Cycle 1
Health 2025-07-24 · Fire 2025-07-24
18 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Shepherd, TX
Woodland Park Nursing & Rehab
1-star overall rating with 1-star inspections with $61,325 in total fines with 18 recent health deficiencies
101 Woodland Park Dr, Shepherd, TX
(936) 628-3388
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
48
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Gulf Coast Ltc Partners
Operator or chain grouping
Approved since
1995-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 2 overall / 3 health / 2 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
Staffing
Hours and turnover
RN hours / resident day
0.22
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.21
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
0.23
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,163
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.57% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 9.65% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.42
Performance 33.33% · Measure score 7.42 · Achievement 7.42 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.41
Baseline 3.47 hours · Performance 3.76 hours · Measure score 2.41 · Achievement 2.41 · Improvement 0.79
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.33% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 16.67% · Lower 95% interval 7.88% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95% |
95.27%
0.3 pts worse
|
Numerator 19 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 10% |
2.29%
7.7 pts worse
|
Numerator 2 · Denominator 20 · Adjusted rate 9.84% |
| Healthcare-associated infections requiring hospitalization | 9.65% |
7.12%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 21.43% · Lower 95% interval 4.8% |
| Staff COVID-19 vaccination coverage | 26% |
8.2%
17.8 pts better
|
Numerator 13 · Denominator 50 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · 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 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 3.2 |
2.1
1.1 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
97.1%
1.3 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 93.8% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
97.9%
About the same
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 0.6% |
2.7%
2.1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 11.5% |
3.3%
8.2 pts worse
|
5.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 10.8% · Q3 10.8% · Q4 12.5% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.5% |
18.9%
7.6 pts worse
|
19.6%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 28.9% · Q3 22.0% · Q4 27.9% · 4Q avg 26.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.0% |
10.8%
3.2 pts worse
|
16.7%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 15.4% · Q3 15.4% · Q4 13.3% · 4Q avg 14.0% · 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 | 14.9% |
15.4%
0.5 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
16.1%
2.9 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 21.6% · Q3 15.8% · Q4 17.5% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.5%
0.5 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 1.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 14.7% |
0.8%
13.9 pts worse
|
1.7%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 13.6% · Q3 16.7% · Q4 22.2% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.0% |
15.0%
3 pts better
|
19.8%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 8.4% · Q3 10.9% · Q4 12.1% · 4Q avg 12.0% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
4.2%
1.5 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 8.5% · Q3 8.2% · Q4 3.6% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.8% |
89.7%
0.9 pts worse
|
81.7%
7.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 77.8% · Q4 76.2% · 4Q avg 88.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
12.0%
1.9 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 12.8% · Expected 14.1% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
25.9%
1.4 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 23.1% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-12 · Fire 2024-06-12
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-10 · Fire 2023-05-10
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-06-12
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 2024-07-25
E · Potential for more than minimal harm
2024-06-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-29
D · Potential for more than minimal harm
2023-05-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-10
Inspection history
Recent health citations
K · Immediate jeopardy
2025-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-08
J · Immediate jeopardy
2025-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-08
G · Actual harm
2025-07-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-07-24
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-07-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-07-24
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 2025-08-08
E · Potential for more than minimal harm
2025-07-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-07-24
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-07-24
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 2025-08-08
E · Potential for more than minimal harm
2025-07-24
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-24
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 2025-08-08
D · Potential for more than minimal harm
2025-07-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-24
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 2025-08-08
J · Immediate jeopardy
2025-04-24
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 2025-04-25
J · Immediate jeopardy
2025-04-24
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 2025-04-25
D · Potential for more than minimal harm
2025-04-24
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-04-25
D · Potential for more than minimal harm
2024-07-15
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 2024-07-16
G · Actual harm
2024-06-12
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 2024-06-13
F · Potential for more than minimal harm
2024-06-12
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-13
D · Potential for more than minimal harm
2024-06-12
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 2024-06-13
F · Potential for more than minimal harm
2023-05-10
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-06-05
E · Potential for more than minimal harm
2023-05-10
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-05-24
E · Potential for more than minimal harm
2023-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-24
E · Potential for more than minimal harm
2023-05-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-05-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-05-10
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-05-10
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 2023-05-24
D · Potential for more than minimal harm
2023-05-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-05-11
J · Immediate jeopardy
2023-05-07
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 2023-05-08
Penalties and ownership
What sits behind the stars
$29,100
2025-07-24
Fine
Fine · fine $29,100
Fine
$12,415
2024-06-12
Fine
Fine · fine $12,415
Fine
$19,810
2023-05-07
Fine
Fine · fine $19,810
Fine
$0
2023-05-07
Payment Denial
Payment Denial · denial start 2023-06-01 · 4 days
4 day denial
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bergeron, Bobby
Operational/Managerial Control · Individual
Murrell, Edward
Corporate Officer · Individual
Nicholson, Louis
Operational/Managerial Control · Individual
Shepherd Ltc Partners Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Cleveland Health Care Center
Cleveland, TX
4-star overall rating with 4-star inspections with $30,198 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Timberwood Nursing and Rehabilitation Center
Livingston, TX
3-star overall rating with 3-star inspections with $8,021 in total fines with 7 recent health deficiencies
#3
The Bradford At Brookside
Livingston, TX
4-star overall rating with 4-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out