Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WILLOWBEND NURSING AND REHABILITATION CENTER
MESQUITE, TX · 162 certified beds · Last Life Safety survey January 22, 2026
CMS Certification Number 675272 · first certified March 1994
Ownership
Operated by THE ENSIGN GROUP · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TX
20 citations — more than 94% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens March 2027 — about 5 months from now. This facility’s last Life Safety survey was January 2026. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 20 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0926 Have policies on smoking.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 20 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 15, 2023 | 11 |
| October 16, 2024 | 5 |
| January 22, 2026 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-10-16 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2024-10-16 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 2 | 2026-01-22 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2026-01-22 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2024-10-16 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2023-09-15 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2023-09-15 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2023-09-15 |
What the citations cover
- Smoke Deficiencies 9
- Egress Deficiencies 5
- Services Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Egress Deficiencies | 5 |
| Services Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 22, 2026 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (January 30, 2026) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (January 30, 2026) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (January 30, 2026) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (March 5, 2026) |
October 16, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 17, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 17, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 17, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 17, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 17, 2024) |
September 15, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (October 6, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.