Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Calder Woods during CMS and state inspections, most recent first.
Kitchen staff were observed preparing and serving food without proper hair or beard restraints, and multiple trash cans were left uncovered. Surveyors also found numerous refrigerated, frozen, and dry storage items that were unlabeled, undated, or left open to air, including dressings, sauces, meats, fruit, seasonings, cornmeal, frosting, and chocolate chips. Staff interviews and facility policy confirmed that hair restraints, covered trash cans, and proper food labeling and dating were required.
Expired medical supplies were found in the medication and supply storage room, including enteral feeding bags with attached gravity sets and Aspira drainage kits past their expiration or use-by dates. Staff, including MAs, LVNs, the DON, and the ADM, stated that nursing staff were responsible for checking supplies and removing expired items, and the facility policy stated outdated medications may not be used.
A MA used the same blood pressure cuff on multiple residents during a med pass and did not disinfect it between uses. Staff stated reusable medical equipment should be cleaned and allowed to dry between residents, and the facility policy required medical equipment to be properly cleaned and disinfected between residents.
Delayed Meal Service and Loss of Dignity During Dining: A resident with severe cognitive impairment and multiple medical diagnoses was seated for lunch with other residents, but her tray was not served with the rest of the table. Staff told her the food was coming while she waited, and she did not receive her meal until 22 minutes after the first tray was served. When the tray finally arrived, she said she was the last one and no longer wanted the food. Interviews confirmed that residents at the same table were expected to be served together within a few minutes.
A resident who required two-person assistance for transfers was moved by a single CNA without a gait belt, contrary to the care plan and facility policy. The resident fell during the transfer, sustaining a neck fracture and other injuries, and required emergency medical intervention.
A resident receiving oxygen therapy did not have physician orders or a care plan addressing her respiratory needs, and her oxygen humidifier was left empty for an extended period. Staff failed to monitor and replace the humidifier as required, and the resident had to remind staff to address the issue. Facility policy for respiratory care and equipment maintenance was not followed.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of facility practices.
A CNA failed to perform hand hygiene between glove changes while providing incontinent care to a resident with multiple medical conditions. Despite facility policy and training requiring hand hygiene at specific points during care, the CNA changed gloves without washing hands, a lapse confirmed by staff interviews and documentation.
A resident with multiple health issues had a physician-ordered chest x-ray due to a change in condition, but the facility failed to document the completion of the x-ray, its results, or notify the physician. The LVN admitted to not documenting the necessary information, which could risk delayed care.
A resident's hydrocodone tablets were unaccounted for after discharge from an LTC facility. The facility's lack of clear procedures for narcotics management led to the oversight. Interviews revealed that the narcotics cabinet was empty and not properly logged, and the medication was not sent to the rehabilitation hospital. The facility reported the missing medication to authorities.
A resident with a stage 3 pressure ulcer on Enhanced Barrier Precautions did not receive proper infection control during wound care, as LVN C failed to wear a gown. Despite training and clear signage, the LVN admitted to the oversight due to being hurried. The interim DON and Administrator confirmed the requirement for PPE use during such care to prevent cross-contamination.
A resident with a history of falls experienced a witnessed fall, but the LTC facility failed to immediately notify the physician as required. The incident was observed by a CNA and reported to an LVN, who conducted an assessment but did not document it or notify the physician. Poor communication during shift change contributed to the lack of documentation and notification.
A resident with Alzheimer's disease experienced a fall that was witnessed by a CNA, but the incident was not documented by the LVN on duty. The LVN conducted an assessment but did not observe injuries or notify the physician, leading to a delay in reporting the incident. The facility's policies on incident reporting and documentation were not followed, resulting in incomplete medical records.
Kitchen Food Storage and Personal Hygiene Deficiencies
Penalty
Summary
The facility failed to properly store, prepare, and distribute food in accordance with professional standards in the kitchen. During the initial kitchen tour on 01/28/2026, a cook with an approximate 2.5-inch beard was observed preparing food without a beard restraint. In the same kitchen area, four large gray trash cans were observed open and without lids. In the walk-in refrigerator, surveyors observed five one-gallon containers of different salad dressings and one one-gallon container of tartar sauce with no open or discard dates. Additional items in the refrigerator included a silver container covered with foil labeled tuna with no prepared or discard date, a container labeled with letters resembling slaw with no prepared or discard date, a round silver container marked BBQ with no prepared or discard date, a container of sliced red potatoes in water covered with foil with no prepared or discard date, a package of thawing red meat that was not labeled or dated, an opened package of cooked corned beef that was not labeled or dated, and a tray of 24 cups of mixed fruit that was not covered, labeled, or dated. In the walk-in freezer, surveyors observed an opened bag of pork patties exposed to air with no open or discard date, an opened bag of cooked Italian sausage with no open or discard date, and a freezer storage bag of fish with no label, open date, or discard date. In the dry storage area, six five-pound containers of opened seasonings, a large box of cornmeal, an open container of chocolate frosting, and a large open box of chocolate chips were all observed open to air and without open or discard dates. During lunch service on Cottage M, a CS was observed serving lunch without a hairnet. On the follow-up kitchen tour on 01/29/2026, the same issues remained with the salad dressings, tartar sauce, opened cooked Italian sausage, fish bag, opened seasonings, cornmeal, and chocolate chips. Interviews confirmed that staff were trained on hair and beard restraint requirements, trash can lid requirements, and food labeling expectations, including item name, open date, and use-by date. The DM, EC, and CS staff stated that hairnets and beard nets were required in the kitchen and that food items should be labeled with receive date, open date, and use-by date. The facility policy also stated that hair restraints were required, beard nets were required when facial hair was visible, and opened food items and storage containers had to be labeled and dated. The ADM stated he did not know the exact protocol for trash cans in food preparation areas, while also stating that kitchen staff were required to wear hairnets and beard nets and follow facility policies and the health code.
Expired Medical Supplies Left in Medication Storage Room
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring that expired medical supplies were removed from the singular medication and supply storage room. During an observation of the room, surveyors found three enteral feeding bags with attached gravity sets, each with a 1200 mL capacity and an expiration date, one additional enteral feeding bag with attached gravity set and expiration date, and two Aspira drainage kits with a use-by date that had expired. During interviews, MA D, LVN I, MA F, and LVN J stated they had been in-serviced on infection control and medication/supply storage and labeling, and each identified nursing staff as responsible for ensuring supplies remained within date and were removed when expired. The DON stated staff were frequently in-serviced on infection control, medication/supply storage and labeling, and that it was her expectation that expired medication or supplies be removed so they would not be used for resident care. The ADM also stated expired medication or supplies were expected to be disposed of and not used on residents. Review of the facility policy titled Storage of Medications stated the nursing staff is responsible for maintaining medication storage preparation areas in a clean, safe, and sanitary manner and that the facility may not use medication that has been discontinued, outdated, or has deteriorated.
Blood Pressure Cuff Not Disinfected Between Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for three of four residents reviewed for infection control. During observation of medication administration, MA D used the same blood pressure cuff on Resident #5, Resident #18, Resident #32, and Resident #21 and did not disinfect the cuff between residents while performing the medication pass. During interview, MA D stated that proper practice is to cleanse the blood pressure cuff between residents with a Sani-wipe and wait 2 minutes for it to dry before using it again, and that failing to do so could take germs from one patient to another resident. Other staff, including LVN H, MA E, CNA G, LVN I, the DON, and the ADM, stated that reusable medical equipment should be disinfected between residents and allowed to dry before being used on another resident. Review of the facility policy titled Environmental Cleaning reflected that medical equipment should be properly cleaned, disinfected, and sharing limited between residents.
Delayed Meal Service and Loss of Dignity During Dining
Penalty
Summary
The facility failed to treat a resident with respect and dignity during lunch service when her meal tray was not served at the same time as the other residents seated at her table. Resident #28 was a female admitted to the facility with diagnoses including vitamin B deficiency, left knee pain, hyperthyroidism, heart disease with heart failure, muscle weakness, limitation of activities due to disability, cognitive communication deficit, anxiety, and hypertension. Her MDS showed a BIMS score of 0, indicating severe cognitive impairment, and her care plan addressed recent unplanned weight loss with interventions to support adequate nutrition and fluid intake. During lunch dining services, seven residents were seated at the table in DR #1. The first resident received a tray at 12:05 p.m., and five other residents received their trays within six minutes of that first tray. Resident #28 did not receive her tray at that time. At 12:13 p.m. and again at 12:19 p.m., she asked staff about her meal tray and was told that her food was coming, with one explanation that culinary staff had to go to the main building to get more bread. Resident #28 finally received her food at 12:27 p.m., twenty-two minutes after the first tray was served. When her tray arrived, Resident #28 stated she was the last one and did not want any of the food now because she had already drunk all of her drink. Staff offered her something else to eat, but she declined. Interviews with the CS A, DM, CK A, and the ADM confirmed that residents at the same table were expected to be served together and that a reasonable time from the first tray to the last tray in DR #1 was about two to seven minutes. The ADM stated the delay occurred because almost all residents at the table changed their minds and wanted a different entrée, and the facility policy stated residents have the right to be treated with respect and dignity.
Failure to Provide Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow established protocols during a bed-to-wheelchair transfer for a resident. The resident, who was dependent on staff for transfers and required assistance from two staff members as per her care plan, was transferred by only one CNA without the use of a gait belt. The CNA was unable to stabilize the resident during the transfer, resulting in the resident falling forward onto the floor. The resident involved had multiple medical conditions, including kidney failure, gastrointestinal hemorrhage, osteoarthritis, and chronic obstructive pulmonary disease. She was cognitively intact and required total assistance for transfers, as documented in her care plan and Minimum Data Set (MDS) assessment. During the incident, the resident sustained a laceration to her nose and left upper extremity, and complained of pain in her neck and extremities. Emergency medical services were called, and the resident was found to have fractures in her neck (C1-C2), necessitating transfer to another hospital for surgery. Interviews and record reviews confirmed that the facility's procedural guidelines required the use of a gait belt and assistance from additional staff for such transfers. Staff members, including the CNA involved, acknowledged that they had been trained on these procedures. However, the CNA did not adhere to the care plan or facility policy at the time of the incident, directly leading to the resident's fall and subsequent injury.
Failure to Provide Proper Respiratory Care and Maintain Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy. The resident, who was cognitively intact and had diagnoses including anxiety disorder, hypertension, and unsteadiness, was observed using a nasal cannula for oxygen. However, there were no physician orders for oxygen therapy or related care in the resident's records at the time of review. The resident's care plan did not include any respiratory treatment, and the MDS assessment did not indicate oxygen therapy. Orders for oxygen therapy were only added after the issue was identified during an interview with a nurse. Additionally, the resident's oxygen humidifier was found to be empty during multiple observations, and the resident reported that staff often forgot to check or change it, requiring her to remind them. The humidifier bottle had not been replaced in a timely manner, and staff interviews confirmed that the humidifier was changed weekly or as needed, but in this case, it had not been addressed despite being empty. The facility's policy required respiratory equipment to be maintained per manufacturer's instructions or physician's orders, but this was not followed for the resident in question.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices, which revealed lapses in the protection and management of confidential resident information and medical documentation. Specific details regarding the nature of the records or the manner in which information was not safeguarded were noted as part of the survey findings.
Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during incontinent care for one resident. During an observation, a CNA performed perineal care and changed gloves multiple times without performing hand hygiene between glove changes, despite being trained to do so. The CNA acknowledged during an interview that she did not complete hand hygiene after glove changes and recognized this as a lapse in protocol. The resident involved was an elderly female with diagnoses including major depressive disorder, hypertension, and a hip fracture, who was admitted recently and had a care plan that did not address infection control interventions. Interviews with other staff, including an LVN and the DON, confirmed that facility policy and training require hand hygiene before, during, and after incontinent care, especially when changing gloves. Review of facility in-service training records and policy documents further supported that hand hygiene is expected at specific points during care. The observed failure to follow these protocols was directly contrary to both facility policy and staff training, as documented in the records and staff interviews.
Incomplete Documentation of X-ray Results
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented. Specifically, the facility did not document the completion of a physician-ordered chest x-ray, the results of the x-ray, or the notification of the physician regarding the results. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident in question was an elderly female with multiple diagnoses, including dementia, pleural effusion, and chronic congestive heart failure. On a specific date, the resident developed a wet cough and shortness of breath, prompting a nurse practitioner to order a chest x-ray. Although the x-ray was completed, the results were not documented in the resident's medical record, and there was no record of physician notification about the change in the resident's condition or the x-ray results. Interviews with facility staff revealed that the x-ray results were available in the facility's portal but were not documented in the resident's chart. A Licensed Vocational Nurse (LVN) acknowledged the oversight and admitted to not documenting the necessary information in the resident's medical record. This lack of documentation could potentially place residents at risk for delayed care and appropriate interventions.
Unaccounted Narcotics for Discharged Resident
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the management and accounting of controlled medications for a resident. The resident, who was cognitively intact and had been admitted with fractures, was prescribed hydrocodone for pain management. Upon discharge, 20 tablets of hydrocodone were not accounted for, and this discrepancy was discovered 55 days later. The facility's records, including the Medication Administration Record (MAR) and care plan, indicated the resident received the medication on specific dates, but there was no documentation of the medication being transferred or destroyed upon discharge. Interviews with various staff members, including interim Directors of Nursing (DONs) and the Administrator, revealed a lack of clear procedures and accountability for narcotics management. The interim DON A discovered that the cabinet used for storing narcotics for destruction was empty and had not been properly logged. The interim DON B, who had been in charge before the current interim DON, stated she had not handled any narcotics for destruction. The facility's policy required narcotics to be logged and stored securely, but this was not followed, leading to the unaccounted medication. Further investigation showed that the narcotics were not sent with the resident to the rehabilitation hospital, as confirmed by the case manager there. The facility attempted to contact the resident's family for clarification but received no response. The interim Administrator acknowledged the issue with narcotics storage and reported the missing medication to the state and local police. The facility lacked a consistent policy for handling narcotics, which contributed to the oversight and loss of the medication.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a resident with a stage 3 pressure ulcer who was on Enhanced Barrier Precautions (EBP). The resident, a female with an elevated white blood cell count and moderately impaired cognition, required wound care that mandated the use of gloves and a gown. However, during an observation, LVN C performed wound care on the resident without wearing a gown, despite the presence of a sign on the resident's door indicating EBP and a supply cart with the necessary personal protective equipment (PPE). LVN C admitted to forgetting to wear a gown during the procedure, attributing the oversight to being in a hurry due to a heavy workload. Both the interim Director of Nursing (DON) and the interim Administrator confirmed that all nursing staff had been trained on EBP requirements, which include wearing gloves and gowns during high-contact care activities to prevent cross-contamination. The facility's policy on Enhanced Barrier Precautions, revised shortly before the incident, also specified the need for gown and glove use during wound care to prevent the transfer of multidrug-resistant organisms.
Failure to Notify Physician of Resident's Fall
Penalty
Summary
The facility failed to immediately notify the resident's physician regarding a change in condition for a resident who experienced a witnessed fall. The incident occurred when a CNA observed the resident standing up from her wheelchair and falling, hitting the side of her forehead. Despite the fall being witnessed and reported to an LVN, no incident report was completed, and the physician was not notified immediately as required by the facility's policy. The resident, who had a history of falls and was diagnosed with Alzheimer's disease, muscle weakness, and gait abnormalities, was assessed by the LVN after the fall. The LVN did not observe any injuries or signs of pain during the assessment, and the resident's family and private sitter were present and made light of the situation. However, the LVN failed to document the assessment or notify the physician, mistakenly believing the incident had been documented by the previous shift. The deficiency was further compounded by poor communication during shift change, leading to the incident not being properly documented or reported. The facility's policy required immediate notification of the physician for accidents involving residents that result in injury or have the potential for requiring physician intervention. The failure to adhere to this policy could result in a delay in treatment and a decline in the resident's health and well-being.
Failure to Document Resident Fall and Notify Physician
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident reviewed for resident records. Specifically, the facility did not document a change in condition and physician notification for a resident who experienced a fall. The resident, an elderly female with Alzheimer's disease and a history of falls, was found to have bruising and swelling on her right eyebrow area, which was not documented as a result of a fall. The incident occurred when a CNA observed the resident standing up from her wheelchair and falling, hitting her forehead. The CNA reported the fall to an LVN, who conducted a head-to-toe assessment but did not observe any injuries or signs of pain. The LVN failed to document the incident or notify the physician, mistakenly believing the incident had been documented by the previous shift. This lack of documentation and communication led to the incident being unreported until a later date when another LVN noticed the resident's injuries. Interviews with facility staff, including the Executive Director, interim DON, and interim Administrator, revealed that the incident was not documented due to poor communication during a shift change. The staff acknowledged the importance of immediate assessment and documentation of falls, as well as notifying the physician to prevent delays in treatment. The facility's policies and in-service training emphasized the need for timely incident reporting and documentation, which were not followed in this case.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 188 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beaumont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaumont Health Care Center | 1.2 mi | ★★★★★ | 2 | 0 |
| Focused Care At Summer Place | 1.8 mi | ★★★★★ | 24 | 0 |
| Spindletop Hill Nursing & Rehab Center | 2 mi | ★★★★★ | 1 | 0 |
| Avir At Beaumont | 2.1 mi | ★★★★★ | 4 | 0 |
| Beaumont Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 1 | 1 |
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