Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowbend Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to immediately report and investigate a family member's concerns about a resident's care, including multiple falls, a change in condition, and additional rib fractures found at the hospital. Despite internal communication of the complaint, the required external reporting to authorities and investigation were not completed, in violation of abuse and neglect reporting regulations.
A medication aide was observed speaking loudly on a personal cellphone near a medication cart and common area, making an inappropriate statement within earshot of multiple residents. This conduct violated facility policy prohibiting personal calls on the floor and disrupted the peace and dignity of residents, as confirmed by the DON and Assistant Administrator.
Three residents with or at risk for pressure ulcers did not receive care consistent with professional standards, including missed weekly wound measurements and failure to reposition as required by care plans and physician orders. Observations and interviews confirmed that residents were left lying flat for extended periods without appropriate offloading or turning, and staff did not consistently follow prescribed interventions.
A resident with moderate cognitive impairment and renal issues was transferred to the hospital for dehydration and acute renal failure, but only a voicemail was left for a friend listed as the second emergency contact, without specifying the hospital. The primary emergency contact (POA) was not notified, and both the POA and friend were unaware of the resident's location, leading to police involvement to locate the resident. Facility staff confirmed that notification procedures were not followed according to policy.
A CNA failed to provide adequate supervision and assistance to a dependent resident with severe cognitive impairment and physical disabilities during a shower, resulting in a fall. The CNA attempted to reposition the resident alone by pulling on a mechanical lift sling while the resident was soapy and unable to support herself, causing the resident to slide out of the shower chair. Facility staff confirmed that two staff members were required for such tasks and that the CNA was alone at the time.
A CNA was accused of being rough with a resident during a transfer, but the facility failed to suspend the CNA pending investigation, contrary to its abuse prevention policy. The resident, who was severely cognitively impaired, denied feeling abused. Despite the policy requiring immediate suspension, the CNA was only moved to a different hall, potentially placing other residents at risk.
A facility failed to report an alleged abuse incident involving a resident to the state agency within the required timeframe. The incident involved a resident reportedly transferred roughly by a CNA. Despite the family member's report, the ADM did not notify the state agency, believing it was unnecessary since the resident did not confirm the abuse. This was contrary to the facility's policy, which requires reporting all allegations of abuse.
The facility's kitchen failed to meet food safety standards, with issues such as unlabeled and undated food items, including sliced cheese, diced peppers, and dialysis meal bags. A container labeled as flour contained expired sugar. The Dietary Manager and Cook acknowledged the importance of proper labeling to prevent foodborne illness, but the facility lacked a specific food storage policy.
The facility failed to provide a clean and homelike environment for several residents, as evidenced by unsanitary conditions in their bathrooms and shower rooms. A resident with anxiety-related diagnoses reported her bathroom was dirty, with observations confirming various stains and substances. Another resident, at risk for falls, lacked a shower curtain, leading to water spreading during showers. Additional residents expressed dissatisfaction with cleanliness, and observations revealed unsanitary conditions in shared bathrooms and shower rooms. Staff interviews indicated daily cleaning was insufficient, and the Housekeeping Supervisor did not view the unclean environment as a risk.
A resident with moderate cognitive impairment and multiple medical conditions was found using a significantly rusted and deteriorated bedside commode, which had been in disrepair since her admission two years prior. Facility staff acknowledged the issue but had not received any prior complaints, and there was no proactive maintenance policy in place.
The facility failed to secure medications in one of its medication rooms, leaving it unlocked and unattended. LVN E admitted to forgetting to close the door, which did not lock automatically. The room contained various medications, including those for diabetes and high blood pressure. Staff interviews confirmed the expectation that medication rooms remain locked to prevent unauthorized access and potential harm.
Failure to Timely Report Alleged Neglect and Injuries
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported immediately, but not later than two hours after the allegation was made, as required by regulation. Specifically, the facility did not report a family member's (FM) concern regarding the care of a resident who had experienced multiple falls and a change in condition. The FM expressed concerns to facility staff about the resident's care, including the timeliness of response to a possible stroke and the presence of additional rib fractures identified at the hospital. Despite these concerns being communicated to the social worker, assistant director of nursing (ADON), and later to the director of nursing (DON) and administrator, the facility did not report the allegations to the State Survey Agency or initiate an investigation as required by their own policy and federal regulations. The resident in question was an elderly male with severe cognitive impairment, a history of falls, and multiple comorbidities including atrial fibrillation, renal insufficiency, urinary tract infection, diabetes, cerebrovascular accident, malnutrition, and muscle weakness. He was dependent on staff for most activities of daily living and had experienced two falls with injury (not major) since admission. On the day of the incident, the resident exhibited right-sided weakness and difficulty feeding himself, prompting the nurse to notify the physician and arrange for hospital transfer for possible stroke evaluation. The FM later reported to staff that the hospital had found additional rib fractures, raising concerns about the adequacy of care and fall prevention in the facility. Interviews with facility staff revealed that the FM's complaints were communicated internally but not reported externally as required. The DON and administrator both stated that they did not believe the situation constituted neglect or required reporting, and no investigation was initiated. The facility's abuse and neglect policy mandates immediate reporting of all allegations to the administrator and appropriate agencies, but this protocol was not followed in this case. The failure to report and investigate the FM's concerns about the resident's care and injuries constituted a deficiency in the facility's compliance with abuse and neglect reporting requirements.
Staff Loud Personal Call Disrupts Resident Environment and Dignity
Penalty
Summary
Medication Aide A was observed speaking loudly on her personal cellphone near a medication cart, in proximity to a nurse's station and a common area where two residents were nearby and seven additional residents were watching television. During the call, Medication Aide A made an inappropriate statement, saying, 'I am so livid I could punch them in the face.' This behavior was audible down the hallway and continued for approximately two minutes before the aide exited the building through a side door. The aide later confirmed in an interview that she was on a personal call regarding a family member and acknowledged that her manner of speaking could have led residents to believe she was referring to them. Facility leadership, including the DON and Assistant Administrator, confirmed that staff are not permitted to take personal calls on the floor and that all staff are aware of this policy. The DON noted that Medication Aide A typically speaks loudly, and both the DON and Assistant Administrator recognized that such conduct could disrupt the peace and dignity of residents, potentially affecting those with PTSD. The facility's policy emphasizes residents' rights to dignity, respect, and a peaceful environment, which were not upheld in this instance.
Failure to Provide Consistent Pressure Ulcer Care and Repositioning
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards of practice for pressure ulcer management and prevention for three residents. Specifically, two residents with existing pressure ulcers did not have their wounds measured during weekly skin assessments as required by facility policy. This omission was confirmed through record reviews and interviews, with the Director of Nursing (DON) acknowledging that wound measurements were not consistently obtained, making it difficult to determine wound progression. Additionally, three residents were not consistently repositioned or turned according to their care plans, physician orders, and facility policy. Multiple observations showed that residents remained lying flat in bed for extended periods without repositioning or the use of pillows to offload pressure, despite care plans and orders specifying repositioning every two hours. Staff interviews revealed inconsistent adherence to turning schedules, with some staff relying solely on air mattresses or reporting that residents did not like to be turned, rather than following prescribed interventions. The residents involved had significant risk factors for pressure ulcers, including immobility, cognitive impairment, and comorbidities such as diabetes, malnutrition, and obesity. One resident was dependent on staff for all mobility, another was in a persistent vegetative state, and another had multiple wounds develop during their stay. The facility's own policy required weekly wound measurements and regular repositioning to prevent and manage pressure injuries, but these standards were not met, as evidenced by the lack of documentation and direct observations.
Failure to Notify Responsible Party and Emergency Contacts of Resident Hospital Transfer
Penalty
Summary
The facility failed to properly notify the responsible party and emergency contacts regarding a resident's transfer to the hospital for dehydration and acute renal failure. The resident, who had moderate cognitive impairment and a history of dehydration, malnutrition, and renal insufficiency, was transferred to the hospital following a physician's order. Documentation showed that only the resident's friend, listed as the second emergency contact, was notified via voicemail, which did not include the name of the hospital to which the resident was sent. The resident's Power of Attorney (POA), who was listed as the primary emergency contact on the face sheet, was not notified of the transfer or the resident's location. The friend who received the voicemail was also not informed of the hospital's name and had to visit the facility and subsequently contact the police to locate the resident. The facility staff eventually determined the resident had been transferred from one hospital to another, but this information was not communicated to the responsible parties in a timely manner. Interviews with facility staff, including the RN involved and the DON, confirmed that the POA should have been notified first, and that the lack of notification could prevent the responsible party from making necessary decisions for the resident. The facility's policy required notification of family or responsible party in the event of a change in condition, but this was not followed in this instance, as evidenced by the lack of timely and complete communication to the resident's POA and emergency contacts.
Failure to Provide Adequate Supervision During Resident Shower Results in Fall
Penalty
Summary
A certified nursing assistant (CNA) failed to provide adequate supervision and assistance to a resident with severe cognitive impairment and physical disabilities during a shower, resulting in a fall. The resident, who had dementia, a cognitive communication deficit, and an absence of the right foot, was totally dependent on staff for bathing and required two staff members for repositioning in the shower, as documented in her care plan. During the incident, the CNA attempted to reposition the resident alone by tugging on the mechanical lift sling while the resident was soapy and unable to support herself, causing the resident to slide out of the shower chair and onto the floor. No other staff were present in the shower room at the time, and the CNA called for assistance only after the fall occurred. Interviews with facility staff confirmed that the expectation was for two staff members to assist with repositioning residents in the shower when using a mechanical lift, and that staff should not pull on the sling to reposition residents due to the risk of falls. The CNA acknowledged being alone during the incident and attempting to reposition the resident without assistance. The incident was documented in the resident's progress notes, and the facility's policy emphasized the need for adequate supervision and assistance to prevent accidents.
Failure to Suspend CNA Following Abuse Allegation
Penalty
Summary
The facility failed to implement its own written abuse and neglect prevention policy and procedure for a resident reviewed for abuse and neglect. The incident involved a certified nursing assistant (CNA) who was accused by a family member of being rough with a resident during a transfer from a chair to a bed. Despite the allegation, the CNA was not immediately suspended pending investigation, as required by the facility's policy. Instead, the CNA was moved to a different hall and continued to work with other residents. The resident involved was an elderly male with a history of cerebrovascular disease, muscle weakness, and other medical conditions. At the time of the incident, the resident was severely cognitively impaired but able to express himself and understand others. The family member reported that the CNA was rough during the transfer, and the resident almost fell off the bed. However, when interviewed, the resident denied feeling abused or experiencing any pain. The facility's policy required the immediate suspension of any employee involved in an allegation of abuse, neglect, or exploitation pending investigation. However, the Director of Nursing (DON) and the Administrator (ADM) did not suspend the CNA because the resident did not confirm the alleged abuse. The Clinical Resource Nurse later confirmed that the facility's policy was to suspend the staff member involved immediately, highlighting a failure to follow established procedures, which could place other residents at risk of abuse.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the state agency within the required two-hour timeframe. The incident involved a resident who was reportedly transferred in a rough manner by a CNA, with allegations of being kicked and thrown onto the bed. The resident, a male with severe cognitive impairment and multiple medical conditions, was dependent on staff for transfers. Despite the family member's report of the incident, the facility's administration did not notify the state agency as required by their policy. The Assistant Director of Nursing (ADON) was informed of the alleged abuse by the resident's family member and conducted an assessment of the resident, finding no visible injuries or distress. The ADON reported the incident to the Administrator (ADM) and the Director of Nursing (DON), who then interviewed the resident. The resident did not confirm feeling abused or neglected, and the CNA involved was reassigned to a different hall. However, the ADM did not report the incident to the state agency, believing it was unnecessary since the resident did not confirm the abuse. The facility's policy on abuse prevention requires that all allegations of abuse, neglect, or exploitation be reported to the appropriate state or federal agencies within specified timeframes. The ADM's decision not to report the incident was based on the resident's response, which was contrary to the facility's policy. This failure to report placed residents at risk of continued abuse, trauma, and psychosocial harm, as the alleged abuse was not properly investigated or addressed by external authorities.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Several deficiencies were noted, including improper labeling and dating of food items. Specifically, a storage bag containing sliced cheese was found without a use-by date or content description. Additionally, a package of diced peppers and five supplemental meal bags intended for dialysis patients were not labeled with dates or contents. Furthermore, a container labeled as flour was found to contain sugar, which was past its use-by date. During an interview, the Dietary Manager (DM) acknowledged the oversight, stating that she usually ensures items are labeled with received and use-by dates. She admitted that the cheese was repackaged without her knowledge and that the sugar should have been discarded. The DM also identified the unlabeled vegetables as peppers and committed to labeling them. She expressed concern about the potential for foodborne illness and contamination, acknowledging the importance of proper labeling to prevent negative effects on residents. The Cook, when interviewed, confirmed his understanding of the need for correct labeling and proper storage of food. He emphasized the importance of providing high-quality food to residents to prevent illness. The facility administrator later revealed that there was no specific food storage policy in place, and they followed the Texas Food Establishment Rules, which do not specify requirements for labeling and dating food items. The U.S. FDA Food Code, however, outlines the necessity for labeling and dating food to ensure safety and compliance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, as observed in the conditions of their bathrooms and shower rooms. Resident #80, a female with moderately impaired cognition and anxiety-related diagnoses, reported her bathroom was dirty. Observations confirmed brown splatters and smudges on the grab bar and wall, a white chalky substance on the floor, and dark dried substances near the toilet. Resident #75, a male with intact cognition and a risk for falls, stated his shower curtain was removed a year ago and never replaced, leading to water spreading during showers. His bathroom also had dried liquid on the walls, a large wet spot on the floor, and a black substance around the shower edges. Resident #41, with moderately impaired cognition and a history of stroke, expressed dissatisfaction with the cleanliness of his room and bathroom, which had urine in the toilet and stains on the wall. Resident #84, also with moderately impaired cognition and at risk for falls, shared similar concerns about cleanliness. Observations of their shared bathroom revealed stains and substances on the walls and trim. Additionally, two shower rooms on Redwood Hall were found to have black and orange residues, with one room having a large brown splatter on a cabinet. Interviews with staff, including a CNA and the Housekeeping Supervisor, indicated that bathrooms were supposed to be cleaned daily, but sometimes required more frequent cleaning due to multiple users. The Housekeeping Supervisor acknowledged the need for deep cleaning but did not consider the unclean environment a risk to residents. The ADM confirmed the responsibility of the Housekeeping Supervisor for monitoring cleanliness and emphasized the importance of a clean environment for residents' comfort.
Failure to Maintain Safe Assistive Devices
Penalty
Summary
The facility failed to ensure that all assistive devices were maintained and free of hazards, specifically concerning the bedside commode used by a resident. The resident, who has moderate cognitive impairment and several medical conditions including dementia and peripheral vascular disease, was observed using a bedside commode that was in significant disrepair, with extensive rusting and paint loss on all metal bars. The resident reported that the commode had been in this condition since her admission to the facility approximately two years ago, but she had not reported it as she was unaware she could do so. Despite the commode's poor condition, the resident did not report any injuries from its use. Interviews with facility staff revealed a lack of proactive maintenance checks on equipment such as bedside commodes, with the maintenance department relying on nursing staff to report issues. The maintenance supervisor and other staff acknowledged the commode's poor condition and the potential risk it posed, but no prior complaints had been recorded. The facility did not have a specific policy for maintenance and equipment repair, relying instead on staff to submit maintenance requests when issues arose.
Medication Room Security Breach
Penalty
Summary
The facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents in one of the four medication rooms reviewed. Specifically, the medication room for Whispering Way was found unlocked and unattended on multiple occasions. During an observation, it was noted that the room contained various medications, including those for diabetes, high blood pressure, and high cholesterol, as well as a pneumonia vaccine. LVN E admitted to leaving the medication room unlocked, stating that she forgot to pull the door closed, and acknowledged that the door did not close automatically. Interviews with staff, including LVN E, RN F, and the DON, confirmed that the medication room should always remain locked to prevent unauthorized access and potential harm. The facility's policy, revised in July 2023, mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel. The failure to adhere to this policy could result in unauthorized access to medications, posing a risk of harm or drug diversion.
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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 Mesquite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewood Rehabilitation And Care Center | 1 mi | — | 2 | 0 |
| Palomino Place | 1.3 mi | — | 11 | 0 |
| Mesquite Village Wellness & Rehabilitation | 1.6 mi | — | 0 | 0 |
| Town East Rehabilitation And Healthcare Center | 1.7 mi | — | 5 | 1 |
| Christian Care Communities And Services Mesquite | 3 mi | — | 1 | 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 August 2026) and official state health department websites.