
E · Potential for more than minimal harm
2025-02-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-07
F · Potential for more than minimal harm
2024-01-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-07
F · Potential for more than minimal harm
2024-01-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-07
E · Potential for more than minimal harm
2024-01-10
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 2024-02-07
E · Potential for more than minimal harm
2024-01-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-07
C · Minimal harm
2022-11-10
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-01-06
C · Minimal harm
2022-11-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-06
Inspection history
Recent health citations
E · 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 2026-01-12
E · Potential for more than minimal harm
2025-04-30
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 2025-05-12
D · Potential for more than minimal harm
2025-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-12
K · Immediate jeopardy
2025-02-27
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 2025-02-28
E · Potential for more than minimal harm
2025-02-27
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-27
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-27
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-27
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 2025-02-28
D · Potential for more than minimal harm
2025-02-27
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-27
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 2025-02-28
E · Potential for more than minimal harm
2024-01-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-07
E · Potential for more than minimal harm
2024-01-10
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 2024-02-07
E · Potential for more than minimal harm
2024-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-07
D · Potential for more than minimal harm
2024-01-10
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 2024-02-07
D · Potential for more than minimal harm
2024-01-10
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 2024-02-07
D · Potential for more than minimal harm
2023-09-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-12
E · Potential for more than minimal harm
2022-11-10
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 2022-12-13
D · Potential for more than minimal harm
2022-11-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-12-13
D · Potential for more than minimal harm
2022-11-10
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 2022-12-13
Penalties and ownership
What sits behind the stars
$23,744
2025-02-27
Fine
Fine · fine $23,744
Fine
Ownership
Childress County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Evergreen Holdco LLC
Operational/Managerial Control · Organization
Gold Tx Trust
Operational/Managerial Control · Organization
Holcomb, Holly
Corporate Officer · Individual
Silberstein, Ari
Operational/Managerial Control · Individual
Silver Tx Trust
Operational/Managerial Control · Organization
Stratton, Emilee
Corporate Officer · Individual
Willowcreek Rehab And Nursing LLC
Operational/Managerial Control · Organization
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