Calder Woods

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Care In-services from the DON on 08/11/25 at 1:25 PM, none were provided before exit. Record review of

the facility policy titled, Respiratory Services dated 01/07/25 indicated, Service standard; healthcare personnel will provide respiratory care in compliance with current standards of practice.Respiratory services may include.oxygen administration.Respiratory equipment utilized will be maintained per the manufacturer's instructions or physician's orders.respiratory treatments will be administered per current standards.unless otherwise ordered by a physician.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Calder Woods

7080 Calder Beaumont, TX 77706

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

said the CNAs and nurses were supposed to document the care because they did the hands-on care. She said it was her expectation staff would document care after the care was provided. She said residents were at risk for delayed care if the proper documentation was not completed. During an interview on 08/11/25 at 3:18 p.m., CNA Z said she completed rounds every two hours on 08/09/25 at 6:00 p.m. through 08/10/25.

She said she completed incontinent care for Resident #1 at approximately 4:30 a.m. on 08/10/25. She said

she did not document the care in Resident #1's care record. She said she was aware she should document care as it was completed. During an interview on 08/11/25 at 3:35 p.m., RN V said Resident #1 was crying and in pain after midnight on 08/10/25. She said she administered pain medication as ordered. She said

she checked Resident #1 approximately 1.5 hours later and she was sleeping. She said she did not document Resident #1's status in the nurse progress notes. She said she was aware she should have documented in the nurse progress notes. She said not documenting resident status could delay care or treatment. Record review of the facility policy Incontinence briefs and pad handling dated 11/18/24 indicated .Documentation associated with handling incontinence briefs and pads includes: -date and time of care -name and title of any staff member who assisted with care . Record review of the facility policy Charting and Documentation dated 10/11/21 indicated All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Documentation in the medical record is primarily electronic; however, there may be some manual documents that are uploaded into the record. 1. The following information is to be documented in the resident's medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents, or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 2. Documentation in the medical

record will be objective (not opinionated or speculative), complete and accurate.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Calder Woods

7080 Calder Beaumont, TX 77706

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #3) residents reviewed for infection control. 1. CNA B failed to perform hand hygiene while performing incontinent care for Resident #3. These failures could place residents at risk for infection through cross contamination of pathogens. Findings included: 1. Record review of Resident #3's admission

Record dated 08/11/25 reflected an [AGE] year-old female admitted to the facility on [DATE REDACTED]. Diagnoses included Major Depressive Disorder, hypertension (high blood pressure), and constipation. Record review of Resident #3's Comprehensive MDS assessment dated [DATE REDACTED] reflected her BIMS score was 99 (unable to complete the interview). The other fields of the MDS assessment were not yet filled out except for her diagnoses which included depression, a hip fracture, and hypertension (high blood pressure). Record

review of Resident #3's Care Plan reviewed on 8/11/25 reflected it had no information or interventions related to infection control. During an observation and interview on 08/11/25 at 9:49 AM, Resident #3 was awake and lying in bed. CNA B and CNA C entered the room and did hand hygiene, closed the door, and closed the blinds. CNA B and CNA C put on gloves. CNA B lowered the resident's brief and cleaned her perineal area appropriately. CNA B removed her gloves and placed new gloves on without completing hand hygiene. CNA B and CNA C assisted Resident #3 to turn onto her side and CNA B cleaned her buttocks.

CNA B rolled the dirty brief inward and threw it away. CNA B removed her gloves and placed new gloves on without completing hand hygiene. CNA B placed a clean brief, adjusted the resident, and covered her. CNA B and CNA C cleaned up the supplies and completed hand hygiene. During an interview with CNA B on 08/11/25 at 9:57AM, she stated she completed hand hygiene first. She stated she would do hand hygiene before, between, and after incontinent care. She stated she realized she had not done hand hygiene after incontinent care and glove changes, and she should have. She stated she was trained to complete hand hygiene after glove changes and when going from a dirty to clean brief. She stated the risk of not performing hand hygiene was that infection could spread. During an interview with LVN A on 08/11/25 at 12:57 PM, she stated hand hygiene should be completed before care, after the change (brief change) itself, and before leaving the room. She stated staff were trained on hand hygiene for infection control purposes.

During an interview with the Director of Nursing on 08/11/25 at 1:25PM, she stated the expectation was for

the facility staff providing incontinent care to perform hand hygiene before starting care, when changing gloves (such as when the gloves were dirty), and after care. The DON stated the ADON and herself were responsible for training about hand hygiene. The Director of Nursing stated not completing proper hand hygiene could cause cross contamination. Record review of a facility In-service Training Report, dated 07/09/25, reflected: CNA B and CNA C's signatures on the first page. The second page included, .Incontinent Care.7. Remove old brief and place in bag. Remove gloves, wash hands and reapply gloves.10. Remove gloves and place in bag. 11. Wash hands and apply new gloves. 12. Apply new brief or pad 13. Remove gloves and wash hands. Record review of the facility policy titled, Incontinence briefs and pad handling, long-term care dated 11/18/24, reflected .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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

If continuation sheet