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Complaint Investigation

Willowbend Nursing And Rehabilitation Center

Inspection Date: September 5, 2025
Total Violations 1
Facility ID 675272
Location MESQUITE, TX
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Inspection Findings

F-Tag F0584

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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.

Based on observation, interview, and record review the facility failed to ensure a safe and decent living environment for one (Common Area) of 2 common areas reviewed for decent living environment. The facility failed to ensure Medication Aide A did not speak loudly and inappropriately while on a personal call around a group of residents in the common area on 09/04/2025. This failure could place residents at risk for

a less peaceful and decent living environment. Findings included: In an observation on 09/04/25 at 3:12 PM, Medication Aide A could be heard down the hallway speaking loudly. Medication Aide A was observed as she stood at the medication cart near a common area and a nurse's station, with two residents in her immediate area, and seven additional residents that sat in the common area watching television.

Medication Aide A was observed as she spoke on her personal cellphone, and she stated, I am so livid I could punch them in the face. Medication Aide A was observed for 2 additional minutes before she looked around and exited the building through a side door. In an interview on 09/04/25 at 3:45 PM, Medication Aide A stated she was not talking on the phone long, turned around, saw the Surveyor, and then walked outside. She stated she might have said something about punching someone in the face. Medication Aide A stated the call was about her family member. She stated she was not talking about any residents.

Medication Aide A stated the risk of taking a phone call and the manner of the phone call was a resident would think she was talking about them. In an interview on 09/05/25 at 12:11 PM, The DON stated all staff were not allowed to take personal calls on the floor. She stated all staff were aware of that rule. The DON stated Medication Aide A did talk loudly most of the time. The DON stated the risk of the staff taking personal, loud phone calls was it would violate the resident's right to have peace in their home. In an

interview on 09/05/25 at 12:35 PM, the Assistant Administrator stated the DON spoke and in-serviced Medication Aide A yesterday regarding their personal phone policy. He stated Medication Aide A was disciplined. The Assistant Administrator stated the risk of staff taking personal phone calls and speaking in

a certain manner on the phone calls was concerns with dignity of a resident and a violation of their right to feel safe. The Assistant Administrator stated some residents might have PTSD, and that particular phone call could have disrupted residents with that diagnosis. The Assistant Administrator stated personal phone calls should have been avoided. Record review of the facility's undated policy titled, Your Rights and Protections as a Nursing Home Resident, reflected the following: Be Treated with Respect: You have the right to be treated with dignity and respect, as wellas make your own schedule and participate in the activities you choose.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

WILLOWBEND NURSING AND REHABILITATION CENTER in MESQUITE, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MESQUITE, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WILLOWBEND NURSING AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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