The Vardell Report.Willowbend Nursing and Rehabilitation Center

Across 10 inspections from September 2023 to August 2026, state surveyors documented 32 findings at Willowbend Nursing and Rehabilitation Center; 31 have a recorded correction and 1 awaits one; CMS lists 2 enforcement actions in the window.

Inspections

10

2023–2026, complaint and standard

Findings

32

Deficiencies cited by state inspectors

Corrected

31

Of 32 findings, with a recorded correction date

Penalties

2

2 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 282026

   Complaint investigation

   1 finding

   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jan 222026

   Standard health inspection

   13 findings

   • F583Keep residents' personal and medical records private and confidential.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Feb 12, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Feb 12, 2026
   • F926Have policies on smoking.Level DNo actual harm, potential for moreCorrected Feb 12, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Nov 202025

   Complaint investigation

   1 finding

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Nov 21, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Sep 52025

   Complaint investigation

   1 finding

   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Nov 21, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Mar 252025

   Complaint investigation

   3 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Apr 17, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 17, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 17, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Feb 72025

   Complaint investigation

   2 findings

   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Mar 5, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 5, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Oct 162024

   Standard health inspection

   4 findings

   The same visit included a complaint investigation.

   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Nov 7, 2024
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Nov 7, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 7, 2024
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Nov 7, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Jan 172024

   Complaint investigation

   2 findings

   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level JImmediate jeopardyCorrected Dec 18, 2023
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Dec 18, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Nov 32023

   Complaint investigation

   2 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Sep 15, 2023
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Nov 30, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Sep 152023

    Standard health inspection

    3 findings

    • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Oct 6, 2023
    • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Oct 6, 2023
    • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Oct 6, 2023

    Enforcement Action

    Civil money penalty, $7,446 imposed November 3, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 15, 2023, the nearest before the penalty date.

    Enforcement Action

    Civil money penalty, $16,801 imposed January 17, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 15, 2023, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in October 2024, September 2025 and January 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424252525252626F584 across all 10 inspections, oldest to newest
2. 2

   Accident Hazards and Supervision, Cited in Three Inspections

   Inspectors cited F689 in October 2024, March 2025 and January 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424252525252626F689 across all 10 inspections, oldest to newest
3. 3

   Telling Families About Changes, Cited in Two Inspections

   Inspectors cited F580 in January 2024 and March 2025. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424252525252626F580 across all 10 inspections, oldest to newest
4. 4

   Protection From Abuse and Neglect, Cited in Two Inspections

   Inspectors cited F600 in September 2023 and November 2023. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424252525252626F600 across all 10 inspections, oldest to newest
5. 5

   Reporting Suspected Abuse, Cited in Two Inspections

   Inspectors cited F609 in February 2025 and November 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424252525252626F609 across all 10 inspections, oldest to newest
6. 6

   Pharmacy Services, Cited in Two Inspections

   Inspectors cited F755 in September 2023 and January 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424252525252626F755 across all 10 inspections, oldest to newest
7. 7

   Medication Labeling and Storage, Cited in Two Inspections

   Inspectors cited F761 in October 2024 and January 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424252525252626F761 across all 10 inspections, oldest to newest
8. 8

   Kitchen and Food Safety, Cited in Two Inspections

   Inspectors cited F812 in October 2024 and January 2026. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23232424252525252626F812 across all 10 inspections, oldest to newest
9. 9

   Infection Control, No Recorded Correction

   F880 was cited in January 2026 and August 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.

   23232424252525252626F880 across all 10 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in three inspections, most seriously at level E.

2. 02

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in three inspections, most seriously at level E.

3. 03

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in two inspections, most seriously at level J.

4. 04

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in two inspections, most seriously at level J.

5. 05

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in two inspections, most seriously at level D.

6. 06

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in two inspections, most seriously at level D.

7. 07

   How are medications stored and secured, and who checks the medication carts?

   Medication Labeling and Storage: cited in two inspections, most seriously at level E.

8. 08

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in two inspections, most seriously at level E.

9. 09

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in two inspections, most seriously at level E. The August 28, 2026 citation has no recorded correction date.

10. 10

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

11. 11

    What led to the 2024 fine, and has it been paid?

    A $16,801 civil money penalty was imposed January 17, 2024. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Texas state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Sep 15, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Nov 3, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Jan 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Oct 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Feb 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Mar 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Sep 5, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Nov 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Jan 22, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Texas state survey agency

  Inspection Aug 28, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 675272

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.