Woodlands Place Rehabilitation Suites

Penalties

• Apr 18, 2024 — Fine ($109,954)

Inspection findings

1. Feb 26, 2026 Health · 11 findings
   • Not serious Scope/severity E

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Mar 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Mar 13, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Mar 13, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Mar 2, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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 Mar 10, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 2, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 2, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0919 Environmental Deficiencies

     Make sure that a working call system is available in each resident's bathroom and bathing area.

     Corrected Mar 15, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Mar 20, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Mar 20, 2026 · CMS fire safety

2. Dec 23, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0551 Resident Rights Deficiencies

     Give the resident's representative the ability to exercise the resident's rights.

     Corrected Dec 28, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Jan 28, 2026 · CMS health inspection

3. Oct 22, 2025 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     CMS health inspection

4. Dec 5, 2024 Fire Safety · 10 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 12, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jan 6, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Dec 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jan 5, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Dec 6, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Dec 10, 2024 · CMS fire safety

5. Apr 18, 2024 Health · 3 findings
   • Serious Scope/severity J Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Apr 19, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Apr 19, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0777 Administration Deficiencies

     Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

     Corrected Apr 19, 2024 · CMS health inspection

6. Nov 16, 2023 Health · 8 findings
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Dec 16, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Dec 15, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Dec 16, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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 Dec 16, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0790 Quality of Life and Care Deficiencies

     Provide routine and 24-hour emergency dental care for each resident.

     Corrected Dec 16, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 16, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Dec 16, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Dec 16, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• FORMAN, MURRAY — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 04/08/2025
• GARVIN, CLIFFORD — operational/managerial control, NOT APPLICABLE, since 08/01/2024
• GARVIN, CLIFFORD — adp of the snf, NOT APPLICABLE, since 08/01/2024
• SANDERSON, CLARK — corporate officer, NOT APPLICABLE, since 08/01/2024
• WALKER, BARRY — adp of the snf, NOT APPLICABLE, since 08/01/2024
• DENISON LONG TERM CARE, LLC — operational/managerial control, NOT APPLICABLE, since 08/01/2024
• FANNIN COUNTY HOSPITAL AUTHORITY — 5% or greater direct ownership interest, 100%, since 08/01/2024
• FUNDAMENTAL ADMINISTRATIVE SERVICES LLC — adp of the snf, NOT APPLICABLE, since 08/01/2024
• FUNDAMENTAL CLINICAL AND OPERATIONAL SERVICES, LLC — adp of the snf, NOT APPLICABLE, since 08/01/2015