Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holland Lake Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
The facility failed to fully implement a comprehensive, person-centered care planning process. An RN administered antihypertensive medications to a resident despite physician-ordered hold parameters based on SBP and HR, relying on personal judgment rather than the written orders and the existing HTN care plan. For four other residents with complex conditions such as CVA with hemiplegia, dementia, bipolar disorder, diabetes, and major depressive disorder, their comprehensive care plans lacked documented admission goals, desired outcomes, discharge plans, discharge assessments, and any assessment or documentation of preferences or potential for future discharge or desire to return to the community. Interviews with leadership and the SW confirmed that discharge planning was expected to be included in the care plans but had not been documented as required.
A resident with multiple comorbidities, including HTN, diabetes, atrial fibrillation, and leukemia, had physician orders for Amlodipine and Metoprolol with specific hold parameters based on SBP and HR. On one occasion, the MAR showed the resident’s SBP and HR were below the ordered thresholds, yet an RN administered both antihypertensive medications, stating she relied on nursing judgment and anticipated therapy would increase the vital signs. The resident later reported feeling cold but otherwise believed medications were given correctly. Facility leadership and nursing staff acknowledged that parameters exist for a reason and that medications must be administered in accordance with physician orders and the facility’s medication administration policy.
Two residents received care from staff who failed to follow proper hand hygiene and glove-changing protocols. An LVN did not change soiled gloves or perform hand hygiene during urostomy care, while a CNA failed to wash hands and change gloves after cleaning fecal matter during incontinence care. Both staff members acknowledged the lapses, and the facility's infection control policy requires hand hygiene at key points during care.
The facility failed to ensure proper storage of nebulizer equipment for three residents, risking infection and equipment damage. Observations revealed that nebulizer masks and tubing were not bagged as required by facility policy. The residents involved had varying degrees of cognitive impairment and respiratory conditions, and their equipment was found either touching the floor or hanging without a bag.
A treatment cart on Hall 200 was left unlocked and unattended, containing various medications and supplies, posing a risk of unauthorized access. The State Surveyor observed the issue, and the DON had to lock the cart after being informed. The facility's policy requires carts to be locked when not in use or out of view, which was not followed in this case.
A facility failed to accurately document a resident's code status, leading to a discrepancy between a DNR order in the electronic health record and a Full Code status in the care plan. Interviews revealed communication errors and reliance on incorrect documentation methods, with staff using different sources to verify code status.
Failure to Implement Physician Orders and Document Person-Centered Discharge Planning in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents, as required by its Comprehensive Care Planning policy. For one male resident with multiple diagnoses including type 2 diabetes, right femur fracture, hypertension, kidney disorder, leukemia, atrial fibrillation, and muscle wasting, the care plan identified potential complications related to hypertension and directed staff to administer antihypertensive medications as ordered and observe for side effects. Physician orders for amlodipine and metoprolol included specific hold parameters based on systolic blood pressure (SBP) and heart rate (HR). Despite these parameters, the MAR showed that on a date when the resident’s BP was 109/52 and HR was 53, the RN administered both medications contrary to the hold orders. In an interview, the RN stated she used her nursing judgment instead of following the physician’s orders, explaining that the resident’s blood pressure was “borderline” and that upcoming therapy and exertion might increase his BP and HR. She acknowledged she should have contacted the physician before giving the medications. This demonstrated a failure to implement the existing comprehensive care plan interventions and physician orders as written for that resident’s hypertension management. For four additional residents, record review of their comprehensive care plans showed no documented discharge plans or discharge assessments, despite their varied and significant medical and psychosocial conditions. These residents had diagnoses including metabolic encephalopathy, hemiplegia/hemiparesis following cerebrovascular events, cerebral infarction, narcolepsy, depression, type 2 diabetes, spinal stenosis, bipolar disorder, emphysema, atrial fibrillation, dementia, atherosclerotic heart disease, cognitive communication deficit, major depressive disorder, nontraumatic subdural hemorrhage, and bilateral foot amputations. Interviews with these residents reflected that some were unsure about staying or recognized they could not live on their own, but the care plans did not document their goals for admission, desired outcomes, preferences, or potential for future discharge, nor whether a desire to return to the community had been assessed. Interviews with the ADON, DON, and SW confirmed that discharge planning was expected to be part of the care plan and that the SW was responsible for documenting it, but it was either assumed to be covered under psychosocial well-being or had not yet been entered into the care plans.
Failure to Follow Antihypertensive Medication Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured medications were administered according to physician orders and established parameters for one resident. The resident was an adult male admitted in early January 2026 with multiple diagnoses, including type 2 diabetes, a right femur fracture, hypertension, kidney and ureter disorder, leukemia, atrial fibrillation, and muscle wasting and atrophy. Physician orders dated 1/26/2026 directed that Amlodipine 10 mg be given once daily by mouth for hypertension, to be held if systolic blood pressure (SBP) was less than 110, and that Metoprolol Tartrate 100 mg be given twice daily by mouth for hypertension, to be held if heart rate (HR) was less than 55 and/or SBP was less than 100. Review of the MAR showed that on 4/7/2026 the resident’s blood pressure was 109/52 and HR was 53, yet the RN administered both Amlodipine and Metoprolol despite the hold parameters in the physician orders. In interviews, the resident reported he believed he received his medications correctly and had no issues with them, noting only that he felt cold. The RN stated she was trained in medication administration and acknowledged administering the antihypertensive medications on that date, explaining she used her nursing judgment instead of following the physician’s hold parameters because she considered the blood pressure “borderline” and anticipated that therapy and the effort of getting up would raise the resident’s blood pressure and HR. She stated she should have contacted the physician before giving the medications. The LVN, ADON, and DON all confirmed that nurses were trained in medication administration and that parameters were in place for a reason, and they described that not following such parameters could cause dizziness, hypotension, inability to stand, fainting, falls, or the resident feeling cold. Review of the facility’s “Administering Medications” policy dated December 2012 stated that medications must be administered in a safe and timely manner and in accordance with orders, including any required time frames, which was not followed in this instance.
Failure to Follow Hand Hygiene and Glove Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during resident care. During urostomy care for a 90-year-old male resident with a history of urinary tract infection, neuromuscular bladder dysfunction, muscle weakness, and Alzheimer's disease, an LVN did not change gloves or perform hand hygiene after her gloves became visibly soiled. She continued to handle clean supplies and complete the procedure with the same soiled gloves, only washing her hands after the care was finished. The LVN acknowledged during interview that she should have performed hand hygiene and changed gloves before handling clean items, attributing her lapse to nervousness. In a separate incident, a CNA providing incontinence care to an 81-year-old female resident with neuromuscular bladder dysfunction, urinary retention, and dementia, failed to wash his hands before donning gloves and did not change gloves or perform hand hygiene after cleaning fecal matter. The CNA continued care with visibly soiled gloves, placed a clean brief on the resident, and exited the room without washing his hands. During interview, the CNA admitted to not following proper infection control practices and noted a lack of recent infection control training, especially for night shift staff. The facility's Director of Nursing confirmed awareness of infection control concerns and stated that infection control training is provided at hire and annually, with periodic spot checks and return demonstrations. The facility's hand hygiene policy requires staff to perform hand hygiene at specific times, including when hands are visibly soiled and after contact with residents with infectious diarrhea. Despite these policies, staff failed to adhere to required infection control practices during resident care.
Failure to Properly Store Nebulizer Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not ensuring that their nebulizer masks and tubing were stored in a bag when not in use. This oversight was observed during a survey, where the nebulizer equipment for the residents was found either touching the floor or hanging on a hook without being bagged. The facility's policy requires that nebulizer equipment be stored in a plastic bag marked with the date and resident's name between uses to prevent infection and damage. Resident #11, a female with severe cognitive impairment and a history of asthma, was observed with her nebulizer equipment on the bedside table with tubing touching the floor. Resident #13, who is cognitively intact and has Chronic Obstructive Pulmonary Disease, had her nebulizer mouthpiece hanging on a hook without a bag. Resident #14, a male with severe cognitive impairment and a history of heart failure, was also found with his nebulizer equipment on the bedside table without being bagged. The Director of Nursing confirmed that the expectation was for staff to bag the equipment to prevent infection and damage.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured and stored in locked compartments, as observed with the treatment cart on Hall 200. The cart was left unlocked in the hallway beside room 216, with no staff members or residents in view. The State Surveyor noted this and informed the Administrator, who acknowledged the issue and promised to address it. However, upon a subsequent observation, the cart remained unlocked, and the Director of Nursing (DON) had to lock it upon being informed by the surveyor. The Wound Care Nurse, upon being informed by the DON, acknowledged that the cart should be locked to prevent unauthorized access to medications. The cart contained various prescription and non-prescription topical creams and dressing supplies, which could pose a risk if accessed by residents. The facility's policy on medication cart security was reviewed, revealing that the cart should be locked at all times when not in use or out of the nurse's view, which was not adhered to in this instance.
Inaccurate Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's advance directive preferences were accurately documented and maintained, leading to a discrepancy in the resident's code status. Specifically, Resident #297 was documented as having a Do Not Resuscitate (DNR) order in the electronic health record, while the care plan and other documentation indicated a Full Code status. This inconsistency was discovered during a review of the resident's records, which revealed a lack of evidence for an Out of Hospital Do Not Resuscitate Order (OOH-DNR) form, progress notes related to the DNR status, and other necessary documentation. Interviews with facility staff, including the Director of Nursing (DON) and the Social Worker (SW), highlighted communication errors and reliance on incorrect documentation methods. The DON admitted to misunderstanding a text message from the SW, leading to the incorrect entry of a DNR order for Resident #297. The SW confirmed that the resident was a Full Code and did not have a DNR status or consent form. The lack of a clear and consistent process for verifying and documenting code status was evident, as staff relied on different sources, such as a book at the nurse's station and electronic charting, which contributed to the confusion.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Weatherford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Fe Health & Rehabilitation Center | 0.2 mi | ★★★★★ | 3 | 0 |
| Hilltop Park Rehabilitation And Care Center | 0.2 mi | ★★★★★ | 17 | 0 |
| College Park Rehabilitation And Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Peach Tree Place | 1.3 mi | ★★★★★ | 8 | 5 |
| Avir At Keeneland | 2.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.