Health inspection·August 19, 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 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 one of three residents (Resident #1) reviewed for infection control. 1. The facility failed to place Enhanced Barrier Precautions signage near Resident #1's room.2. CNA A and CNA B failed to implement Enhanced Barrier Precautions while providing incontinent care to Resident #1. 3. CNA A failed to perform hand hygiene while providing incontinent care to Resident #1.These failures could place residents at risk for healthcare associated cross contamination and infections. Findings include:Record review of Resident #1's face sheet, dated 08/19/25, reflected an [AGE] year-old male, who most recently admitted to the facility on [DATE]. Resident #1 had diagnoses which included sepsis (a life-threatening complication of an infection which occur when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body), functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), and urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine).Record review of Resident #1's MDS Assessment, dated 07/07/25, reflected he had a catheter (a thin, flexible medical tube used to drain fluids or deliver medications to or from the body, most commonly a urinary catheter which drains urine from the bladder ).Record review of Resident #1's Physician's Orders, dated 08/19/25, reflected he was on Enhanced Barrier Precautions and Standard Precautions due to having a catheter. The orders specified, .Resident is not limited to room or activities. [NAME] PPE inside the room.Staff must don gown and gloves when performing high contact care such as bathing/showering, peri -care/brief changes, dressing changes, meds via enteral tube or central line, toileting, transfers, providing hygiene, changing linens, device care. The start date for this order was 07/01/25 and there was no set end date.Record review of Resident #1's Care Plan, dated 08/19/25, reflected he had a catheter due to his diagnosis of benign prostatic hyperplasia and urinary obstruction. A goal for Resident #1 was to show no signs or symptoms of urinary infection. The start date for this focus area was 07/01/25 and there was no set end date. The Care Plan did not specify any focus area for Enhanced Barrier Precautions or standard precautions.Observation on 08/19/2025 at 12:20 PM revealed there was no Enhanced Barrier Precaution signage by Resident #1's room. Neither CNA A nor CNA B donned a gown upon entering Resident #1's room to provide incontinent care . When performing incontinent care, CNA A did not perform hand washing or hand hygiene or change gloves between wiping Resident #1's perineum and obtaining new wipes from the clean wipe pack. When CNA A did change gloves, she did not wash her hands or apply hand sanitizer before putting on another pair of gloves.During an interview with CNA A on 08/19/2025 at 12:30 PM, she stated she was allergic to hand sanitizer and forgot to wash her hands between glove changes. She stated the failure placed residents at risk for healthcare associated Residents Affected - Few Page 1 of 2 676352 676352 08/19/2025 Stonemere Rehabilitation Center 11855 Lebanon Road Frisco, TX 75035

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cross contamination and infections.During an interview with RN C on 08/19/2025 at 12:58 PM, he stated he was not aware Enhanced Barrier Precautions signage was not posted near Resident #1's door. He stated this placed residents at risk for infection, should staff fail to see the sign and use appropriate PPE.During an interview with the Director of Nursing on 08/19/2025 at 1:00 PM, she stated she was not aware Enhanced Barrier Precautions signage was not posted near Resident #1's door. She stated she would place a sign on the door immediately. The Director of Nursing said the risk of improper hand washing/hand hygiene during incontinent care included the risk of cross contamination and infection .Record review of the facility's Enhanced Barrier Precautions policy, dated 12/2024, reflected, .Enhanced Barrier Precautions shall apply to the care of all residents in the facility with an infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, colostomy care, medication administration via g-tube, and device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing.Record review of the facility's Hand-Washing/Hand Hygiene policy, dated 12/2024, reflected, .The facility considers hand hygiene the primary means to prevent the spread of infections.2.All personnel shall follow the hand-washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.9.The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 676352 Page 2 of 2