The violations occurred during morning care on November 20 at Jourdanton Nursing and Rehabilitation, where inspectors observed CNAs H and I enter the room of Resident #11 and immediately begin intimate care without washing their hands first.
Resident #11 has lived at the facility for over a decade, readmitted in 2020 with multiple complex conditions including vascular dementia, schizoaffective disorder, diabetes, and irritable bowel syndrome. The resident scores 9 on cognitive assessments, indicating moderate impairment, and requires total assistance with bowel and bladder incontinence.
The resident's care plan specifically addresses skin integrity problems related to "history of excoriation on the scrotum due to moisture, friction, or incontinence" and calls for maintaining proper incontinence care to prevent further breakdown.
At 6:33 AM, inspectors watched the two CNAs enter the room and begin care without the required hand washing. CNA H compounded the violation by changing gloves during the procedure without sanitizing his hands between the contaminated and clean phases of care.
The assistant cleaned the resident's buttocks, then changed gloves before touching clean briefs without using hand sanitizer between the glove changes.
When confronted two minutes later, both nursing assistants admitted their failures.
"They stated they had not washed their hands before starting the care," inspectors wrote. CNA H acknowledged changing gloves "but did not use sanitizer between change of gloves."
Both staff members told inspectors "they forgot but knew hand hygiene was important to prevent infection for the residents." They confirmed receiving annual infection control training.
The facility's Director of Nursing explained proper protocols during an interview the same morning. Staff must wash hands before starting resident care and use sanitizer or wash hands between glove changes to prevent infection spread, she said.
The DON confirmed providing infection control training annually and checking staff skills on the same schedule.
The facility's own infection control policy, dating to 2018, explicitly requires employees to wash hands for ten to fifteen seconds before and after direct contact with residents. The policy designates alcohol-based hand rub as the preferred method in most situations.
Staff must use alcohol-based sanitizer "before moving from contaminated body site to clean body site during resident care" and "after removing gloves," according to facility guidelines.
The violations put residents at risk for infection through improper care practices, inspectors determined. For Resident #11, with existing skin breakdown from moisture exposure and total incontinence, the infection control failures created additional vulnerability.
The resident's complex medical history compounds the risks. Vascular dementia affects cognitive abilities, while schizoaffective disorder involves abnormal thought processes and unstable mood. Diabetes can slow wound healing and increase infection susceptibility.
Irritable bowel syndrome, affecting the large intestine, causes symptoms including abdominal pain, bloating, gas, constipation, and diarrhea that complicate incontinence management.
The inspection found these hand hygiene failures despite the facility's stated commitment to annual training and skill verification. Both CNAs demonstrated awareness of proper infection control protocols but failed to follow them during actual patient care.
The November 21 complaint inspection documented the violations as causing minimal harm or potential for actual harm. However, for residents like #11 with compromised skin integrity and multiple medical vulnerabilities, even basic infection control lapses can have serious consequences.
The facility failed to establish and maintain an adequate infection prevention and control program designed to provide a safe, sanitary environment and help prevent communicable disease transmission, inspectors concluded.
The observation lasted just two minutes but revealed systemic gaps between policy and practice in fundamental infection control procedures that protect the facility's most vulnerable residents from preventable harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jourdanton Nursing and Rehabilitation from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Jourdanton Nursing and Rehabilitation
- Browse all TX nursing home inspections