Woodland Park Nursing & Rehab
101 Woodland Park Dr, Shepherd, TX 77371 · San Jacinto County · 100 certified beds · avg 58 residents/day · certified since May 9, 1995
Part of chain: GULF COAST LTC PARTNERS (20 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jul 24, 2025 · F-0880
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 8, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jul 24, 2025 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 8, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 24, 2025 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 8, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 24, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 25, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 12, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 13, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (32)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 10, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jul 24, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 24, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 24, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jul 24, 2025 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jul 24, 2025 | E · Potential for harm, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jul 24, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jul 24, 2025 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Jul 24, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 24, 2025 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Jul 24, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 24, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 24, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jul 24, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 24, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 24, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 24, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Apr 24, 2025 | C · Minimal risk, facility-wide | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jul 15, 2024 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Jun 12, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 12, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jun 12, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 12, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 10, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| May 10, 2023 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| May 10, 2023 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 10, 2023 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| May 10, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 10, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| May 10, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 10, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 15).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 0 | F |
| 2024 | 5 | 1 | G ▲ |
| 2025 | 18 | 4 | K ▲ |
| 2026 | 1 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $31,330.
| Date | Type | Amount / length |
|---|---|---|
| Jul 24, 2025 | Fine | $18,915 |
| Jun 12, 2024 | Fine | $12,415 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.23 | 3.46 | 3.95 | bottom 42% in Texas; bottom 23% in the U.S. |
| Registered Nurse hours | 0.17 | 0.44 | 0.69 | bottom 4% in Texas; bottom 2% in the U.S. |
| Weekend total nurse staffing | 2.98 | 3.04 | 3.50 | top 43% in Texas; bottom 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.18 | 0.34 | 0.48 | bottom 17% in Texas; bottom 10% in the U.S. |
| Total nursing staff turnover (%) | 57.4 | 55.3 | 45.8 | bottom 38% in Texas; bottom 20% in the U.S. |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.94, RN 0.16, weekend 2.71. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 3/5 · short-stay residents: 2/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bergeron, Bobby | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/15/2024 |
| Graham, Alan | Individual | ADP of the SNF | NOT APPLICABLE | 01/21/2008 |
| Kazigo, Nakizito | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Murrell, Edward | Individual | Corporate Officer | NOT APPLICABLE | 01/15/2024 |
| Nicholson, Louis | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/15/2024 |
| Shepherd KTFW, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/15/2024 |
| Shepherd LTC Partners INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/15/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Cleveland Health Care Center | 10.9 mi | Cleveland, TX | ★★★☆☆ | 3/5 | |
| Timberwood Nursing and Rehabilitation Center | 12.4 mi | Livingston, TX | ★★★★☆ | 3/5 | |
| The Bradford at Brookside | 17.7 mi | Livingston, TX | ★★★☆☆ | 4/5 | |
| Pine Ridge Health Care LLP | 19.4 mi | Livingston, TX | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675484.