Crowell Nursing Center: Hand Hygiene Violations - TX
Federal inspectors observed the violation on April 8 at Crowell Nursing Center during routine care for Resident #26, who requires substantial assistance with toileting and is frequently incontinent of both urine and bowel.
CNA C began the care properly, washing her hands and putting on gloves before cleaning the resident's perineal area with three wipes. Working with another assistant, she then cleaned the resident's rectal and buttocks area with three additional wipes and removed soiled linens.
But when CNA C removed her dirty gloves, she immediately put on new gloves without washing her hands first. Only after completing the care and pulling up the resident's covers did she remove the clean gloves and wash her hands.
The 26-year-old female resident has severe cognitive impairment from dementia, muscle weakness, and a history of stroke that damaged her brain's language centers. Her care plan specifically addresses her incontinence risk, noting she faces "complications of incontinence" due to cognitive impairment.
When questioned the next morning, CNA C acknowledged her error. She told inspectors she "should have washed her hands when she removed her gloves after cleaning Resident #26 and before placing new gloves and putting on the new brief."
Her colleague, CNA D, confirmed that staff could use hand sanitizer between glove changes if needed. Both assistants understood the consequences of their actions.
"If they do not perform proper hand hygiene then a resident could get an infection and the staff could spread infection," CNA C told inspectors. CNA D agreed.
The facility's Assistant Director of Nursing, who trained staff on hand hygiene, expects workers to wash hands when removing gloves, before putting on new gloves, or whenever gloves become soiled. The Director of Nursing confirmed this expectation and added that hand hygiene must be performed frequently in the dining room as well.
Both nursing leaders acknowledged that improper hand hygiene allows staff to spread infections.
CNA C had received quarterly infection control training on hand hygiene just three weeks before the violation. The March 20 training covered "Hand Hygiene Policy and Procedure Review," proper handwashing technique, and when to use alcohol-based hand gel versus washing with soap and water.
The facility's hand hygiene policy, last reviewed in February 2022, explicitly states that "the use of gloves does not replace hand hygiene." The policy requires handwashing when moving from a contaminated body site to a clean body site during resident care.
This represents exactly the scenario inspectors witnessed. CNA C moved from cleaning the resident's rectal area to applying a clean brief without the required handwashing step between removing contaminated gloves and donning fresh ones.
Federal regulations require nursing homes to maintain infection prevention programs that provide safe, sanitary environments and help prevent the development and transmission of communicable diseases. The violation puts vulnerable residents at risk for infections and tissue breakdown.
Resident #26's condition makes her particularly susceptible to complications from poor hygiene practices. Her severe dementia leaves her unable to advocate for herself or communicate discomfort. Her frequent incontinence requires multiple daily intimate care interactions with staff.
The inspection found this hand hygiene failure affected few residents, but the potential consequences extend beyond the individual patient. Healthcare-associated infections can spread rapidly through nursing facilities, particularly among residents with compromised immune systems and cognitive impairments who cannot maintain their own hygiene.
The violation occurred despite recent training and clear policies. CNA C demonstrated knowledge of proper procedures when questioned but failed to follow them during actual patient care, highlighting the gap between classroom instruction and bedside practice in long-term care facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crowell Nursing Center from 2026-04-09 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 14, 2026 · Our methodology
CROWELL NURSING CENTER in CROWELL, TX was cited for violations during a health inspection on April 9, 2026.
CNA C began the care properly, washing her hands and putting on gloves before cleaning the resident's perineal area with three wipes.
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.
Frequently Asked Questions
- What happened at CROWELL NURSING CENTER?
- CNA C began the care properly, washing her hands and putting on gloves before cleaning the resident's perineal area with three wipes.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in CROWELL, TX, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from CROWELL NURSING CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 675013.
- Has this facility had violations before?
- To check CROWELL NURSING CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.