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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the
development and transmission of communicable disease and infection for four (Residents #1, #2, #3 and
#4) of five residents reviewed for infection control.
Residents Affected - Some
MA M failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #1, #2, #3
and #4.
These failures could place residents at-risk of cross contamination which could result in infections or illness.
Findings included:
Record review of Resident #1's face sheet on 08/17/23 revealed Resident #1 was an [AGE] year-old male
admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of malignant neoplasm (form of
cancerous tumor), Type 2 diabetes, hypertension (high blood pressure), disorder of water balance, and
respiratory failure.
Record review of Resident #2's face sheet on 08/17/23 revealed Resident #2 was an [AGE] year-old female
admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Type 2 diabetes,
hypertension, respiratory failure, and contusion of the left knee.
Record review of Resident #3's face sheet on 08/17/23 revealed Resident #3 was a [AGE] year-old female
admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of hypertension, pneumonia
(inflammatory condition of the lung), and heart failure.
Record review of Resident #4's face sheet on 08/17/23 revealed Resident #4 was an [AGE] year-old female
admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of hypertension, chronic
obstructive pulmonary disease (progressive lung disease), and hyperlipidemia (high cholesterol).
Observation on 08/17/23 between 9:45 AM-10:20 AM of MA A revealed she failed to disinfect the reusable
blood pressure cuff with a disinfecting wipe between blood pressure readings on Resident #1, Resident #2,
Resident #3, and Resident #4. MA A cleaned the blood pressure cuff after medication administration for
Resident #4 with disinfectant wipes from her medication cart.
Interview on 08/17/23 at 10:20 AM with MA A revealed she was aware of the requirement to disinfect
(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:
675759
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
675759
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonegate Nursing and Rehabilitation
4201 Stonegate Blvd
Fort Worth, TX 76109
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
the blood pressure cuff between residents, but the presence of the surveyor made her nervous. She
revealed that not disinfecting equipment between residents could cause infections to be passed from one
resident to another.
Interview on 08/17/23 at 10:23 AM with the ADON revealed she and the DON were responsible for training
staff on infection control, hand hygiene, and disinfecting equipment. The ADON stated staff were expected
to perform hand hygiene upon exiting every resident room. If equipment was used, staff were to disinfect
after every use prior to using the equipment on the next resident. The ADON stated MA A should have
disinfected the blood pressure cuff after every use to ensure she was not cross contaminating or passing
infection from one resident to another.
Interview on 08/17/23 at 11:45 AM with the DON revealed the expectation was that staff would disinfect all
reusable medical equipment between each resident use, to avoid cross contamination. The DON stated
staff had disinfecting wipes available to them. She revealed she completed a staff in-service training
immediately on disinfection of reusable medical equipment.
Record review of training for MA A revealed an in-service dated 08/17/23 entitled Infection Control with
emphasis on COVID-19, Hand Hygiene, Disinfecting Blood Pressure Equipment before and after each
resident.
Review of facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, dated October
2018, reflected: .Resident-Care Equipment, including reusable items and durable medical equipment will be
cleaned and disinfected according to current recommendations for disinfection revealed Reusable items are
cleaned and disinfected or sterilized between residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675759
If continuation sheet
Page 2 of 2
