Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure a resident who entered the facility with
an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's
clinical condition demonstrated that catheterization was necessary for 1 of 3 residents (Resident #23) and a
resident who was incontinent of bladder received appropriate treatment and services to prevent urinary
tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #133)
reviewed for indwelling catheters.
1. The facility failed to have an appropriate diagnosis for Resident #23's Foley catheter.
2. The facility failed to prevent Resident #133's urinary catheter drainage bag from touching the floor.
These failures could place residents at risk for inappropriate placement of indwelling catheters, discomfort
or injury, and urinary tract infections.
Findings include:
1. Record review of Resident #23's face sheet, dated 10/11/23, indicated a [AGE] year-old female who was
admitted to the facility on [DATE]. Her diagnoses included hypertensive chronic kidney disease (a
long-standing kidney condition that develops over time due to persistent or uncontrolled high blood
pressure), anxiety disorder (persistent and excessive worry that interferes with daily activities), diabetes
mellitus type 2 (chronic condition that affects the way the body processes blood sugar), stage 4 pressure
ulcer to the right foot (a sore) , and stage 2 pressure ulcer of sacral region (a sore has broken through the
top layer of the skin and part of the layer below in the tailbone area).
Record review of Wound Assessments, dated 09/18/23, for Resident #23 indicated:
* Wound #1-was present on admission, located on right upper arm, and was a 2cm x 1.5cm x 0cm fluid
filled intact blister.
* Wound #2-was present on admission, pressure wound, located on the pelvic region-sacral area, vascular
classification, and was a 1.10cm x 0.8cm stage 2 partial thickness.
* Wound #3-was present on admission, pressure wound, located in the pelvic region-coccyx area, vascular
classification, and was a 1cm x 1cm x 0cm stage 2 partial thickness.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
676109
Printed: 05/15/2026
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
676109
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2023
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 0690
Level of Harm - Minimal harm
or potential for actual harm
* Wound #4-was present on admission, located on the plantar foot-left heel area, vascular classification,
and was a 2cm x 0.3cm x 0.3cm stage 2 partial thickness; and
* Wound #5-was present on admission, located on plantar foot-left heel area, vascular classification, 1.5cm
x 1.5cm fluid filled blister.
Residents Affected - Some
Record review of the care plan, dated 09/20/23, indicated Resident #23 was at risk for infection related to
indwelling catheter due to multiple wounds.
Record review of an admission MDS, dated [DATE], indicated Resident #23 had moderately impaired
cognition with a BIMS score of 08 out of 15. She required extensive assistance of 1 person for toileting; she
had an indwelling catheter; she had not had a trial of a toileting program; she was not rated for urinary
incontinence because she had a catheter; she was at risk of developing pressure ulcers; she had an
unhealed pressure ulcers; she had 2 stage 2 pressure ulcer on admission; and she had 1 stage 4 pressure
ulcer on admission.
Record review of physician orders for October 2023 indicated Resident #23 had an order, dated 10/03/23,
for a Foley catheter with related diagnosis of hypertensive chronic kidney disease.
Record review of the Wound Evaluation and Management Summary indicated Resident #23 had the
following:
* 09/20/23-a non-pressure wound to upper arm, a non-pressure wound to the right buttock, a stage 2
pressure ulcer to the sacrum, a stage 2 pressure ulcer to the left foot, and a stage 4 pressure ulcer to the
right heel. There was no indication of a stage 3 or 4 to the sacrum.
* 09/27/23-a non-pressure wound to the right buttock, a stage 2 pressure ulcer to the sacrum, a stage 2
pressure ulcer to the left foot, and a stage 4 pressure ulcer to the right heel. The non-pressure wound to the
right buttock was healed. There was no indication of a stage 3 or 4 to the sacrum.
* 10/04/23-all wounds were healed.
During an observation on 10/09/23 at 09:37 a.m. revealed Resident #23 was in her bed. She had a Foley
catheter.
During an observation and interview on 10/09/23 at 11:42 a.m. revealed Resident #23 was in her bed. She
had a Foley catheter. Her family member was at the bedside and said the catheter was in place because
she had wounds on her bottom. She said the wounds were healed.
During an observation on 10/10/23 at 10:41 a.m. revealed Resident #23 was in her bed. She had a Foley
catheter.
During an observation on 10/11/23 at 11:15 a.m. revealed Resident #23 was in her bed. She had a Foley
catheter with yellow sediment in the tubing.
During an interview on 10/11/23 at 11:20 a.m., LVN F said Resident #23 had Foley catheter because she
had wounds on her bottom. She said the physician was keeping the Foley catheter in place to prevent the
wounds on the bottom from getting bad again. She said the wounds that healed were stage 2 pressure
wounds. She said she did not realize Resident #23's catheter should have been removed after
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676109
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
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
676109
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2023
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 0690
the 14-day assessment period because it did not meet the criteria for a catheter to be used.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 10/11/23 11:25 p.m., ADON E said Foley catheters could be retained for stage 3 or
4 pressure wounds to the bottom. She said they should be removed when the wounds healed. She said the
indwelling catheters could be used for certain diagnoses and conditions such as urinary retention and
neurogenic bladder. She said she did not realize Resident #23 should have had the catheter removed. She
said the resident could have discomfort or acquire a urinary tract infection if the catheter were to remain.
Residents Affected - Some
During an interview on 10/11/23 at 12:14 p.m., the Administrator said the facility did not have a policy, but
they followed the federal guideline requirements for Foley catheters.
Record review of an email attachment received on 10/11/23 from the MDS Nurse indicated CMS's RAI
Version 3.0 Manual, dated 10/2019, 6. Urinary Incontinence and Indwelling Catheter: Use of indwelling
catheter (H0100 is checked): (Presence of situation in which catheter use may be appropriate intervention
after consideration of risks/benefits and after efforts to avoid catheter use have been unsuccessful with
coma, terminal illness, stage 3 or 4 pressure ulcer in area affected by incontinence, need for exact
measurement of urine output, and history of inability to void after catheter removal were listed.
Surveyor: [NAME], [NAME]
2 . Record review of Resident #133's face sheet, dated 10/11/23, indicated a [AGE] year-old male admitted
to the facility on [DATE]. His diagnoses included Benign Prostatic Hyperplasia (an age-related prostate
gland enlargement that can cause urination difficulty). Due to this diagnosis, Resident
#133 had an indwelling urinary catheter (a catheter which is inserted into the bladder to drain urine).
Record review of a Baseline Care Plan, dated 10/03/23, indicated Resident #133 had an alteration in
bladder elimination and had an indwelling urinary catheter.
Record review indicated an admission MDS had not been completed for Resident #133 at the time due to
being in process.
Record review of physician orders for October 2023 indicated Resident #133 had an order, dated 10/05/23,
for an indwelling urinary catheter with related diagnosis of Benign Prostatic Hyperplasia.
Record review of a Competency Assessment Catheter Care, Urinary form, dated September 2014,
indicated the following. 2b. Be sure the catheter tubing and drainage bag are kept off the floor.
During an observation on 10/09/23 at 12:00 p.m., Resident #133 was transported via wheelchair to the
dining room for the noon meal by COTA H. The urinary catheter was in a privacy bag below Resident
#133's wheelchair with the bag touching the floor as he was wheeled into the room.
During a joint interview on 10/09/23 at 12:30 p.m., CNA B and CNA C both said Resident
#133â Euro's urinary catheter drainage bag was sitting on the floor. They said they received training
on urinary catheter care and the drainage bag should never touch the floor due to risk of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676109
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
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
676109
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2023
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 0690
infection.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 10/09/23 at 12:44 p.m., LVN A said Resident #133's urinary drainage bag was on
the floor. She said the drainage bag should not be touching the floor. She said in-service and training had
been provided in facility in the past. LVN A said potential issues could be infections from contamination of
an unclean floor, the urinary drainage bag could potentially be caught on any objects and/or catheter could
be pulled out causing harm to residents. LVN A said she monitors the CNAs correct positioning of urinary
drainage bags.
Residents Affected - Some
During an interview on 10/09/23 at 12:45 p.m., ADON D said Resident #133's urinary drainage bag should
not touch floor due to risk of infection.
During an interview on 10/09/23 at 12:57 p.m., COTA H said she transported Resident #133 from the
therapy department to the dining room for the noon meal. She said she was unaware Resident #133's
urinary catheter drainage bag had been dragged during transport. She said she had received training in the
past regarding urinary catheter care and placement of tubing and drainage bags.
During an interview on 10/09/23 at 2:19 p.m., Resident #133 said he wasn't sure why he had a urinary
catheter and it was inserted pre-admission while at the hospital. Resident #133 said facility staff positioned
the catheter bag below his wheelchair when he was out of bed and in the chair.
During an interview on 10/11/23 at 2:00 p.m., the DON/Infection Preventionist said her expectation was for
staff to be aware of urinary catheter bag placement to prevent contamination on floors. She said staff were
educated on urinary catheter bag placement in the past.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676109
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
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
676109
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2023
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure each resident's drug regimen was free from
unnecessary drugs when used without adequate monitoring for 1 of 13 residents (Resident #24) reviewed
for unnecessary medication.
Residents Affected - Few
The facility failed to monitor Resident #24 for side effects of the anticoagulant medication Eliquis (a blood
thinning medication).
This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black
colored stools related to the use of the anticoagulant medication.
Findings include:
Record review of Resident #24's face sheet, dated 10/09/23, indicated an [AGE] year-old female who was
admitted to the facility on [DATE] with a diagnosis which included atrial fibrillation (an irregular and often
rapid heart rhythm that can lead to blood clots in the heart and increases the risk of a stroke).
Record review of a care plan, initiated 09/13/23, indicated Resident #24 received an anticoagulant
medication, Eliquis with interventions which included monitor for bleeding in the urine, nose and stool.
Record review of an admission MDS, dated [DATE], indicated Resident #24 had a BIMS score of 15, which
indicated intact cognition. Resident #24 had a diagnosis of atrial fibrillation and received an anticoagulant
medication 6 of 7 days during the look back period.
Record review of the physician orders dated October 2023, indicated Resident #24 was prescribed Eliquis
(a blood thinning medication) 2.5 mg two times a day for atrial fibrillation with a start date of 09/09/23. The
orders did not address monitoring the anticoagulant medication.
Record review of a MAR, dated 10/11/23, indicated Resident #24 received Eliquis 2.5 mg two times a day
from 10/01/23 to 10/11/23 with a start date of 09/08/23.
Record review of the electronic record for Resident #24 indicated the nurses did not document monitoring
of side effects of anticoagulant daily with medication administration.
During an interview and record review on 10/11/23 at 12:37 p.m., LVN F said Resident #24 was her patient.
She said Resident #24's Eliquis should have been monitored for side effects and was not , it was
overlooked. LVN F said the nurses caring for a resident were responsible for adding monitoring to the
computer system. She said the ADONs double checked to ensure anticoagulants were monitored. LVN F
said it was just overlooked. She said she was educated on monitoring anticoagulants. LVN F said the risk of
an anticoagulant not monitored was bleeding.
During an interview on 10/11/23 at 12:47 p.m., ADON E said Resident #24 should have been monitored for
the side effects of Eliquis. She said the admission nurse was responsible for the addition of monitoring into
the system. ADON E said the nurses worked as a team and were all responsible for double checking for
medication monitoring. She said it was just overlooked. ADON E said the nurses were
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676109
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
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
676109
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2023
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
educated on monitoring of anticoagulant medication. She said the risk of Eliquis not monitored was a
possible bleeding risk.
During an interview on 10/11/23 at 12:50 p.m., the DON said Resident #24 should have been monitored for
side effects of the anticoagulant medication Eliquis and was not. She said it was overlooked. The DON said
the nurses were in-serviced on monitoring anticoagulant medication. She said the admission nurse was
responsible for putting the medication monitoring in the computer system when they received the order for
the medication. The DON said the ADONs were responsible for double checking within 24 to 72 hours after
an order of an anticoagulant medication was placed for monitoring. The DON said she did random checks
but had not checked Resident #24's chart. She said the risk of Eliquis not monitored was bleeding. The
DON said her expectation was all residents on anticoagulants be monitored .
During an interview on 10/11/23 at 1:10 p.m., LVN G said she was the nurse that admitted Resident #24
and completed the admission paperwork. She said she was unaware Resident #24's anticoagulant
medication was not being monitored. LVN G said she received education and was aware anticoagulant
medication had to be monitored for side effects. She said she had problems putting the medication
monitoring in the computer system before and had to get another nurse to help her. LVN G said she should
have had another nurse check and make sure the monitoring was put in the system correctly. She said she
must have put the medication monitoring in the system incorrectly or overlooked it. LVN G said the risk of
not monitoring the anticoagulant/ Eliquis was possible bleeding, bruising and staff being unaware to monitor
for bleeding.
During an interview on 10/11/23 at 1:20 p.m., the Administrator said the nurses were responsible for
monitoring anticoagulants medication. She said the ADONs were responsible for double checking
medication for monitoring during the admission process meeting. The Administrator said the
interdisciplinary team went over every admission record the morning after or the Monday morning after a
weekend. She said her expectation was all anticoagulant medication be monitored.
During an interview on 10/11/23 at 3:00 p.m., the Administrator said the facility did not have a specific
policy for monitoring anticoagulant medication.
Record review of the Reference obtained from the internet on 10/12/23 from, How Rx ELIQUIS®
(apixaban) Can Help | Safety Info (bmscustomerconnect.com) indicated, . ELIQUIS can cause bleeding,
which can be serious, and rarely may lead to death. This is because ELIQUIS is a blood thinner medicine
that reduces blood clotting. While taking ELIQUIS, you may bruise more easily and it may take longer than
usual for any bleeding to stop.
Call your doctor or get medical help right away if you have any of these signs or symptoms of
bleeding when taking ELIQUIS:
*
unexpected bleeding or bleeding that lasts a long time, such as unusual bleeding from the
gums, nosebleeds that happen often, or menstrual or vaginal bleeding that is heavier
than normal
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676109
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
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
676109
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2023
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 0757
*
Level of Harm - Minimal harm
or potential for actual harm
bleeding that is severe or you cannot control
*
Residents Affected - Few
red, pink, or brown urine; red or black stools (looks like tar)
*
coughing up or vomiting blood or vomit that looks like coffee grounds
*
unexpected pain, swelling, or joint pain
*
headaches, or feeling dizzy or weak
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676109
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
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
676109
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2023
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure based on the comprehensive assessment of a
resident, residents who use psychotropic drugs received gradual dose reductions, and behavioral
interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 13 residents
(Resident #24) reviewed for unnecessary medications.
The facility failed to monitor Resident #24 for behaviors or side effects for the antidepressant medication,
Lexapro.
This failure could place residents at risk for adverse consequences such as dizziness, drowsiness,
oversedation, agitation, restlessness, and suicidal thoughts related to the use of psychotropic medications.
Findings include:
Record review of Resident #24's face sheet, dated 10/09/23, indicated an [AGE] year-old female who was
admitted to the facility on [DATE] with a diagnosis which included major depressive disorder (also known as
depression is a serious mood disorder that effects how a person thinks feels and handles daily activities)
Record review of a care plan, initiated 09/13/23 , indicated Resident #24 received the antidepressant
medication Lexapro with interventions which included monitoring for side effects of the medication and
record behaviors on the behavior tracking record and observe for changes in mood or behaviors and notify
the physician.
Record review of an admission MDS, dated [DATE], indicated Resident #24 had a BIMS score of 15, which
indicated intact cognition. Resident #24 had a diagnosis of major depressive disorder and received an
antidepressant medication 6 of 7 days during the look back period.
Record review of the physician orders, dated October 2023, indicated Resident #24 was prescribed
Lexapro 20 mg every day for major depressive disorder with a start date of 09/09/2023.
Record review of a MAR, dated 10/11/23, indicated Resident #24 received Lexapro 20 mg every day for
major depressive disorder from 10/1/23 to 10/11/23 with a start date of 09/08/23, with no monitoring for
behaviors or side effects noted.
Record review of the electronic medical record for Resident #24 contained no documentation of monitoring
for behaviors or side effects of Lexapro from 10/1/23 to 10/11/23.
During an interview and record review on 10/11/23 at 12:37 p.m., LVN F said Resident #24 was her patient.
She said Resident #24's Lexapro should have been monitored for side effects and behaviors and was not.
LVN F said the nurses providing care for a resident were responsible for adding medication monitoring into
the computer system. She said the ADONs double checked to ensure antidepressant medication were
monitored. LVN F said it was just overlooked. She said she was educated on monitoring antidepressant
medication. LVN F said the risk of an anticoagulant not monitored was bleeding.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676109
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
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
676109
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/11/2023
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 10/11/23 at 12:47 p.m., ADON E said Resident #24 should have been monitored for
the side effects of Lexapro but was overlooked. She said the admission nurse was responsible for the
addition of medication monitoring into the system. ADON E said the nurses worked as a team and were all
responsible for double checking for medication monitoring. She said it was just overlooked. ADON E said
the nurses were educated on monitoring of antidepressant medication. She said the risk of Lexapro not
monitored was behavior issues if not strong enough and the physician would be unaware if there was a
therapeutic range.
During an interview on 10/11/23 at 12:50 p.m., the DON said Resident #24 should have been monitored for
side effects of the antidepressant medication, Lexapro and was not. She said it was overlooked. The DON
said the nurses were in-serviced on monitoring antidepressant medication. She said the admission nurse
was responsible for putting the monitoring in the computer system when they received the order for the
medication. The DON said the ADONs were responsible for double checking within 24 to 72 hours after the
order of an antidepressant medication was placed for monitoring. The DON said she did random checks but
had not checked Resident #24's chart. She said the risk of Lexapro not being monitored was a potential of
the medication not at a therapeutic dose. The DON said her expectation was all residents on
antidepressant medication be monitored.
During an interview on 10/11/23 at 1:10 p.m., LVN G said she was the admission nurse for Resident #24
and completed the admission paperwork. She said she was unaware Resident #24's antidepressant
medication was not being monitored. LVN G said she received education and was aware antidepressant
medication had to be monitored for side effects and behaviors. She said she had problems putting the
monitoring in the computer system before and had to get another nurse to help her. LVN G said she should
have had another nurse check and make sure the monitoring was put in the system correctly. She said she
must have put the monitoring in the system incorrectly or overlooked it. LVN G said the risk of not
monitoring the antidepressant was a risk of behavior issues and the medication not being effective.
During an interview on 10/11/23 at 1:20 p.m., the Administrator said the nurses were responsible for
monitoring antidepressant medication. She said the ADONs were responsible for double checking
medication for monitoring during the admission process meeting. The Administrator said the
interdisciplinary team went over every admission the morning after or the Monday morning after a
weekend. She said her expectation was all antidepressant medication be monitored.
Record review of the facility's policy, revised 04/18/23, titled, Psychotropic Drugs indicated: .Psychotropic
drugs are those drugs that affect brain activities associated with mental processes and behavior. These
drugs include but are not limited to the following categories of drugs: . 2. Anti-depressant; .The facility is
expected to attempt a gradual dose reduction in two separate quarters . the first year . attempted annually.
A gradual dose reduction is clinically contradicted if: A. Target symptoms returned or worsened after the
most recent attempt at a gradual dose reduction and the physician documents the clinical rationale.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676109
If continuation sheet
Page 9 of 9
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
FAQ · About this visit
Common questions about this visit
What happened during the October 11, 2023 survey of CALDER WOODS?
This was a inspection survey of CALDER WOODS on October 11, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CALDER WOODS on October 11, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, an..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.