Calder Woods: Hand Hygiene Failures During Incontinent Care - TX
The resident at the center of the inspection finding was an elderly woman admitted to Calder Woods that same day. She had been diagnosed with major depressive disorder, hypertension, a hip fracture, and constipation. Her cognitive assessment was incomplete at the time of the inspection, listed only as unable to be performed. Her care plan contained nothing about infection control.
Inspectors observed the care directly. At 9:49 a.m., a second nursing assistant and the aide identified in the report as CNA B entered the room together. Both performed hand hygiene at the start and put on gloves. CNA B lowered the resident's brief and cleaned her perineal area. Then she removed her gloves and put on a new pair — without washing her hands first.
The two aides turned the resident onto her side. CNA B cleaned her buttocks, rolled the soiled brief inward, and threw it away. She removed her gloves again and put on another new pair — again without washing her hands.
She then placed a clean brief on the resident, adjusted her, and covered her. Only after finishing, while cleaning up supplies, did CNA B perform hand hygiene.
Eight minutes later, inspectors interviewed her. CNA B said at first that she had done hand hygiene. Then she reconsidered. She acknowledged she had not washed her hands after the glove changes during care, and said she knew she should have. She said she understood the risk: that skipping hand hygiene could spread infection.
What made the lapse harder to explain was what inspectors found in the facility's own training records. On July 9, five weeks before the inspection, CNA B had signed her name to an in-service training report on incontinent care. The second page of that document laid out the procedure step by step. Step seven: remove the old brief, place it in a bag, remove gloves, wash hands, reapply gloves. Step ten: remove gloves and place in bag. Step eleven: wash hands and apply new gloves. Step thirteen: remove gloves and wash hands.
She had signed it. She had not followed it.
The facility's written policy on brief and pad handling, dated November 2024, described the same sequence. Perform hand hygiene, put on gloves. Remove and discard gloves, perform hand hygiene, put on clean gloves. Discard the soiled brief. Remove and discard gloves. Perform hand hygiene.
The Director of Nursing, interviewed at 1:25 p.m. on the day of the inspection, described the expectation the same way: hand hygiene before starting care, when changing gloves, and after care was complete. She said she and the assistant director of nursing were responsible for training staff on the practice. She said failing to complete proper hand hygiene could cause cross contamination.
The licensed vocational nurse on duty said the same. Hand hygiene before care, after the brief change itself, before leaving the room. Staff had been trained on it.
The inspection was triggered by a complaint. Inspectors reviewed six residents for infection control practices and cited the deficiency for one.
The federal finding classified the harm level as minimal or potential, meaning inspectors did not document that the resident suffered an infection as a result. What they documented was the gap between what a facility trains its staff to do and what a staff member actually did, observed in real time, on a woman who had arrived at the facility that morning and whose care plan had not yet included a single note about keeping her safe from infection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Calder Woods from 2025-08-11 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.
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Last verified: November 3, 2026 · Our methodology
CALDER WOODS in BEAUMONT, TX was cited for violations during a health inspection on August 11, 2025.
The resident at the center of the inspection finding was an elderly woman admitted to Calder Woods that same day.
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.