Stonemere Rehab: Missing Infection Control Signs - TX
The registered nurse responsible for the unit told federal inspectors on August 19 that he was completely unaware Enhanced Barrier Precautions signage was not posted near Resident #1's door. RN C acknowledged this "placed residents at risk for infection, should staff fail to see the sign and use appropriate PPE."
The Director of Nursing expressed identical ignorance during her interview at 1:00 PM the same day. She also had no knowledge the required warning signs were absent and promised to "place a sign on the door immediately" after inspectors pointed out the violation.
Enhanced Barrier Precautions represent one of the most basic infection control measures in nursing homes, designed to prevent the spread of multidrug-resistant organisms and healthcare-associated infections. The missing signage meant staff entering the resident's room might not have worn proper protective equipment for weeks or months.
According to the facility's own policy, dated December 2024, 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." The policy also covers residents with "wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO."
The policy requires staff to "wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during high contact resident care activities." These activities include dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, colostomy care, medication administration via feeding tube, and device care involving central lines, urinary catheters, feeding tubes, tracheostomy equipment, ventilators, and wound care for any skin opening requiring a dressing.
Without proper signage, staff performing any of these routine care activities on Resident #1 might have unknowingly exposed themselves and subsequently contaminated other residents throughout the facility.
The Director of Nursing acknowledged to inspectors that "the risk of improper hand washing/hand hygiene during incontinent care included the risk of cross contamination and infection." This admission underscored how the missing signage created a dangerous gap in the facility's infection prevention protocols.
Stonemere's Hand-Washing/Hand Hygiene policy, also dated December 2024, states that "the facility considers hand hygiene the primary means to prevent the spread of infections." The policy requires "all personnel shall follow the hand-washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors."
The policy emphasizes that "the use of gloves does not replace hand washing/hand hygiene" and describes the "integration of glove use along with routine hand hygiene" as "recognized as the best practice for preventing healthcare-associated infections."
But policies mean nothing when key staff members remain unaware of basic safety requirements for individual residents. The fact that both the unit nurse and the Director of Nursing were oblivious to the missing signage suggests a fundamental breakdown in the facility's infection control oversight.
The violation occurred despite federal regulations requiring nursing homes to maintain comprehensive infection prevention and control programs. These programs must include proper identification of residents requiring enhanced precautions and clear communication of those requirements to all staff members.
Healthcare-associated infections in nursing homes can prove particularly devastating for elderly residents with compromised immune systems. Multidrug-resistant organisms spread rapidly in congregate care settings when proper precautions fail.
The inspection found that few residents were affected by this particular violation, and the level of harm was classified as minimal. However, the potential consequences of uncontrolled infection spread in a nursing facility extend far beyond any single resident.
Federal inspectors discovered the missing signage during a complaint investigation on August 19. The complaint that triggered the inspection was not specified in the available documentation, but the infection control violation emerged during the review process.
Stonemere Rehabilitation Center's failure to maintain proper Enhanced Barrier Precautions signage represents exactly the kind of basic safety oversight that can transform a single infected resident into a facility-wide outbreak. The nursing staff's complete ignorance of the missing signs suggests this was not a recent oversight but a sustained failure of the facility's infection control systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonemere Rehabilitation Center from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
STONEMERE REHABILITATION CENTER in FRISCO, TX was cited for violations during a health inspection on August 19, 2025.
The missing signage meant staff entering the resident's room might not have worn proper protective equipment for weeks or months.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.