Willowbend Nursing And Rehabilitation Center

Penalties

• Jan 17, 2024 — Fine ($16,801)
• Nov 3, 2023 — Fine ($7,446)
• Sep 15, 2023 — Fine ($46,168)

Inspection findings

1. Jan 22, 2026 Health · 17 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Feb 12, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Feb 12, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Feb 12, 2026 · CMS health inspection

   • 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 Feb 12, 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 Feb 12, 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 Feb 12, 2026 · CMS health inspection

   • Not serious Scope/severity E

     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.

     Corrected Feb 12, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Feb 12, 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 Feb 12, 2026 · CMS health inspection

   • Not serious Scope/severity E

     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 Feb 12, 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 Feb 12, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 12, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0926 Environmental Deficiencies

     Have policies on smoking.

     Corrected Feb 12, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0223 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.

     Corrected Jan 30, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Jan 30, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Jan 30, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0347 Smoke Deficiencies

     Properly provide smoke detection systems in areas open to corridors.

     Corrected Mar 5, 2026 · CMS fire safety

2. Nov 20, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Nov 21, 2025 · CMS health inspection

3. Sep 5, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     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 Nov 21, 2025 · CMS health inspection

4. Mar 25, 2025 Health · 3 findings
   • Not serious Scope/severity D 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 17, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Apr 17, 2025 · CMS health inspection

   • Not serious Scope/severity D 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.

     Corrected Apr 17, 2025 · CMS health inspection

5. Feb 7, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Mar 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Mar 5, 2025 · CMS health inspection

6. Oct 16, 2024 Health · 9 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 Nov 7, 2024 · CMS health inspection

   • Not serious Scope/severity D 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.

     Corrected Nov 7, 2024 · 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 Nov 7, 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 Nov 7, 2024 · CMS health inspection

   • Not serious Scope/severity D

     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 Oct 17, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Oct 17, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Oct 17, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

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

     Corrected Oct 17, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Oct 17, 2024 · CMS fire safety

7. Jan 17, 2024 Health · 2 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 Dec 18, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 18, 2023 · CMS health inspection

8. Nov 3, 2023 Health · 2 findings
   • 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 Sep 15, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Nov 30, 2023 · CMS health inspection

9. Sep 15, 2023 Fire Safety · 14 findings
   • Not serious Scope/severity C

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Oct 6, 2023 · CMS fire safety

   • Serious Scope/severity J

     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 Oct 6, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Oct 6, 2023 · 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 Oct 6, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0347 Smoke Deficiencies

     Properly provide smoke detection systems in areas open to corridors.

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

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

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Oct 6, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Oct 6, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 02/09/2007
• DAHESHPOUR, SEPEHR — adp of the snf, NOT APPLICABLE, since 03/01/2025
• DAHESHPOUR, SEPEHR — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• DAHESHPOUR, SEPEHR — managing control - governing body, NOT APPLICABLE, since 03/01/2025
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• NICCUM, KEVIN — adp of the snf, NOT APPLICABLE, since 03/01/2007
• NICCUM, KEVIN — operational/managerial control, NOT APPLICABLE, since 03/01/2007
• NICCUM, KEVIN — managing control - governing body, NOT APPLICABLE, since 03/01/2007
• TAYLOR, STEPHEN — corporate officer, NOT APPLICABLE, since 07/01/2025
• CARETRUST GP LLC — adp of the snf, NOT APPLICABLE, since 03/01/2007
• CARETRUST REIT INC — adp of the snf, NOT APPLICABLE, since 03/01/2007
• CTR PARTNERSHIP LP — adp of the snf, NOT APPLICABLE, since 03/01/2007
• EASTLAND MEMORIAL HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 02/20/2015
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 03/01/2007
• MESQUITE HEALTH HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 03/01/2007
• TOWN EAST HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 02/20/2015
• TOWN EAST HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 08/12/2025