Willowbend Nursing and Rehabilitation Center
2231 Highway 80 E, Mesquite, TX 75150 · Dallas County · 162 certified beds · avg 131 residents/day · certified since Mar 1, 1994
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jan 17, 2024 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 18, 2023 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Jan 17, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 18, 2023 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Nov 3, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 15, 2023 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Sep 15, 2023 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 6, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (31)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 22, 2026 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
| Jan 22, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jan 22, 2026 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jan 22, 2026 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 22, 2026 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 22, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 22, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 22, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jan 22, 2026 | D · Potential for harm, one-off | The facility did not have policies on smoking. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 25, 2025 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Mar 25, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Mar 25, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Feb 7, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 16, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Oct 16, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Oct 16, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 16, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 3, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 3, 2023 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Sep 15, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Sep 15, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Sep 15, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 13).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 2 | J ▲ |
| 2024 | 6 | 2 | J ▲ |
| 2025 | 7 | 0 | E |
| 2026 | 13 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $70,415.
| Date | Type | Amount / length |
|---|---|---|
| Jan 17, 2024 | Fine | $16,801 |
| Nov 3, 2023 | Fine | $7,446 |
| Sep 15, 2023 | Fine | $46,168 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.49 | 3.46 | 3.95 | top 35% in Texas; bottom 36% in the U.S. |
| Registered Nurse hours | 0.27 | 0.44 | 0.69 | bottom 20% in Texas; bottom 7% in the U.S. |
| Weekend total nurse staffing | 3.11 | 3.04 | 3.50 | top 33% in Texas; bottom 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.35 | 0.34 | 0.48 | top 34% in Texas; bottom 43% in the U.S. |
| Total nursing staff turnover (%) | 52.9 | 55.3 | 45.8 | bottom 48% in Texas; bottom 30% in the U.S. |
| RN turnover (%) | 40.0 | 54.6 | 42.9 | top 30% in Texas; top 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.51, RN 0.27, weekend 3.13. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Eastland Memorial Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 02/20/2015 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 02/09/2007 |
| Caretrust GP LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Caretrust Reit INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Ctr Partnership LP | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Daheshpour, Sepehr | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2025 |
| Daheshpour, Sepehr | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Daheshpour, Sepehr | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Mesquite Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Niccum, Kevin | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2007 |
| Niccum, Kevin | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2007 |
| Niccum, Kevin | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2007 |
| Taylor, Stephen | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2025 |
| Town East Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/20/2015 |
| Town East Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 08/12/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Edgewood Rehabilitation and Care Center | 1.0 mi | Mesquite, TX | ★★★★☆ | 4/5 | |
| Palomino Place | 1.3 mi | Mesquite, TX | ★★☆☆☆ | 2/5 | abuse |
| Mesquite Village Wellness & Rehabilitation | 1.6 mi | Mesquite, TX | ★★★☆☆ | 3/5 | |
| Town East Rehabilitation and Healthcare Center | 1.7 mi | Mesquite, TX | ★☆☆☆☆ | 1/5 | abuse |
| Christian Care Communities and Services Mesquite | 3.0 mi | Mesquite, TX | ★★★★☆ | 3/5 | |
| Cheyenne Medical Lodge | 3.0 mi | Mesquite, TX | ★★★★★ | 4/5 | |
| Mesquite Tree Nursing Center | 3.0 mi | Mesquite, TX | ★★★★☆ | 3/5 | |
| Le Reve Rehabilitation & Memory Care | 4.2 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | abuse |
| Golden Acres Living and Rehabilitation Center | 4.5 mi | Dallas, TX | ★★★☆☆ | 3/5 | |
| Balch Springs Nursing Home | 5.2 mi | Balch Springs, TX | ★★☆☆☆ | 1/5 | |
| Advanced Health & Rehab Center of Garland | 5.7 mi | Garland, TX | ★☆☆☆☆ | 1/5 | |
| Villages of Lake Highlands | 7.1 mi | Dallas, TX | ★★☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675272.