Stonemere Rehabilitation Center: Infection Control Lapse - TX
The sign in question was an Enhanced Barrier Precautions notice, the kind posted outside a resident's room to alert anyone entering that extra protective measures apply during hands-on care. For Resident 1, no such sign had been placed on the door. The Director of Nursing said she was unaware it was missing. She told inspectors she would put one up immediately.
Enhanced Barrier Precautions are not a minor procedural formality. They exist for residents who have infections, known colonizations with drug-resistant organisms, open wounds, or indwelling medical devices such as urinary catheters, feeding tubes, or central lines. The precautions require staff to wear a clean gown during high-contact care activities: bathing, dressing, changing briefs, assisting with toileting, wound care, any procedure involving a device. The logic is straightforward. During incontinent care, a staff member without a gown can transfer pathogens from one resident to the next, or from a contaminated surface to a wound or catheter site.
The facility's own Enhanced Barrier Precautions policy, dated December 2024, spelled this out in detail. The policy listed the exact situations that trigger precautions and the exact protective steps required. The hand hygiene policy, also dated December 2024, went further: gloves alone are not enough. The facility's written standard held that glove use does not replace hand washing, and that combining gloves with routine hand hygiene is the recognized best practice for preventing healthcare-associated infections.
The Director of Nursing confirmed the risk herself. She told inspectors that improper hand washing during incontinent care created the risk of cross-contamination and infection. That is not a contested point. It is what the facility's own leadership said out loud when asked.
What the inspection does not resolve is how long the sign had been missing. The report does not say when Resident 1's precaution status was established, or how many staff members entered that room without knowing the precautions applied. It does not say whether gowns were used during that period, or whether hand hygiene was performed correctly. Those questions remain open.
What is documented is the gap between what the facility wrote down and what it did. Stonemere's December 2024 policies described a system designed to protect residents from the spread of infections. The sign on the door is how that system communicates to every person who crosses the threshold, including staff who may be new, pulled from a different unit, or simply moving fast during a busy shift. Without the sign, the system depends on each individual already knowing the precautions apply. That is a different system entirely, and a weaker one.
The Director of Nursing said she would fix it that afternoon. Whether the underlying breakdown, the one that allowed the sign to go missing in the first place, was addressed is not something the inspection report answers. Resident 1 had been in that room the whole time.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
STONEMERE REHABILITATION CENTER in FRISCO, TX was cited for violations during a health inspection on August 19, 2025.
For Resident 1, no such sign had been placed on the door.
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.