Ebony Lake Nursing: Hand Hygiene Failure During Care - TX
The patient, a man whose age was redacted in inspection records, has lived with the effects of a stroke that left him paralyzed and weak on the right side of his body. He has type 2 diabetes. He cannot toilet himself. Two staff members are required to reposition him in bed. When inspectors reviewed his records, his cognitive assessment placed him in the moderately impaired range, meaning he may have had limited ability to notice or object to what was happening.
He was entirely dependent on the people caring for him to get it right.
On April 28, at 2:15 in the afternoon, inspectors watched CNA A and a second nursing assistant enter his room and set supplies on the bedside table. CNA A washed her hands, put on a gown and gloves, and removed the man's soiled brief. Then she pulled off her gloves and put on a new pair without washing or sanitizing her hands. She cleaned the perineal area. She removed those gloves. She did not wash her hands. She put on another pair of gloves. She finished the procedure.
She washed her hands when it was over. So did her colleague. That was the only hand hygiene either of them performed during the entire process, other than CNA A's wash at the very start.
Ten minutes after the observation ended, inspectors interviewed CNA A directly. She did not dispute what they had seen. "I should have sanitized or washed my hands before donning new gloves," she said. She acknowledged she should have done it between each glove change. Her explanation: "I forgot about it because I was nervous."
She also said she understood the consequence. The potential negative outcome, she told inspectors, "could be a spread of infection."
CNA A said she had received training on infection control and handwashing.
The facility's Director of Nursing, interviewed the following day, confirmed what the procedure should have been: hands washed if gloves were visibly soiled, or hand sanitizer used between glove changes. She said the Assistant Director of Nursing and she were responsible for monitoring staff compliance with infection control practices. She, too, named the risk plainly: "cross contamination or infection even though the staff had the gloves as a barrier, they still could contaminate or give the resident an infection."
That last point matters. Gloves are not a substitute for hand hygiene. They contain whatever contamination is already on the hands when they go on, and they can transfer it to the next surface touched. Removing soiled gloves and immediately donning new ones without cleaning the hands in between defeats the purpose of changing gloves at all.
The inspection was triggered by a complaint and completed April 29. Inspectors cited the facility for failing to maintain an infection control program designed to prevent the spread of disease. The violation was tagged at a level of minimal harm or potential for actual harm, affecting one resident.
The man at the center of the finding, dependent on staff for every aspect of his personal care, diabetic, partially paralyzed, cognitively impaired, had no way to enforce the standard himself. He had no way to know, in the moment, whether the person caring for him was doing it safely. He had no way to object.
He had to trust that someone was watching. On April 28, the only people watching were federal inspectors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ebony Lake Nursing and Rehabilitation Center from 2026-04-29 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 19, 2026 · Our methodology
Ebony Lake Nursing and Rehabilitation Center in Brownsville, TX was cited for violations during a health inspection on April 29, 2026.
Two staff members are required to reposition him in bed.
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.