01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-22 | 15 | 2026-01-22 | 4 |
| Cycle 2 | 2024-10-16 | 9 | 2024-10-16 | 5 |
| Cycle 3 | 2023-09-15 | 7 | 2023-09-15 | 11 |
CMS CCN 6752722026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Willowbend Nursing And Rehabilitation Center
2231 Highway 80 E · Mesquite, TX 75150 · Dallas County
Certified beds162CMS provider file
Recent citation rows51current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
51 rows in the current release
4 rows carry G–L scope/severity codes; 4 carry J–L. 13 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-22 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0583Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0695Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · HEALTHF0926Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Have policies on smoking.
Correction field: Deficient, Provider has date of correction · 2026-02-122026-01-22 · FIREK0223Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2026-01-302026-01-22 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2026-01-302026-01-22 · FIREK0341Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2026-01-302026-01-22 · FIREK0347Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly provide smoke detection systems in areas open to corridors.
Correction field: Deficient, Provider has date of correction · 2026-03-052025-11-20 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-11-21 · complaint2025-09-05 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-11-21 · complaint2025-03-25 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-17 · complaint2025-03-25 · HEALTHF0686Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-04-17 · complaint2025-03-25 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-04-17 · complaint2025-02-07 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2025-03-05 · complaint2025-02-07 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-03-05 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-01-17 | Fine | $16,801 | 0 |
| 2023-11-03 | Fine | $7,446 | 0 |
| 2023-09-15 | Fine | $46,168 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- EASTLAND MEMORIAL HOSPITAL DISTRICTOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 02/20/2015
- DAHESHPOUR, SEPEHRIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 03/01/2025
- NICCUM, KEVINIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 03/01/2007
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/09/2007
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- TAYLOR, STEPHENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2025
- TOWN EAST HEALTHCARE, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/20/2015
- DAHESHPOUR, SEPEHRIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2025
- NICCUM, KEVINIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2007
- CARETRUST GP LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2007
- CARETRUST REIT INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2007
- CTR PARTNERSHIP LPOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2007
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2007
- MESQUITE HEALTH HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/01/2007
- TOWN EAST HEALTHCARE, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 08/12/2025
- DAHESHPOUR, SEPEHRIndividual · ADP OF THE SNFNOT APPLICABLE · since 03/01/2025
- NICCUM, KEVINIndividual · ADP OF THE SNFNOT APPLICABLE · since 03/01/2007
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.51per resident day
RN hours0.27per resident day
Weekend nurse hours3.13per resident day
Staff turnover52.9%CMS reported field
06 / LOCAL RECORDS
Open the Mesquite ledger →Other published facilities nearby
Cheyenne Medical Lodge139 beds · CMS overall 5/527 citation rowsChristian Care Communities And Services Mesquite180 beds · CMS overall 4/523 citation rowsEdgewood Rehabilitation And Care Center142 beds · CMS overall 4/524 citation rowsMesquite Tree Nursing Center143 beds · CMS overall 4/543 citation rowsMesquite Village Wellness & Rehabilitation149 beds · CMS overall 3/527 citation rowsPalomino Place120 beds · CMS overall 2/535 citation rowsTown East Rehabilitation And Healthcare Center130 beds · CMS overall 1/541 citation rows