Whitehall Rehab & Nursing
WHITEHALL REHAB & NURSING in CROCKETT, TX — inspection on February 25, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an observation on 02/23/2026 at 11:06 am, Resident #53 was lying in bed, and her call light was attached to itself at the wall out of reach.
During an observation on 02/23/2026 at 3:53 pm, Resident #53 was lying in bed and her call light remained attached to itself at the wall out of reach. Resident #53 was unable to communicate or answer questions regarding call light.
During an observation on 02/24/2026 at 11:05 am, Resident #53 was lying in bed and her call light was on the wall plug out of reach. Resident #53 had trouble communicating but was able to demonstrate pushing the call light when it was handed to her.
During an interview on 02/24/2026 at 11:10 am, CNA A said that Resident #53 could use her call light but never did.
She said they kept her door open so they could visibly see her when making rounds and checked her every 2 hours to ensure she was good.
She said all residents should have access to their call lights and could have negative outcomes if they couldn't call for help.
During an interview on 02/25/2026 at 8:40 am LVN E said that all staff should ensure each resident could reach their call light so they could call for help if they need to.
She said Resident #53 did not use her call light that she was aware of but should still have it near in case she wanted to use the light.
She said a call light out of reach could result in resident injuries.
During an interview on 02/25/2026 at 9:46 am, the DON said that all staff should ensure resident call lights were in reach.
She said each time rounds were made the call light should be placed back in reach for the residents to use if they desired before leaving the room.
She said the staff were trained verbally on call light placement on hire and annually.
She said she expected each resident to have access to their call light to prevent injuries.
During an interview on 02/25/2026 at 1:16 pm, the Administrator said that residents call lights should always be within reach and was the responsibility of everyone that rounds.
She said all staff were trained on call light placement on hire, annually and as needed and discussed through resident rights.
She said if call lights were not in place resident injuries could occur.
Record review of a facility policy titled Call Light Response, dated 8/11/13, indicated, Place call light/bell within patient's reach regardless of patient location such as:in bed, on commode, unaccompanied in sitting area .
675624 02/25/2026
Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835
During an interview on 02/24/2026 at
said the MDS nurse completed the care plans, and she did not have a part in the revision or review of care plans.
She said that the nurses did use the care plan at times but mainly followed the orders.
She said incomplete care plans could cause a delay in care or inaccurate care.
During an interview on 02/24/2026 at 4:20 pm, the Regional Reimbursement Consultant said that she was responsible for the MDS assessment oversight at the facility.
She said the facility had not had a consistent MDS nurse for several months and she did not micromanage the department.
She said she came to the facility 1-2 times a week but completed most of her work offsite.
She said that she had been reviewing and revising care plans as they came due but had not completed them all.
She said that Resident #53 should have had a care plan to reflect her feeding tube and need for EBP.
She said the care plan should have been reviewed and revised with her comprehensive care plans and somehow it was missed.
She said inaccurate care plans could result in residents not receiving care.
During an interview on 02/25/2026 at 9:46 am, the DON said that the interdisciplinary team met to discuss resident care on admission, quarterly and with significant changes.
She said during those meetings the team completed the team meeting note and the MDS nurse was responsible for reviewing and revising the care plan accordingly.
She said the corporate MDS nurse that had been covering was not participating in the meetings and could not speak to why.
She said inaccurate care plans could result in resident care delays and injuries.
During an interview on 02/25/2026 at 1:16 pm, the Administrator said that the MDS nurse was responsible for reviewing and revising the resident's care plan.
She said they had a lot of turnover with the MDS nurse position and the regional reimbursement consultant had been helping.
She said the comprehensive care plan should be revised quarterly and as needed and should reflect all care the residents required.
She said she expected the care plans to be revised per the regulations to prevent resident care issues.
Record review of a facility policy titled Comprehensive Care Plans dated 9/04/2024 indicated, .Comprehensive Care Plans Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3.
The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .
675624 02/25/2026
Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835
During an interview on 02/25/2026 at 1:16 pm, the Administrator said that the CNAs were responsible for the residents ADL care, and the nurses should be providing oversight that the care was completed.
She said their process had been for the CNA to complete a skin observation sheet with each bath or shower, the nurse reviewed them, and she would see that that process was completed.
She said she expected all residents to receive personal hygiene per the schedule to prevent skin breakdown and infections.
Record review of a facility policy titled Clinical Practice Guideline Activities of Daily Living dated 1/23/2016 indicated, .Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene .
675624 02/25/2026
Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835
Review of Facility policy dated 09/13/2024 Hydraulic Lift (Hoyer Lift) .Policy: To enable one individual to lift and move a resident safely, with as little effort as possible.Procedure.Record Review of Manufacturer's recommendations accessed www.medline.com 02/11/2026Indicated: Always inspect slings prior to each use Signs of rips. tears. or frays indicate sling wear which is unsafe and could result in injury Signs of fading. bleached areas. or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury Any slings with signs of wear or improper laundering should be immediately removed from use.Always confirm compatibility between the connection style of the patient sling and the patient lift before use.Do not remove sling labels. If sling labels are removed or no longer legible. sling must be immediately removed from use.Frequency of laundering should follow facility guidelines, or when the sling is soiled.
Refer to the sling's tag for laundering instructions and follow all wash instructions.
675624 02/25/2026
Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835
During a phone interview on 2/25/2026 at 11:11 am,
monthly.
She said her last visit was 2/10/2026 and she reviewed Resident #34's medications.
She said the use of psychotropic medications must have an appropriate diagnosis with the use of Seroquel and dementia was not an appropriate diagnosis for its use according to CMS regulations.
She said she had been reminding the facility monthly since January 2025 that an appropriate diagnosis was needed.
She said the facility had not responded to her in person and would tell her they were working on it.
She said the purpose of the Pharmacy Consultant was to make sure things were in order and help the facility get in compliance.
She said she had sent the MD messages before requesting a new diagnosis with no response.
She said the last time she contacted him was in August 2025 and he told her he reminded the nurses to complete it but did not change the diagnosis.
During an interview on 2/25/2026 at 11:25 am, the ADON said she had been employed at the facility since [DATE].
She said she was still in training.
She said she would be responsible for helping the DON with pharmacy recommendations.
She said she was not aware Resident #34 did not have an appropriate dx for the use of Seroquel.
She said the resident had behaviors and was not sure if he was on psych services.
She said the pharmacy consultant helped to keep the facility in compliance with state regulations and making sure the appropriate diagnosis were being used.
She said consent for psychotropic medications should be completed before the initial dose was given to the resident, either written or verbal.
She said there was a risk of not knowing what medications would be given and they should be made aware of the side effects of the medications.
She said she did not see the pharmacy recommendation for Resident #34 that indicated he needed an appropriate diagnosis for the use of Seroquel after the pharmacy consultant visited the facility last week.
During an interview on 2/25/2026 at 1:20 pm, the Administrator said the Pharmacy Consultant visited the facility monthly which included reviewing medications, and they would give recommendations.
She said the DON was responsible for ensuring the recommendations were completed and sent them to the physicians usually in a day or two after the consultant's visit.
She said she was not aware that Resident #34 did not have an appropriate diagnosis for the use of Seroquel and the Pharmacy Consultant had been telling the facility for over a year that one was needed for its continued use.
She said going forward she would be involved in ensuring the pharmacy recommendations were completed.
She said there could be a negative impact for the residents if they were not done.
Record review of a facility policy titled Drug Regimen Review Process revised 10/3/2018 indicated, .It is the policy of this facility to conduct a drug regimen review upon a resident's SNF Prospective Payment System (PPS) admission and as indicated throughout the resident's stay.
Medication irregularities identified and reported by the consultant pharmacist are maintained in an orderly, organized manner to trach physician or nursing response.
Monthly Drug Regimen Review: The Consultant pharmacist reviews the medication of each resident at least monthly and more frequently if deemed necessary.
Recommendations that require Physician response are sent to Physician timely for follow up or the Physician is contacted by phone as indicated.
The DON will validate that all recommendations sent to Physician, once returned are acted upon timely .
675624 02/25/2026
Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835
accurate for a resident who was on weekly weight monitoring.
She said he had a lot of behaviors and
February 10, 2026.
She was responsible for monitoring the POC documentation in the resident records
documenting meal intakes and the nurse aides were responsible for the documentation.
She said if a resident did not eat, staff should let the charge nurse know so interventions could be put in place. If documentation were not correct, they should complete an addendum and if not then it could lead someone to believe the information was correct.
During an interview on 2/25/2026 at 1:20 pm, the Administrator said meal intakes should be recorded by the charge nurses daily.
She said Resident #34 liked to snack and stayed up at night.
She said she was made aware of the documentation that LVN J made on Resident #34.
She said staff should have better documentation and it varied with the intake Resident #34 received.
She said at night they would give him snacks if he was up.
She said if the documentation was entered into the system in error, the staff should create an addendum to correct the incorrect information.
She said if the information were not corrected, it would be inaccurate and could impact care.
She said they started conducting in-services with the staff and have changed their system for a better recording of meal intakes for the residents.
Record review of an in-service training report dated 2/25/2026 by the Administrator titled meal service and documentation of intake was conducted.
Record review of a facility policy titled Clinical Document Guidelines revised 3/25/2025 indicated, .The patient's clinical record provides a record of the health status, including observations, measurements, history and prognosis and serves as the primary document describing healthcare services provided to the patient.
The clinical record is used by the healthcare team to record, preserve and communicate the patient's progress and current treatment .
During an interview on 02/25/2026 at
all staff.
She said if the resident was on EBP, EBP should be followed.
Hand hygiene should occur
linens should always be bagged and not carried freely in the hallway.
She said not following the infection control program could lead to the spread of infections.
Record review of a facility policy titled Infection Prevention and Control Program dated 11/2024 indicated, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.6.
Enhanced Barrier Precautions EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP are indicated for residents with any of the following: a.
Infection or colonization with an MDRO when Contact Precautions do not otherwise applyb.
Wounds and/or indwelling medical devices (e.g., central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status During high-contact resident care activities:12. e.
Soiled linen shall be collected at the bedside and placed in a linen bag.
When the task is complete, the bag shall be closed securely and placed in the soiled utility room.
Soiled linen shall not be kept in the resident's room or bathroom .
Record review of a facility policy titled Hand Hygiene revised 2/11/2022 indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6 a.
The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
675624 02/25/2026
Whitehall Rehab & Nursing 1116 E Loop 304 Crockett, TX 75835