Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to treat each resident with respect and dignity
and care for each resident in a manner and in an environment that promoted maintenance or enhancement
of his or her quality of life for one (Resident #147) of five residents reviewed for dignity.
The facility failed to treat Resident #147 with dignity and promote enhancement of his quality of life when
the resident was not provided a privacy bag for his foley bag (collection bag for urine) on 05/13/2025.
This failure placed residents at risk of not having their right to a dignified existence maintained.
Findings included:
Record review of Resident #147's Face Sheet, dated 05/13/2025, reflected the resident was a [AGE]
year-old male who admitted to the facility on [DATE]. Resident #147 had diagnoses which included
obstructive and reflux uropathy (urine flow is blocked) and central cord syndrome (affects motor function in
arms and legs).
Record review of Resident #147's Comprehensive MDS (tool used to assess functional capabilities and
health needs) Assessment, dated 05/12/2025, reflected Resident #147 was cognitively intact with a BIMS
(tool used to assess cognition) score of 15. Section H (bowel and bladder) reflected Resident #147 had an
indwelling foley catheter.
Record review of Resident #147's Comprehensive Care Plan, dated 05/13/2025, reflected Resident #147
had an indwelling catheter related to obstructive and reflux uropathy. One intervention was to provide a
catheter bag with an attached cover.
During an observation, an interview on 05/13/25 at 9:34 AM, Resident #147 was sitting in his wheelchair in
the doorway of his room. His foley catheter bag was not in a privacy bag. Resident #147 stated he came to
the facility on Friday and a staff member told him the previous day they would bring him a bag to cover it but
did not. Resident #147 stated he wanted the foley bag hid because it was embarrassing.
During an interview on 05/13/2025 at 9:38 AM, CNA B stated she just came on shift and was going to get
Resident #147 a privacy bag. She stated she planned to get one as soon as she finished rounding on her
residents. She stated it was important for the resident's dignity and other residents might
(continued on next page)
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
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
675856
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675856
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whitesboro Health and Rehabilitation Center
1204 Sherman Dr
Whitesboro, TX 76273
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
not want to see the foley bag.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 05/13/2025 at 9:47 AM, RN A stated the Resident #147's foley bag should have
been covered. She stated it could be embarrassing for the resident. She stated no one wanted to walk
around with a foley bag and have everyone see what was in it.
Residents Affected - Some
During an interview on 5/13/2025 at 11:30 AM, the DON stated she instructed staff to get Resident #147 a
foley bag with an attached cover and remind the resident to call staff to empty the foley bag. The DON
stated it was important to ensure foley bags were covered for the dignity of the resident. She stated the
nurses and CNAs were responsible for monitoring to ensure foley bags were covered. She stated she
would in-service staff.
During an interview on 05/15/2025 at 1:40 PM, the administrator stated it was important to keep the foley
catheter bag in a privacy bag for the resident's dignity. He stated it could be embarrassing for the resident.
Review of the facility's policy Catheter Care did not reflect the use of a privacy bag.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675856
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675856
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whitesboro Health and Rehabilitation Center
1204 Sherman Dr
Whitesboro, TX 76273
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review the facility failed to ensure the resident environment remained
as free from accident hazards as possible and each resident received adequate supervision and assistive
devices to prevent accidents for 1 (Resident #41) of 8 residents reviewed for accident hazards.
The facility failed to ensure Resident #41's fall mat was not folded up and leaned against a wall when
Resident #41 was lying in bed on 05/13/2025.
This failure could place residents at risk of harm and serious injuries.
Findings included:
Record review of Resident #41's Physician's Order, dated 04/08/2025, reflected low bed with floor mat at
bedside.
Record review of Resident #41's Face Sheet, dated 05/13/2025, reflected the resident was an [AGE]
year-old male who admitted to the facility on [DATE]. Resident #41 had diagnoses which included
unsteadiness on feet and a history of falls.
Record review of Resident #41's Quarterly MDS Assessment, dated 03/16/2025, reflected severely
impaired cognition with a BIMS score of 01. The Quarterly MDS Assessment indicated that the resident had
dementia and seizure (abnormal brain activity affecting muscle control) disorder.
Record review of Resident #41's Comprehensive Care Plan, dated 03/31/2025, reflected Resident #41 was
at risk for falls r/t Confusion, Gait/balance problem. One intervention was Keep bed in lowest position with
floor mat at bedside.
During an observation on 05/13/2025 at 9:26 AM, Resident #41 was lying in bed asleep. Resident #41's fall
mat was folded up and leaned against the wall near his bed.
During an interview on 05/13/2025 at 9:47 AM, RN A stated Resident #41 had tried to get out of bed
without assistance. She stated it was important to have Resident #41's fall mat next to his bed to prevent
injury if he fell. She stated she was not sure if the fall mat was to be used at nighttime or any time the
resident was in bed.
During an interview on 05/13/2025 at 11:30 AM, the DON stated Resident #41's fall mat should have been
placed next to the bed while the resident was lying in bed. She stated it should be put up when the resident
was not in bed. She stated this intervention helped prevent an injury if the resident fell.
During an interview on 05/15/2025 at 1:15 PM, CNA B stated Resident #41's bed had to be in the lowest
position and the floor mat next to the bed when Resident #41 was in bed. She stated this was important to
prevent injury if the resident fell.
During an interview on 05/15/2025 at 1:40 PM, the Administrator stated it was important to have a fall mat
in place in case Resident #41 tried to transfer or was non-compliant with waiting for staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675856
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675856
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whitesboro Health and Rehabilitation Center
1204 Sherman Dr
Whitesboro, TX 76273
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
to assist him. He stated if the resident rolled out of the bed, the fall mat could prevent injury.
Level of Harm - Minimal harm
or potential for actual harm
The facility did not provide a policy for fall mats prior to exit.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675856
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675856
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whitesboro Health and Rehabilitation Center
1204 Sherman Dr
Whitesboro, TX 76273
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure a resident who was incontinent of
bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #41
and Resident #24) of 10 residents reviewed for infection control.
1.
The facility failed to ensure Resident #41's foley catheter (tube that drains urine) bag was not touching the
floor when the resident was lying in bed on 05/13/2025.
2.
The facility failed to ensure CNA D wiped from front to back when providing incontinent care to Resident
#24 on 05/15/2025.
These failures could place residents at risk of cross-contamination and development of infections.
The findings included:
Resident #41
Record review of Resident #41's Face Sheet, dated 05/13/2025, reflected the resident was an [AGE]
year-old male who admitted to the facility on [DATE]. Resident #41 had diagnoses which included
neuromuscular dysfunction of the bladder (bladder does not function properly) and hypertension (high
blood pressure).
Record review of Resident #41's Quarterly MDS Assessment, dated 03/16/2025, reflected severely
impaired cognition with a BIMS score of 01. The MDS Assessment reflected Resident #41 had an
indwelling foley catheter.
Record review of Resident #41's Comprehensive Care Plan, dated 03/13/2025, reflected Resident #41 has
indwelling foley catheter. Interventions included Position catheter bag and tubing below the level of bladder
and in a privacy bag and check tubing for kinks and maintain drainage bag off the floor.
During an observation on 05/13/2025 at 9:26 AM, Resident #41 was lying in bed asleep. Resident #41's
foley bag (collects urine) was in a privacy bag and hung on the bedrail. The bottom of the privacy bag was
touching the floor.
During an interview on 05/13/2025 at 9:47 AM, RN A stated Resident #41's foley bag should not have been
touching the floor. She stated it was not supposed to be on the floor because it could collect bacteria,
become contaminated, and cause infection.
During an interview on 05/13/25 at 11:30 AM, the DON stated it was important to prevent foley catheter
bags from touching the ground to prevent contamination and infection. She stated the nurse and CNAs
were responsible for monitoring the foley bags to ensure they were kept off of the floor. The
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675856
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675856
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whitesboro Health and Rehabilitation Center
1204 Sherman Dr
Whitesboro, TX 76273
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
DON stated she was in-servicing staff.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility's policy Catheter Care reflected Be sure the catheter tubing and drainage bag are kept
off the floor.
Residents Affected - Few
Resident #24
Record review of Resident #24's Face Sheet, dated 05/14/2025, reflected the resident was an [AGE]
year-old female who admitted to the facility on [DATE]. Resident #24 had diagnoses which included
dementia and the need for assistance with personal care.
Record review of Resident #24's Quarterly MDS Assessment, dated 04/03/2025, reflected moderate
impaired cognition with a BIMS score of 08. Section G (functional status) indicated Resident #24 required
extensive assistance with toileting needs.
Record review of Resident #24's Comprehensive Care Plan, dated 04/07/2025, reflected ADL Self Care
Performance Deficit. One intervention was to assist resident with toileting needs.
During an observation and interview on 05/15/2025 at 10:17 AM CNA D and CNA E provided incontinence
care for Resident #24. CNA D and CNA E washed their hands in resident's restroom and put on gloves.
CNA D pulled down the front of Resident #24's brief and used a single wipe with each pass to clean the
resident, wiping in a downward motion. Resident #24 rolled to her left side and CNA E held the resident
while CNA D cleaned the resident's bottom. CNA D did not wipe the resident from the front to the back,
ensuring to wipe toward the bottom. After cleaning Resident #24's bottom, CNA D stated she should have
wiped from front to back. CNA D did not clean the resident again. CNA D dropped the soiled brief into the
trash bag. She used hand sanitizer when changing gloves. CNA D placed a clean brief under Resident #24
and applied barrier cream to the resident's bottom. CNA D used hand sanitizer when changing gloves. CNA
D secured the tabs on each side of the brief and pulled up the resident's blanket. CNA D and CNA E
removed their gloves and washed their hands in the resident's restroom. Upon exiting Resident #24's room,
CNA D stated she should have wiped the resident from front to back to prevent infection. She stated it was
important to not transfer anything. She stated not cleaning correctly could cause the resident to get a
urinary tract infection.
During an interview on 05/15/2025 at 11:42 AM, the DON and Regional Nurse stated it was important for
staff to clean the residents properly when providing incontinence care to prevent the spread of infection.
The DON stated staff would be in-serviced.
Review of the facility's policy Infection Control Policy and Procedures Manual 2019, updated March 2024,
reflected The facility will establish and maintain an Infection Control Program designed to provide a safe,
sanitary and comfortable environment and to help prevent the development and transmission of disease
and infection.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675856
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675856
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whitesboro Health and Rehabilitation Center
1204 Sherman Dr
Whitesboro, TX 76273
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to establish and maintain 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 for 3 (Residents
#24, #23, and #1) of 12 residents reviewed for infection control.
Residents Affected - Some
The facility failed to ensure LVN C cleaned the blood pressure cuff between residents when administering
medication to Residents #24, #23, and #1 on 05/14/2025.
These failures could place residents at risk of cross-contamination and development of infections.
The findings included:
During observation and interview on 05/14/2025 at 7:59 AM, LVN C was observed administering
medication to residents. LVN C took a blood pressure cuff into Resident #24's room and checked her blood
pressure prior to preparing the medication to administer. LVN C did not use a wipe to sanitize the blood
pressure cuff when she returned to the medication cart. After administering the medication to Resident #24,
LVN C took the blood pressure cuff into Resident #23's room and checked her blood pressure. She
returned to the medication cart and did not use a wipe to sanitize the blood pressure cuff. LVN C prepared
the medication and took it to Resident #23. LVN C took the blood pressure cuff into Resident #1's room to
check his blood pressure. LVN C returned to the medication cart to prepare Resident #1's medication to
administer. LVN C did not use a wipe to sanitize the blood pressure cuff. LVN C administered the
medication to Resident #1 and returned to the medication cart. LVN C stated she did not clean the blood
pressure cuff between residents. LVN C stated it was important to sanitize items used for more than one
resident to control infection.
During an interview on 05/14/2025 at 8:50 AM the Regional Nurse stated LVN C was probably nervous
about being watched and forgot to clean the blood pressure cuff. She stated they would follow-up with LVN
C.
During an interview on 05/14/25 at 10:53 AM, the DON stated LVN C should have cleaned the blood
pressure cuff between residents. She stated any equipment used for more than one resident must be wiped
with a sanitizing wipe between residents. She stated this was important for infection control. The DON
stated she had already provided 1:1 in-service to LVN C.
Review of the facility's policy Infection Control Policy and Procedures Manual 2019, updated March 2024,
reflected The facility will establish and maintain an Infection Control Program designed to provide a safe,
sanitary and comfortable environment and to help prevent the development and transmission of disease
and infection .Ensure that reusable equipment is appropriately cleaned, disinfected, or reprocessed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675856
If continuation sheet
Page 7 of 7
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Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0522GeneralS&S Epotential for harm
Have an externally vented heating system.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the May 15, 2025 survey of Whitesboro Health and Rehabilitation Center?
This was a inspection survey of Whitesboro Health and Rehabilitation Center on May 15, 2025. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Whitesboro Health and Rehabilitation Center on May 15, 2025?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.