Health inspection·November 20, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for neglect allegations. The facility failed to ensure they reported the FM's concern about the care Resident #1 received at this Nursing Facility. This failure could place all residents at risk if the facility did not follow the HHSC guidelines for reporting allegations resulting in the residents having emotional turmoil and decreased health and psycho-social well-being.Findings included: Record review of Resident #1's admission MDS Assessment, dated 09/13/25, revealed, a [AGE] year old male who admitted [DATE] with a BIMS score of 07 (Severe cognitive impairment). He used a walker and wheelchair for mobility and was dependent on dressing. He needed supervision/ touching assistance with eating, oral and personal hygiene. He needed substantial/maximal assistance with showers and toileting and partial assistance with sitting and standing and transfers. He was occasionally incontinent and not rated for bowel movement. He had diagnoses of atrial fibrillation, renal insufficiency, UTI, DM, CVA, malnutrition, muscle weakness, fatigue, repeated falls, difficulty walking, unsteadiness on feet, other speech/language deficits following CVD, constipation and disorientation. He had rare pain occasionally and had a fall within the last six months prior to admission. And he had two falls since admission with injury except major. Record review of Resident #1's Care Plan, dated 09/11/25, revealed he was at risk for impaired cognitive function or impaired thought processes, at risk for infection related to UTI during recent hospitalization, at risk for ADL self-care performance deficit related to disorientation: CVA Bell's palsy, AMS, UTI, at risk for falls related to history of falls, multiple falls during recent hospitalization, multiple falls during stay with the FM, muscle weakness, unsteadiness on feet fatigue, repeated falls, at risk for pain related to rib fracture, complaints of rib pain during recent hospitalization, at risk for has urinary infection and at risk for altered cardiovascular status related to cardiac pacemaker placement, at risk for atrial fibrillation, at risk for CVA. And at risk for renal insufficiency. Record review of Resident #1's Nurses note dated 09/14/25 at 12:32 pm by LVN C revealed, Resident continues on follow up for PO (by mouth) antibiotic Cefdinir 300 mg (milligram) 1 cap (capsule) for UTI. No adverse drug effects noted. Resident is tolerating the medication well. Continues on fall follow up Day 2/3. Resident is awake, alert and oriented x 2. No s/sx (signs and symptoms) of SOB (Shortness of breath), distress or pain voiced. No delayed injuries. Fall precautions in place, bed in the lowest position, fall mat at bedside. Call light and bed remote within reach. Record review of Resident #1's Nurses note Page 1 of 4 675272 675272 11/20/2025 Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 09/14/2025 at 1:24 pm by LVN C revealed, Resident is having right sided weakness and was having difficulty feeding self. Unable to grip his spoon at lunch time to feed himself, vitals taken 127/69, 70, 97.8F, 18, 98% RA (room air). Resident is alert and oriented x 2-3. Speech is clear. Resident was able to eat by [sic] breakfast by himself. Informed the Doctor regarding the weakness. N/O (new order) received from the Doctor to send resident to the hospital for further testing and CAT scan to r/o (rule out) stroke. Informed the FM. Informed the DON. Called EMS to arrange transportation to the hospital. They will arrive here shortly to take resident to the hospital. Interview on 09/14/25 was attempted with Resident #1 but he was at another facility in another town. Interview on 09/25/15 at 3:40 pm, the FM stated Resident #1 went to the hospital 09/14/25. The FM stated on 09/15/25 they went to the facility and told the SW A and ADON B about the nurses not paying attention to Resident #1's change of condition and his falls. The FM stated they were very upset and told SW A and ADON B that the hospital said Resident #1 had more rib fractures. They stated they were upset with LVN C for not sending Resident #1 out sooner than he did 09/14/25 for looking like he had a stroke. They stated feeling the facility knew they had done something wrong because they cancelled Resident #1's care plan meeting scheduled for 09/15/25. They stated they wanted to have Resident #1's care plan meeting anyway, to complain about his care at this facility. Interview on 09/25/25 at 4:05 pm , LVN C stated he was the weekend supervisor 09/14/25 and he saw Resident #1 around 6:00 am, and he was fine and responded normally to him when he asked him questions and he did not have any stroke like symptoms. He stated Resident #1 did not have any falls during his shift but he had fallen twice two days prior and they were doing neuro checks. He stated the FM came to visit late morning and took Resident #1 to his room and then she said Resident #1 was having stroke like symptoms. He stated telling the FM Resident #1 ate his breakfast without assistance and was doing fine and would check him out. He stated he assessed Resident #1 and he was fine and his vitals and neuro checks were within normal limits. He stated Resident #1 did not have any knots on his head or anywhere else. He stated he checked Resident #1's chest and he said he had no pain. He stated he had no rib pain, no slurred speech, his right arm was not flaccid and fingers not contracted. He stated the FM left the facility sometime after 11:00 am. He stated he moved resident #1 back to the common area by the nurses station then around 12:30 pm he noticed Resident #1 was not able to grip his spoon to eat during lunch so CNA D assisted him with his meal. He stated he was doing fine eating with assistance. He stated he assessed Resident #1 then his Doctor and the FM were notified. He stated Resident #1's Doctor told him to send him out for a CT scan to determine if he had a stroke. He stated around 1:00 pm he called for EMS to transfer Resident #1 and then he was transferred to the hospital. Interview 09/25/25 at 5:45 pm, ADON B stated Resident #1 had a change of condition for a possible stroke Sunday 09/14/25 and was sent to the hospital. She stated she and SW A had a meeting with the FM on 09/15/25 about concerns with LVN C not sending Resident #1 to the hospital sooner. She stated the FM also had concerns about the two falls Resident #1 had at this facility and had more rib injuries now. She stated the FM said she was going to tell everyone about how Resident #1 was treated at this nursing facility. She stated the FM felt Resident #1 was not taken care of properly. She stated after the meeting 09/15/25 she reported the FM's complaint to the DON and Administrator. She stated the FM was very upset and the FM just wanted to tell them how she felt without reviewing his records. Interview on 09/25/25 at 6:02 pm, SW A stated Resident #1 went to the hospital 09/14/25 for having a possible stroke. She stated the FM visited the facility on 09/15/25 about Resident #1 falling the night after he admitted and a second fall after that. She stated the FM said Resident #1's recent hospital report revealed he had more injured ribs from falling. She stated they tried to explain to the FM they had done their 675272 Page 2 of 4 675272 11/20/2025 Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few best to prevent him from falling by frequently monitoring and toileting him and keeping his bed in the lowest position but the FM was upset. She said she told the FM the facility doctor, assessed him and he was fine after he had fallen 09/11/25 and 09/12/25. She stated after the FM left the facility 09/15/25 she spoke to the DON and Administrator about the FM's complaints and how upset she was. Interview on 09/25/25 at 6:10 pm, the DON stated Resident #1 admitted [DATE] with a history of falls at home and he went to the hospital for a change of condition 09/14/25. She stated prior to Resident #1 admitting to this nursing home he fell at the hospital. She stated she found out by reviewing Resident #1's hospital records he had a rib that was fractured at the hospital. She stated after Resident #1 admitted to this nursing facility, he had two falls but they were minor injuries on 09/11/25 and 09/12/25 and neuro checks were being done. She stated the morning of 09/15/25, SW A said she spoke to the FM about Resident #1's falls and why was he not sent to the hospital sooner. She stated she was not able to attend the meeting because of being on a phone call and ADON B was already in the meeting. She stated by the time she was off the phone the FM had already left this facility. She stated she did not call the FM to get more information. She stated this facility did not need to report this complaint to HHSC because they did everything they could have done for Resident #1. She stated they did not investigate to see if the allegations was true because she reviewed his medical record and did not see any issues. She stated they did not fail to report Resident #1's falls or change of condition to his doctor and the FM. Interview on 09/25/25 at 6:43 pm, the Administrator stated Resident #1 was at the facility for a very short time. He stated Resident #1 had two falls while he was at this facility with minor injuries and on 09/14/25 Resident #1 had a change of condition and was sent to the hospital. He stated the FM did not directly complain to him about Resident #1 but ADON B said on 09/15/25, the FM expressed concerns about additional ribs being fractured from falling. He stated the FM had concern about Resident #1's fall, something about falls with injury on 09/12/25 and 09/13/25. He stated he was responsible for reporting abuse and neglect allegations to HHSC and they should be reported in two hours of being notified. He stated he did not report the FM complaint 09/14/25 to the State Agency because there was no neglect. He stated they did not investigate the allegation and based on all that they did he did not feel it was needed. He stated after being notified by ADON B about Resident #1 being diagnosed with more rib fractures he did not feel it was reportable to the State Agency because it was not true. He stated there was no report of Resident #1 having a change of condition prior to being sent to the hospital 09/14/25. He stated the FM never reached out and called or left him a message about any concerns. He stated he did not contact the FM to gather more information. Record review of the facility's Abuse and Neglect policy dated 11/2017 and revised 10/2023 revealed, Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. This policy applies to all Facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the Facility. Purpose: Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.H. Reporting/ Response: 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the 675272 Page 3 of 4 675272 11/20/2025 Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150

F 0609 applicable timeframes, as per this policy and applicable regulations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675272 Page 4 of 4