Estates Healthcare and Rehabilitation: Urine Cup Left on Resident's Bedside - TX
When a federal inspector walked into the room on the morning of April 28, the graduated cylinder was still there on the bedside table, traces of yellow liquid visible at the bottom, sitting alongside the resident's water cup, her hairbrush, and her book. It had been there since around 6:00 a.m., when the night shift emptied her urinary catheter collection bag and set the cylinder down rather than taking it to the bathroom.
The resident, identified in inspection records as Resident #4, uses a wheelchair and cannot access her bathroom on her own. She told the inspector she had asked the CNAs not to leave the cylinder on her table, but they forget and do it anyway. She had no way to move it herself.
She also said she was worried about someone else.
"She was concerned that the CNAs would do the same thing with a resident who might be confused," the inspection report states, "and that resident might drink from it."
That concern was not abstract. The cylinder is a clear container. It looks like something you could drink from. A confused resident, disoriented or thirsty, would have no obvious reason to know otherwise.
Every staff member the inspector interviewed two days later said the same thing: the cylinder should never have been on that table. The director of nursing said the bedside table is considered a clean surface and the cylinder was "definitely not clean," and that a confused resident might try to drink from it. A CNA described it as "unsanitary and gross." An RN said dirty items cannot share space with clean ones like a drink cup or food. An LVN said urine measuring cups cannot be left where clean items are. Another CNA said the cylinders should always be rinsed and left in the bathroom. A second CNA said the risk was both contamination and the simple fact that it was unpleasant for residents to have it there.
Six staff members. Six consistent answers. None of them could explain why the night shift had left it on the table anyway, and the director of nursing said she did not know who had done it.
The facility's own infection control policy states that consistent use of proper hygienic practices by staff is critical to preventing the spread of infections. The policy is undated.
Federal inspectors cited the facility for failing to maintain an infection prevention and control program, rating the violation at the level of minimal harm. One resident was affected in the eight reviewed for infection control.
The citation captures something narrower than what Resident #4 was describing. Her concern was not about herself. She was already aware of the problem, already frustrated by it, already asking staff to stop. What she raised with the inspector was the resident down the hall who might not know what they were looking at, who might be thirsty, who might reach for what looked like a cup.
She had no way to fix it herself. She could not get to the bathroom. She could ask the CNAs, and they would agree with her, and then the next shift would come and the cylinder would be back on the table by morning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Estates Healthcare and Rehabilitation Center from 2026-05-01 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Estates Healthcare and Rehabilitation Center in Fort Worth, TX was cited for violations during a health inspection on May 1, 2026.
The resident, identified in inspection records as Resident #4, uses a wheelchair and cannot access her bathroom on her own.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.