Health inspection·December 3, 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 observation, interview and record review the facility failed to 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 disease and infection for two (Resident #1 and, Resident #2) of three residents reviewed for infection control in that:-LVN A failed to perform hand hygiene and changed her gloves at the appropriate times while providing urostomy care for Resident #1.-CNA B failed to perform hand hygiene and change his gloves at the appropriate times while providing incontinence care for Resident #2.These deficient practices could place residents at risk for infection due to improper care practices.Findings included: Review of Resident #1's face sheet, dated 10/16/25, revealed a 90- year- old male admitted to the facility on [DATE] with diagnoses of urinary tract infection, neuromuscular dysfunction of bladder (occurs when an injury or disease disrupts the electrical signals between the nervous system and bladder function), muscle weakness and Alzheimer's disease (a degenerative brain disorder that leads to a progressive and irreversible decline in memory and cognitive abilities). Review of Resident #1's MDS assessment, dated 09/01/25, revealed Resident #1 required total dependence with most ADLs and one-person assistance with transfer. Resident #1 had a urostomy (a device that redirects the ureter (transport tube) to the abdomen to bypass the bladder after bladder or urinary tract problems). Review of Resident #1 's care plan, dated 09/18/25, revealed Resident #1 had urostomy due to diagnosis of bladder obstruction. The Its goal was to show no signs and symptoms of urinary infection through review date of 09/28/25. Observation of urostomy care on Resident #1 on 10/15/25 at 1:30 p.m. revealed LVN A washed her hands and put on gloves before the start of care. She prepared a clean field on a bedside table. LVN A removed Resident #1's brief. She emptied the urine from the pouch and removed the whole pouching system. The drained urine was clear yellow without sediments. She cleansed the stoma (a surgically created opening in the skin). There was no swelling, irritation or redness noted on the stoma area. LVN A's gloves were visibly soiled. She did not change gloves, washed her hands, or performed hand hygiene. She retrieved a new pouching system with the same soiled gloves. She prepped the skin area before inserting a new pouch system. LVN A used the same soiled gloves throughout the urostomy care. She removed her gloves and washed her hands. LVN A picked up the trash before exiting Resident #1's room. During In an interview on 10/15/25 at 1:46 p.m., LVN A said she was employed by the facility since February 2025 and received infection control training about 3 months ago. LVN A stated she should have washed her hands and performed hand hygiene before picking up the new and clean pouching system for the urostomy. LVN A said she was nervous., She said that was the reason she failed to follow a good infection control practice. She noted Resident #1 could get an infection and become sick. Review of Resident #2's face sheet, dated 10/16/25, revealed the resident was an 81- year- old female admitted to the facility on [DATE] with diagnoses of retention of urine, neuromuscular dysfunction of the bladder ((occurs when an injury or disease disrupts the electrical Residents Affected - Some (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: 675633 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 675633 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holland Lake Rehabilitation and Wellness Center 1201 Holland Lake Dr Weatherford, TX 76086 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)