Whitesboro Health: Abuse Protection Failures - TX
That account came from CNA F, the aide who was in the room when it happened and who pulled the two men apart. She was among the staff interviewed during a complaint inspection at Whitesboro Health and Rehabilitation Center, completed January 30, 2026. Federal inspectors cited the facility for failing to protect residents from abuse, a violation that regulators classified as causing minimal harm or the potential for actual harm.
The two residents at the center of the incident, identified in inspection records only as Resident #1 and Resident #2, both live in the facility's memory care unit.
CNA F told inspectors she was in the dining room when Resident #2 walked to the sofa where Resident #1 was sitting and hit him on the right side of his head. Resident #1 was watching television. After the strike, Resident #2 began kicking his foot toward Resident #1, though she said his foot did not make contact. She separated the residents and notified the charge nurse on duty, LVN E, who worked nights in the memory care unit.
Resident #1 did not express pain. He told staff he was not hit.
LVN E said CNA F came to him after separating the residents and told him what had happened. He assessed both men. Neither had visible injuries. He kept them separated and continued to monitor Resident #1 through the rest of the shift. He also said another incident had occurred sometime before this one, though he could not remember the details. He said he had put notes in the chart at the time.
After the altercation, Resident #2 was placed on one-to-one monitoring.
The Director of Nursing told inspectors she was called and informed that Resident #2 had swatted at Resident #1. She said they were unsure whether Resident #1 had actually been struck, and so, on the side of caution, reported the incident. She said the residents were immediately separated and a skin assessment was completed for everyone on the unit to check for any injuries that had gone unnoticed. A secured care consult was scheduled. Staff discussed interventions, activities, and things Resident #2 was interested in.
Resident #2 was later transferred to a sister facility. The Director of Nursing said he was doing well there.
She described Resident #2 as territorial, a man who liked his space and did not want people in his room. She said if he saw someone do something to upset a CNA or a female resident, he would stand up and stare them down, but had not previously become physical. Looking back, she said, Resident #1 had been talking and moving things around in the dining and activity room, and that had probably upset Resident #2. She said in-service training was provided to staff after the altercation. The most important intervention at the time, she said, was monitoring Resident #2.
The Social Worker told inspectors she spoke with both residents after the incident. She found Resident #2 sitting on the couch in the dining room looking at a book. She spoke with Resident #1 as well. Neither man had any memory of what had happened.
LVN E, reached by phone on the evening of February 1, said the facility had conducted in-service training on abuse, neglect, and resident altercations. He said staff were taught that when a resident became upset, the right approach was to talk low and calm, and to redirect. He said any abuse should be reported to the Administrator, who also served as the facility's Abuse Coordinator. He confirmed that Resident #2 had behaviors when aides tried to change him, but said he had not previously struck another resident.
CNA F said the two men had no prior altercation between them before this incident.
The facility's own abuse and neglect policy, reviewed by inspectors, states that residents have the right to be free from abuse, including abuse by other residents, and that physical abuse includes hitting, slapping, pinching, and kicking. The policy does not carry a date.
What the inspection record captures is a sequence of events that moved quickly once CNA F separated the men: the charge nurse was notified, both residents were assessed, one-to-one monitoring was initiated, the incident was reported up the chain, and a consult was scheduled. The Director of Nursing said a follow-up meeting was typically scheduled but that Resident #2 had already moved to another facility before it happened.
What it does not fully resolve is the earlier incident LVN E mentioned, the one he said happened "a while back" but could not detail. He said he had charted what CNA F told him at the time. Inspectors did not describe what, if anything, those chart notes contained or whether the prior event had been reviewed as part of the complaint investigation.
Resident #2 does not remember striking Resident #1. Resident #1 does not remember being struck. The man who was hit sat on the couch in the dining room afterward and told the Social Worker nothing had happened. He told staff he was not hit. He was wearing his cowboy hat, and he went on watching television, and whatever he experienced in the moment between when Resident #2 crossed the room and when CNA F stepped between them, he could not retrieve it.
He had no injury that anyone could find.
That is the condition inspectors documented: two men in a memory care unit, one of whom walked across a room and hit the other, and neither of whom could tell anyone what it was like.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Whitesboro Health and Rehabilitation Center from 2026-01-30 including all violations, facility responses, and corrective action plans.
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: August 9, 2026 · Our methodology
Whitesboro Health and Rehabilitation Center in Whitesboro, TX was cited for abuse-related violations during a health inspection on January 30, 2026.
That account came from CNA F, the aide who was in the room when it happened and who pulled the two men apart.
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.