Inspection·January 29, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 for 1 (Resident #1) of 3 residents reviewed for infection control practice. Residents Affected - Few CNA A and CNA B failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #1. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet, dated 01/29/25, revealed the resident was a 78- year- old female admitted to the facility on [DATE] with diagnoses diabetes mellitus and Alzheimer's disease. Review of Resident #1's quarterly MDS assessment, dated 01/13/25, revealed she required dependent assistance with most activity of daily living (ADLs) and one-person assist. Resident #1 was always incontinent of bladder and bowel. Review of Resident #1's care plan undated revealed the Resident #1 is at risk for skin breakdown due to decreased circulation in the lower extremities relate to peripheral vascular disease. Observation of incontinent care for Resident #1 on 01/29/25 at 1:42 p.m. revealed CNA A and CNA B did not wash their hands before the start of care. Both CNAs donned gloves. CNA A and CNA B removed the resident's brief which was completely soiled with urine and fecal matter. CNA A wiped the resident from front to back. Her gloves were visibly soiled, but she continued to use it to clean the resident. CNA A did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA B was assisting CNA A to provide care to Resident #1. CNA B wore the same gloves for repositioning including touching the perineal area and fastened the clean brief to the resident. CNA A and CNA B doffed their gloves. Both exited Resident #1's room without washing hands or performing hand hygiene. In an interview on 01/29/25 at 1:55p.m with CNA A, she said she had been employed in the facility for 2 years but left and started again today. She could not remember the last time she received infection control training or in-services. CNA A stated cross contamination meant mixing clean with dirty. CNA A stated she should have washed hands and changed gloves before retrieving the clean brief and (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 2 Event ID: 455906 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 455906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lone Star Rehabilitation & Wellness Center 2601 Northwest Loop Stephenville, TX 76401 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)