Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Whitesboro Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, schizophrenia, and bipolar disorder, who had a documented history and care plan indicating potential for physical behaviors and prior episodes of swinging at staff and another resident, approached another cognitively impaired resident with Alzheimer’s disease who was sitting on a couch watching television and wearing a cowboy hat. The first resident hit the seated resident on the side of the head and then kicked his foot toward him, though the kick did not make contact. Staff and nursing notes confirmed prior knowledge that this resident might try to hit, and CNAs had been cautioned about his behaviors, yet the incident still occurred, resulting in a failure to protect residents from abuse as defined by the facility’s abuse policy.
A resident with dementia and delusional disorders broke a window and exited the building, remaining missing for about 30 minutes before being found in the staff smoking area. The resident, previously assessed as low risk for elopement and with no prior exit-seeking behavior, was last seen rearranging items in her room before staff discovered her absence and the broken window. She was found uninjured and transported to the hospital for evaluation.
A resident with an indwelling urinary catheter was observed in a hallway with the catheter bag exposed and not covered by a privacy bag, despite the care plan requiring it for dignity. Staff interviews confirmed the expectation to use privacy bags, but the facility's policy did not address this practice.
A resident with severe cognitive impairment and a history of falls was found with the call light out of reach, despite care plan interventions requiring accessibility. Staff interviews confirmed the expectation for call lights to be within reach, but the facility lacked a specific policy on call light placement, resulting in a failure to accommodate the resident's needs.
A CNA did not perform hand hygiene between glove changes while providing incontinence care to a resident with multiple medical conditions, resulting in improper handling of clean items and the resident's environment. This failure to follow infection control protocols was observed and confirmed by staff interviews, in violation of the facility's infection prevention policy.
A resident with an indwelling foley catheter was not provided with a privacy bag for his catheter collection bag, despite this being part of his care plan. The resident expressed embarrassment, and staff acknowledged the importance of covering the bag for dignity, but the privacy bag was not supplied as required.
A LVN failed to clean a blood pressure cuff between use on three residents during medication administration, using the same cuff on multiple individuals without sanitizing it as required by facility infection control policy. Facility leadership confirmed that shared equipment must be disinfected between residents to prevent infection transmission.
A resident with a history of falls, dementia, and seizure disorder was found lying in bed without the required fall mat in place, as it was folded and leaned against the wall. Staff interviews revealed uncertainty about when the fall mat should be used, despite care plan and physician orders specifying its necessity while the resident was in bed. The facility did not provide a policy for fall mats prior to exit.
Two residents did not receive appropriate infection control during catheter and incontinence care. One resident's Foley catheter bag was observed touching the floor, contrary to care plan and policy requirements. Another resident was not cleaned from front to back during incontinence care, increasing the risk of infection. Both incidents were acknowledged by staff as improper practice.
A resident with epilepsy and severe cognitive impairment did not receive four doses of prescribed Lacosamide due to staff being unable to locate the medication in the cart and failing to follow procedures for unavailable medications. Documentation was incorrectly completed, and the resident experienced multiple seizures, requiring hospital evaluation.
A resident with epilepsy and severe cognitive impairment did not receive four doses of her prescribed antiepileptic medication due to nursing staff being unable to locate the medication, despite it being present in the narcotic box. The MAR was inaccurately documented as if the medication had been administered, and proper procedures for medication unavailability and notification were not followed. The resident experienced multiple seizures and required hospital evaluation.
A nurse transported a resident with significant fall risk and mobility deficits using a rollator walker as a wheelchair, despite knowing this was not the correct procedure. The resident fell while being moved, sustaining fractures to her left arm and right hip. Staff interviews confirmed that rollators should not be used for transport, and the facility lacked a specific safe patient handling policy at the time.
Failure to Protect Cognitively Impaired Residents From Peer-to-Peer Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from abuse by other residents, specifically when one cognitively impaired male resident in the memory care unit physically struck another cognitively impaired male resident. The resident who was hit had Alzheimer’s disease and unspecified psychosis, with severely impaired cognition (BIMS score of 05), wandered daily, and required assistance with self-care and mobility. His comprehensive care plan addressed impaired cognition and dementia but did not include any behaviors toward staff or other residents. At the time of the incident, he was sitting on a couch in the dining room watching television and wearing a cowboy hat when another resident approached him. The resident who initiated the physical contact had dementia, schizophrenia, and bipolar disorder, with severely impaired cognition (BIMS score of 00) and a care plan that identified potential for physical behaviors. His care plan interventions included medication review and minimizing disruptive behaviors by offering diversionary tasks. Prior to the incident, nursing notes documented that this resident had been agitated with staff and had swung at a staff member and another resident on separate occasions, requiring redirection to his room and environmental modifications to decrease stimulation. CNAs reported being warned to watch this resident because he might try to hit staff, and one CNA described that he had swung at her when she attempted to seat him in a chair without arms, noting that his response depended heavily on how he was approached. On the day of the incident, a CNA observed the resident with a history of physical behaviors walk to the sofa where the other resident was sitting and hit him on the right side of his head while he was wearing his cowboy hat. The CNA also reported that the aggressor began kicking his foot toward the seated resident, although his foot did not make contact. Another account from facility leadership described the action as the aggressor walking over and tapping the seated resident on his cowboy hat. The LVN on duty documented that he was informed that the seated resident was on the couch and the other resident hit him, and he noted that no injury was observed. Interviews after the event showed that both residents denied remembering the incident, and the resident who was struck denied being hit when asked. Despite prior documentation of the aggressor’s physical behaviors and staff awareness that he might attempt to hit, the facility did not prevent the incident in which one resident physically struck another, resulting in a failure to protect residents from abuse as defined in the facility’s abuse/neglect policy, which includes hitting and kicking as physical abuse.
Failure to Prevent Resident Elopement Through Window
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, bipolar disorder, and delusional disorders broke a window in her room, exited the building, and was found lying on a bench in the staff smoking area approximately 30 minutes after being noted missing. The resident had a history of severely impaired cognition, as indicated by a BIMS score of 07, but had not previously exhibited exit-seeking behavior or attempted to elope. At the time of the incident, the resident was ambulatory with a walker and independent in most activities of daily living. The resident's care plan identified her as being at risk for wandering, with interventions in place to monitor and intervene as appropriate. However, on the day of the incident, staff last observed the resident rearranging items in her dresser before leaving to administer medication to another resident. Upon returning, the staff member found the resident missing and discovered the broken window. The resident was located outside in a gated courtyard area, having used furniture to break the window and exit the building. She was assessed and found to have no injuries, though she refused to re-enter the building and was subsequently transported to the hospital for evaluation. Interviews with staff and review of records confirmed that the resident had not previously demonstrated behaviors indicating a risk for elopement, and her most recent elopement risk assessment had classified her as low risk. Staff reported that the resident was generally pleasant, enjoyed social interaction, and had frequent family visits. The incident was unexpected, and staff responded by searching the facility and locating the resident within 30 minutes of her being found missing.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
A deficiency occurred when a male resident with a history of benign prostatic hyperplasia and cerebral infarction, who had an indwelling urinary catheter, was observed sitting in his wheelchair in the hallway with his urinary catheter bag exposed and not covered by a privacy bag. The resident's care plan specifically included the intervention to position the catheter bag and tubing below the level of the bladder and in a privacy bag. During the observation, the resident stated that the bag was usually covered, and a CNA acknowledged that the privacy bag was missing and should be replaced to maintain the resident's dignity. Further interviews with facility staff, including a CNA, LVN, DON, and ADON, confirmed that the expectation was for urinary catheter bags to be covered for resident dignity. However, the facility's catheter care policy did not address the use of privacy bags. The failure to provide a privacy bag for the resident's urinary catheter bag resulted in the resident not being treated with respect and dignity, as required by their care plan and facility expectations.
Failure to Ensure Call Light Accessibility for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a history of falls had reasonable accommodation of needs, specifically regarding access to the call light system. On the date of observation, the resident was found lying in bed with the call light cord on the floor, approximately two feet away from the head of the bed, making it inaccessible. The resident, who had dementia, poor vision, and required staff assistance for self-care, was unable to use the call light and did not respond to questions about its use due to cognitive limitations. Staff interviews confirmed that the call light was supposed to be clipped near the resident's pillow and within reach, but this was not the case during the observation. Further interviews with facility staff, including a CNA, LVN, the Administrator, DON, and ADON, revealed that it was the expectation for all residents to have access to their call lights for safety and to request assistance. However, the facility did not have a specific policy regarding call light placement, and staff were expected to monitor and ensure accessibility during rounds. The lack of a policy and failure to ensure the call light was within reach for this resident constituted a deficiency in accommodating the resident's needs and preferences as outlined in the care plan.
Failure to Follow Hand Hygiene Protocols During Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinence care for one resident. During observation, a CNA provided incontinence care to a female resident with a history of hypertension and chronic obstructive pulmonary disease, who was frequently incontinent of bowel and bladder. The CNA washed his hands before starting care and used gloves while cleaning the resident. However, after removing his soiled gloves, the CNA did not perform hand hygiene before retrieving a clean brief from a cabinet and putting on new gloves. The CNA then continued care, touching clean items and the resident's environment with gloves that had not been changed after cleaning the resident, and only washed his hands after completing the care and before exiting the room. Interviews with the CNA, LVN, DON, and ADON confirmed that the CNA did not follow proper hand hygiene protocols, specifically failing to wash hands or use hand sanitizer between glove changes and after removing soiled gloves. The facility's infection control policy requires hand hygiene before and after assisting a resident with personal care and emphasizes that glove use does not replace the need for hand washing. The failure to adhere to these protocols was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection prevention and control program.
Failure to Provide Privacy Bag for Foley Catheter
Penalty
Summary
A deficiency occurred when a male resident with obstructive and reflux uropathy and central cord syndrome, who was cognitively intact and had an indwelling foley catheter, was not provided with a privacy bag for his catheter collection bag. The resident's care plan specifically included the intervention to provide a catheter bag with an attached cover. On the day of observation, the resident was seen sitting in his wheelchair in the doorway of his room with his foley catheter bag uncovered. The resident reported that staff had told him they would bring a privacy bag but had not done so, and he expressed embarrassment about the situation. Staff interviews confirmed that the foley bag should have been covered to maintain the resident's dignity, and that both CNAs and nurses were responsible for ensuring this. The facility's policy on catheter care did not mention the use of a privacy bag. The failure to provide the privacy bag as outlined in the care plan resulted in the resident not being treated with dignity and not having his right to a dignified existence maintained.
Failure to Sanitize Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when a licensed vocational nurse (LVN) did not clean a blood pressure cuff between use on three different residents during medication administration. Observations showed that the LVN used the same blood pressure cuff on multiple residents without sanitizing it with a wipe between each use, despite returning to the medication cart after each resident. The LVN acknowledged not cleaning the cuff between residents and stated awareness of the importance of sanitizing shared equipment to control infection. Interviews with facility leadership confirmed that equipment used for more than one resident must be wiped with a sanitizing wipe between uses, as outlined in the facility's infection control policy. The policy requires reusable equipment to be appropriately cleaned, disinfected, or reprocessed to prevent the development and transmission of communicable diseases and infections.
Failure to Ensure Fall Mat in Place for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards and that a resident received adequate supervision and assistive devices to prevent accidents. Specifically, a resident with a history of unsteadiness, falls, dementia, and seizure disorder was observed lying in bed without the required fall mat in place; instead, the mat was folded and leaned against the wall. Physician's orders and the resident's care plan both specified that the bed should be kept in the lowest position with a floor mat at bedside as a fall prevention intervention. Multiple staff interviews confirmed that the fall mat was intended to be in place whenever the resident was in bed to help prevent injury in the event of a fall. The DON, CNA, and Administrator all stated the importance of the fall mat being positioned next to the bed while the resident was present. However, the facility did not provide a policy for fall mats prior to exit, and there was uncertainty among staff regarding when the mat should be used, contributing to the failure to implement the prescribed intervention.
Deficient Infection Control in Catheter and Incontinence Care
Penalty
Summary
A deficiency was identified when a male resident with neuromuscular dysfunction of the bladder and an indwelling Foley catheter was observed lying in bed with his catheter bag, contained in a privacy bag, touching the floor. The resident's care plan specified that the catheter bag and tubing should be kept below the level of the bladder and off the floor. Both the RN and DON confirmed that the catheter bag should not have been on the floor, as this could lead to contamination and infection. Facility policy also required that catheter tubing and drainage bags be kept off the floor. Another deficiency was observed during incontinence care for a female resident with dementia and a need for assistance with personal care. During care, a CNA failed to wipe from front to back while cleaning the resident, which is necessary to prevent infection. The CNA acknowledged the error after the care was completed but did not correct it at the time. The resident's care plan required assistance with toileting, and the facility's infection control policy emphasized the importance of proper cleaning to prevent the spread of infection.
Failure to Administer Anti-Seizure Medication as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was prescribed Lacosamide, an anti-seizure medication. The resident, who had diagnoses including metabolic encephalopathy, epilepsy, and severe intellectual disability, was admitted for respite care and had a physician's order for Lacosamide 200 mg to be administered twice daily. Despite this order, the resident did not receive four doses of the medication over a two-day period. Documentation in the medication administration record incorrectly indicated that the medication had been given, but a review of the narcotic count sheet and interviews with staff confirmed that the medication was not administered as ordered. The failure to administer the medication was due to staff being unable to locate the Lacosamide in the medication cart, as it was not in its usual alphabetical order. Both LVNs responsible for medication administration during this period stated that they could not find the medication and believed it was unavailable. They attempted to contact the pharmacy and checked the emergency kit, but did not notify the DON or the physician immediately about the unavailability of the medication. The medication was later found in the cart, but not before the resident missed multiple doses and subsequently experienced several seizures, resulting in a transfer to the hospital for evaluation. Interviews with staff revealed a lack of adherence to procedures for handling unavailable medications, including failure to notify appropriate parties and to document actions taken. The facility's policy required immediate reporting of medication errors to the physician and DON, as well as completion of a medication error report. The incident was discovered through an audit of medication records and narcotic sheets, which confirmed that the medication was not administered as prescribed and that documentation had been falsified.
Failure to Administer Antiepileptic Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of metabolic encephalopathy, epilepsy, and severe intellectual disability did not receive her prescribed antiepileptic medication, Lacosamide, for two consecutive days. The medication was ordered to be administered twice daily, but four doses were missed. Documentation in the Medication Administration Record (MAR) indicated the medication had been given, but a review of the narcotic count sheet and interviews with nursing staff revealed that the medication was not actually administered on those days. Nursing staff reported being unable to locate the Lacosamide in the facility, despite it being present in the narcotic box. Both nurses responsible for medication administration during the incident stated they believed the medication was unavailable and did not notify the DON or physician immediately. Instead, they attempted to contact the pharmacy and checked the emergency kit, but did not escalate the issue or follow established procedures for unavailable medications. The MAR was inaccurately documented, showing the medication as administered when it was not. The resident subsequently experienced multiple seizures and was sent to the hospital for evaluation. The physician confirmed being notified of the missed doses and stated that missing the medication could induce seizures. The facility's investigation found that the nurses failed to administer the medication as ordered and did not follow proper protocols for medication unavailability or documentation.
Improper Use of Rollator Walker for Resident Transport Resulting in Injury
Penalty
Summary
A deficiency occurred when a nurse transported a resident using a rollator walker as a wheelchair, contrary to proper procedures. The resident, who had a history of falls with injury, rheumatoid arthritis, prior fractures, advanced osteoarthritis, lack of coordination, and muscle weakness, required staff assistance for walking and toileting. Despite these needs, the nurse allowed the resident to choose the rollator for transport to the restroom, even though the nurse was aware that a wheelchair should have been used for such transfers. During the transport, the resident attempted to adjust herself in the seat of the rollator while it was in motion and subsequently fell forward, resulting in a non-displaced hairline fracture to her left proximal humerus and a periprosthetic fracture around her right internal prosthetic hip joint. The incident was documented in nursing notes, and the resident was sent to the emergency room for evaluation and treatment. The nurse involved admitted to having previously used the rollator for transfers and acknowledged that she should have used a wheelchair, especially given the resident's weakness and history of fractures. Interviews with other staff members, including CNAs and therapy staff, confirmed that the correct method for transporting residents is by wheelchair or ambulation with a gait belt, and that rollators are not to be used as transport devices. The facility did not have a specific safe patient handling policy at the time of the incident. The event led to the identification of Immediate Jeopardy due to the failure to provide adequate supervision and assistance devices to prevent accidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Whitesboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gainesville Convalescent Center | 13.4 mi | ★★★★★ | 18 | 0 |
| Renaissance Care Center | 13.4 mi | ★★★★★ | 1 | 0 |
| Pecan Tree Rehab And Healthcare Center | 13.4 mi | ★★★★★ | 13 | 2 |
| Avir At River Valley | 15.1 mi | ★★★★★ | 1 | 0 |
| Focused Care At Sherman | 15.8 mi | ★★★★★ | 3 | 0 |
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