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Complaint Investigation

Woodland Park Nursing & Rehab

April 24, 2025 · Shepherd, TX · 101 Woodland Park Dr
Citations 4
CMS Rating 1/5
Beds 100
Provider ID 675484
Healthcare Facility
Woodland Park Nursing & Rehab
Shepherd, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Woodland Park Nursing & Rehab in Shepherd, TX — inspection on April 24, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0644
Coordinate assessments with the pre-admission screening and resident review program; and referring

guidelines of the PASRR process for Long Term Care 11.

Notify physicians and obtain orders for

submission of the IDT form.

675484 04/24/2025

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

actions that can be measured.

minimal harm Deficiency Text Not Available

675484 04/24/2025

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift.

She said she

assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN.

She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift.

She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN.

She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift.

She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls.

The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed on 04/24/25 at 02:50 p.m.

The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies.

675484

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 675484 B.

Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Park Nursing & Rehab 101 Woodland Park Dr Shepherd, TX 77371

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Shepherd, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Woodland Park Nursing & Rehab or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.