Calder Woods: Hand Hygiene Failures During Care - TX
The violation occurred during a federal inspection on August 11 at Calder Woods, where inspectors observed CNA B providing incontinence care to a resident with depression and a hip fracture. The aide changed gloves twice during the procedure without washing her hands, creating potential for cross-contamination.
The resident, identified as a female who scored 99 on cognitive assessment — meaning she was unable to complete the interview — had been admitted with major depressive disorder, hypertension, and constipation. Her care plan contained no information about infection control interventions.
At 9:49 AM, inspectors watched as CNA B and another aide entered the resident's room. Both initially performed proper hand hygiene, closed the door and blinds, and put on gloves before beginning care.
CNA B lowered the resident's brief and cleaned her perineal area appropriately. But when her gloves became soiled, she removed them and put on new ones without washing her hands first.
The aides then helped the resident turn onto her side. CNA B cleaned the woman's buttocks, rolled the dirty brief inward, and threw it away. Again, she removed her soiled gloves and put on fresh ones without performing hand hygiene.
Only after placing a clean brief and adjusting the resident did CNA B finally wash her hands.
When confronted eight minutes later, CNA B initially claimed she had completed proper hand hygiene. But under questioning, she acknowledged her failures.
"She stated she realized she had not done hand hygiene after incontinent care and glove changes, and she should have," the inspection report noted. "She stated she was trained to complete hand hygiene after glove changes and when going from a dirty to clean brief."
CNA B understood the consequences. She told inspectors that not performing hand hygiene meant "infection could spread."
The facility's own training materials, signed by CNA B on July 9, explicitly outlined the required steps. The in-service training document stated: "Remove old brief and place in bag. Remove gloves, wash hands and reapply gloves... Remove gloves and place in bag. Wash hands and apply new gloves. Apply new brief or pad. Remove gloves and wash hands."
LVN A, interviewed at 12:57 PM, confirmed the facility's expectations. Hand hygiene should be completed "before care, after the change (brief change) itself, and before leaving the room," she said. Staff received training on hand hygiene for infection control purposes.
The Director of Nursing was even more specific about when hand washing was required. Staff providing incontinence care must perform hand hygiene "before starting care, when changing gloves (such as when the gloves were dirty), and after care."
She acknowledged that she and the Assistant Director of Nursing were responsible for training staff about hand hygiene. Not following proper procedures "could cause cross contamination," she said.
The facility's written policy on incontinence brief handling, dated November 18, 2024, laid out the same requirements CNA B had ignored. The policy required staff to "perform hand hygiene, put on gloves... remove and discard your gloves, perform hand hygiene, put on clean gloves... discard soiled brief... remove and discard your gloves... perform hand hygiene."
Federal inspectors determined the violation created minimal harm or potential for actual harm. But the failure represented a fundamental breakdown in infection control — a certified nursing assistant ignoring basic protocols she had been trained on just weeks before, while caring for a vulnerable resident unable to advocate for herself.
The resident's care plan contained no infection control interventions despite her multiple medical conditions and cognitive impairment. Her comprehensive assessment remained largely incomplete except for diagnoses including depression, hip fracture, and high blood pressure.
CNA B's admission that she understood the risks of her actions — that infections could spread without proper hand hygiene — made the violation particularly troubling. She knew the rules, had signed training documents acknowledging them, and chose to skip critical safety steps anyway.
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.
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 20, 2026 · Our methodology
CALDER WOODS in BEAUMONT, TX was cited for violations during a health inspection on August 11, 2025.
The aide changed gloves twice during the procedure without washing her hands, creating potential for cross-contamination.
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.