The violation occurred on October 16 at 12:34 PM on Hall 500 at Pflugerville Care Center. CNA A and CNA B distributed meal trays to multiple residents without using hand sanitizer or washing hands between each delivery, according to federal inspection records.
Both assistants touched residents' doors while setting up food trays and moved the food cart down the hallway. The inspection report documented the staff "moving from one resident to another without using hand hygiene between meals."
When confronted 16 minutes later, CNA A admitted the mistake. "I had just started at the facility today," the assistant told inspectors at 12:50 PM. "I did get training on hand hygiene when they did the orientation but I forgot."
The assistant understood the consequences. "If hand hygiene is not used in residence contamination and getting sick," CNA A said.
CNA B gave a similar account five minutes later. "I was in training," the assistant said. "I just started this morning and received training on hand hygiene."
Like the colleague, CNA B knew the risks. "If proper hand hygiene is not used when passing food to residents, they could get sick."
Both assistants had received infection control training that very morning but failed to follow protocols during their first meal service.
An LVN interviewed at 3:22 PM described proper procedure. "Staff should sanitize their hands before grabbing food trays to give to the residents, then again before grabbing another food tray," the nurse said.
The LVN called it "an infection control issue" and said witnessing such behavior would prompt immediate correction. "If I saw a staff member not using hand hygiene, I would remind them."
Another CNA explained standard practice during a 3:38 PM interview. "When passing out food trays she is supposed to use hand hygiene between giving food trays to residents," according to the inspection report.
That assistant described the proper sequence: "When she gives a food tray to a resident, she will clean her hands and repeat the process."
The CNA said she had never witnessed improper hygiene practices. "She has not seen any staff not using hand hygiene at the facility and if she did, she would remind them to use hand hygiene while serving residents food."
The assistant recognized the danger. "It was an infection control issue and not using hand hygiene put the resident at risk of getting sick."
The Director of Nursing spoke with inspectors at 3:48 PM and confirmed facility expectations. "Proper hand hygiene should be always done when giving food to residents at the facility," the DON said. "Hands should be cleaned in between trays."
The DON acknowledged learning about the violation involving CNA A and CNA B and had "already completed the in-service" retraining.
Despite the immediate response, the DON claimed no previous knowledge of hygiene violations. "DON has not witnessed staff not using hand hygiene and if she does then she will remind them and do in-service training."
The facility's hand hygiene policy addresses meal service specifically. The undated document states staff "may use alcohol-based hand cleaner or soap/water" and lists "before and after assisting a resident with meals" as required times for hand cleaning.
The violation occurred during the most vulnerable moment for infection transmission. Food service requires staff to enter multiple rooms, touch various surfaces, and have direct contact with residents who may have compromised immune systems.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm" affecting "some" residents. The finding places Pflugerville Care Center at risk for cross contamination and infections among the resident population.
The timing proved particularly concerning. Both assistants had completed orientation training on proper hand hygiene the same morning they violated protocols. The gap between knowledge and practice occurred within hours of instruction.
The inspection revealed a facility where policies existed but implementation failed during actual care delivery. Staff understood infection control principles but abandoned them during routine tasks, creating unnecessary health risks for vulnerable residents who depend on proper hygiene practices for protection from preventable illnesses.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pflugerville Care Center from 2025-11-24 including all violations, facility responses, and corrective action plans.