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Complaint Investigation

Whitesboro Health And Rehabilitation Center

September 10, 2025 · Whitesboro, TX · 1204 Sherman Dr
Citations 3
CMS Rating 2/5
Beds 95
Provider ID 675856
Healthcare Facility
Whitesboro Health And Rehabilitation Center
Whitesboro, TX  ·  View full profile →
Inspection Summary

Whitesboro Health and Rehabilitation Center in Whitesboro, TX — inspection on September 10, 2025.

Found 3 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.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During an interview on 09/10/2025 at 2:14 PM, the DON stated her expectation was for nursing staff to ensure urinary catheter bags were covered for the dignity of the residents.

During an interview on 09/10/2025 at 3:20 PM, the ADON stated residents with a urinary catheter should have it in a privacy bag for the resident's dignity.The facility's policy Catheter Care, undated, did not address the use of a privacy bag.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Whitesboro Health and Rehabilitation Center

1204 Sherman Dr Whitesboro, TX 76273

SUMMARY STATEMENT OF DEFICIENCIES

The facility failed to ensure the call light system in Resident #2's room was in a position accessible to the resident on 09/10/2025.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Findings included:

Record review of Resident #2's Face Sheet, dated 09/10/2025, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia (decline in cognitive function that interferes with daily life) and unsteadiness on feet.

Record review of Resident #2's Quarterly MDS Assessment, dated 08/20/2025, reflected severe cognitive impairment with a BIMS score of 03. Resident #2 required staff assistance for self-care needs.

Record review of Resident #2's Comprehensive Care Plan, dated 09/01/2025, reflected the resident was at risk for falls.

One of the interventions was to ensure the call light was within reach and encourage the resident to use it for assistance as needed.

During an observation and interview on 09/10/2025 at 9:40 AM, Resident #2 was lying in bed awake. Resident #2's call light cord was on the floor approximately two feet to the right of the head of his bed.

When he was asked if he used his call light, Resident #2 replied no. A further attempt to interview the resident was unsuccessful due to his cognitive status. CNA B came into the resident's room and stated the resident did not use the call light. He stated Resident #2 had poor vision and the call light was normally clipped near the resident's pillow. CNA B placed the call light within the resident's reach. He stated it was important for the call light to be within the resident's reach so he could use it to call for help.

During an interview on 09/10/2025 at 10:23 AM, LVN C stated Resident #2 did not use the call light and staff had to anticipate his needs.

She stated staff tried to keep the call light clipped on Resident #2's bed.

She stated it was important to ensure the call light was within the resident's reach because it was a safety issue. LVN C stated it was also Resident #2's right to have access to his call light.

During an interview on 09/10/2025 at 1:45 PM, the Administrator stated the facility did not have a policy specific to call light placement. He stated the expectation was for all residents to have access to their call lights. He stated the nursing staff monitored call light placement during rounds, and all staff should ensure the call light is within reach before leaving a resident's room. He stated the call light should have been clipped within Resident #2's reach.

During an interview on 09/10/2025 at 2:14 PM, the DON stated Resident #2's call light should have been within his reach so if he wanted to use it he could.

During an interview on 09/10/2025 at 3:20 PM, the ADON stated all residents should have their call light in reach. He stated it was for the residents' safety and to ensure they could notify staff if they needed assistance of any kind.The facility did not provide a policy related to the use of call lights.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Whitesboro Health and Rehabilitation Center

1204 Sherman Dr Whitesboro, TX 76273

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited Whitesboro Health and Rehabilitation Center in Whitesboro, TX for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-09-10.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of Whitesboro Health and Rehabilitation Center.

Correction Status: Deficient, Provider has no plan of correction.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Whitesboro, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Whitesboro Health and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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