Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure that residents had a right to organize and
participate in resident groups in the facility for 6 of 6 anonymous residents reviewed for resident council.
Residents Affected - Some
Six residents in a confidential resident group interview were unaware that meeting minutes were created
prior to their participation in the group meeting for the month of August 2023.
This failure placed 6 residents that frequently would attend meetings, and that could participate in a
Resident Council, at risk of not having the right to voice their concerns in a Resident Council meeting.
The findings were:
During a confidential group meeting on 08-16-3023 at 02:04 PM, 6 of 6 residents stated the facility assisted
them with monthly resident council meetings the last Thursday of the month. One of 9 residents stated that
the next group meeting was scheduled for 08-31-2023 at 10:30 AM. All 6 of the 6 residents stated that they
were not aware that the 08-31-2023 meeting minutes were already created. All 6 of the 6 residents stated
that the minutes could not be created before the meeting because the meeting had not taken place and the
AD could not know what topics, concerns, and grievances the residents could have made.
Interview on 08-17-2023 at 12:06 PM the AD stated that she had been employed with the facility a total of
17 years, 10 years as AD and the 7 prior years as a CNA. She stated in her role she created/made the
activities calendar every month, researched activities that would be beneficial for the resident population at
the facility and attended and typed up the Resident Council meeting minutes monthly. She stated prior to
the meetings she went around and reminded residents of the meeting and asked what topics they wanted
discussed at the meetings. She stated that she spoke to the resident attendees listed on the previous
meeting minutes first. She stated that the residents listed on the minutes in the Attendee section are
residents who attended the previous meeting and are not residents who she anticipated would attend the
next group meeting. She stated once she knew the group topics that would be covered in group they are
noted. She stated after the adjournment of the group those noted topics and discussions are added to the
meeting minutes. She stated that the resident council had not met for the month of August 2023. She stated
she created the August group minutes after this surveyor asked for the June, July, and August 2023 group
minutes and she could not provide them because the August 2023 meeting had not yet taken place. She
stated she prepared the 08-31-2023, minutes based off some of the items that would be discussed at that
meeting. She stated it was not common practice for surveyors to ask for the meeting minutes of the same
month that the facility survey had taken place. She stated that she had never before created the meeting
minutes ahead of time. She stated
(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 6
Event ID:
676021
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
676021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clarewood House Extended Care Center
7400 Clarewood Dr
Houston, TX 77036
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 0565
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
that she told the DON that she had created the minutes ahead of time to provide to the surveyor. She
stated that the DON advised her to tell the surveyor why the group meetings minutes for August 2023 were
created a head of time, but she was nervous and did not say anything.
Interview on 08-17-23 at 01:28 PM the DON stated that the AD had been in her role for the last 10 plus
years. She stated that the AD was only the resident council facilitator. She stated that the AD's role was to
write notes of what had been discussed by the residents during the meeting and type those discussion
notes into minutes. She stated that the AD told her that she created the 08-31-23 group minutes prior to the
meeting because the surveyor asked for the August minutes the facility had not yet had. She stated that the
AD panicked when the surveyor asked for the August minutes and there was none, and therefore the AD
typed up the minutes in advance to give to the surveyor as requested. She stated that the AD had not
created group meeting minutes before the meeting had taken place in the past. She stated it was her
expectations that the AD would not create meeting minutes prior to the minutes and put specific resident
names that had attended and adjourned a meeting that had not took place. She stated that the AD should
have had agenda items written down, but minutes should not have been written out until after meetings
end. She stated that she attends every resident council meeting, and that the AD never created the minutes
prior to the meetings she had attended.
Interview on 08-17-23 at 01:50 PM the DON stated per resident's request and invitation she attended
approximately 3 meetings yearly. She stated she does not know off the top of her head which 3 meetings
she had attended, and she was not listed on the meeting minutes because it was an invitation to attend by
the residents.
Interview on 08-17-23 at 03:41 PM the ED stated that the AD had worked for the facility for a long time. He
stated he does not believe the AD intended to create minutes to an event that has not taken place. He
stated the AD had mistaken the agenda for the minutes. He stated that it was his expectations that the AD
does not have minutes created before the resident council meetings. He stated moving forward he would
assist in writing minutes and participate in the group meetings.
Record Review 08-17-2023 at 11:30 AM of Resident Council Minutes dated 08-31-2023, at 10:30 AM
revealed the AD and 6 residents attended the group meeting.
Opening Question: Resident Rights. Do you believe you can exercise your rights without interference,
discrimination, or reprisal from the facility? Residents replied- yes.
Resident's Grievance and Satisfaction: Residents are satisfied with their care.
Consensus: All members of the extended care center (ECC) Resident Council, as well as the other
residents present, have collectively come to the consensus that they are receiving great and adequate
medical and room care from our staff of RNs, LVNs and CNAs. No complaints, medically at this time.
Housekeeping, Maintenance, Foodservice, Administrator's, Laundry Department, Bus Driver, Therapy
Services, and ECC Activity Director work diligently seeking ways to bring stimulation presentations for
resident's pleasure.
Closing and Adjournment: Resident Council president adjourned the meeting until 09-28-2023.
Record review of the AD's Certification of Completion dated 05-26-14 revealed she successfully completed
90 hours of course work/90 hours practicum.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676021
If continuation sheet
Page 2 of 6
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
676021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clarewood House Extended Care Center
7400 Clarewood Dr
Houston, TX 77036
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 0565
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Record review of Resident Council Meetings revised date of February 2021. Policy Statement. The facility
supports resident's right to organize and participate in the resident council. Policy Interpretation and
Implementation. 1. The purpose of the resident council is to provide a forum for: a. residents, families, and
resident representatives to have input in the operation of the facility's b. discussion of concerns and
suggestions for improvement. c. consensus building and communication between residents and facility staff:
and d. dissemination information and gathering feedback from interested residents. 2. All residents are
eligible to participate in the resident council. The facility staff encourages residents who are willing to
participate . 6. A Resident Council Response Form will be utilized to track issues and their resolution .
Record review of Policy Charting and Documenting revised date of July 2017. Policy Interpretation and
Implementation 3. Documentation in the medical record will be objective (not opinionated or speculative),
complete, and accurate.
Record review of AD's Job Description, print, signed and dated by AD on 01-30-14. PHYSICAL
AND/SENSORY REQUIREMENTS: (With or without the aid of mechanical devices). 4. Must function
independently and have flexibility, personal integrity, and the ability to work effectively with residents,
personnel, and support agencies . I acknowledge . and . I further understand that it is my responsibility to
inform my supervisor at any time that I am unable to perform these functions . Acceptable job performance
includes completion of all job responsibilities as well as compliance with the policies, procedures, rules and
regulations of my department and the facility. I have read and understand this job description.
Review of previous resident council meetings from June, July and August 2023 reflected an average of 7
resident council members who attended.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676021
If continuation sheet
Page 3 of 6
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
676021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clarewood House Extended Care Center
7400 Clarewood Dr
Houston, TX 77036
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility failed to implement a comprehensive
person-centered care plan, consistent with the resident rights that included measurable objectives and
timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in
the comprehensive assessment for 1 of 13 residents (Resident #1) reviewed for care plans.
-The facility failed to ensure a comprehensive care plan for pressure wounds was implemented for Resident
#1.
This failure placed residents at risk of not receiving care and treatment to meet the resident's physical,
mental, and psychosocial needs.
Findings include:
Record review of Resident #1's face sheet undated revealed a [AGE] year-old female admitted to the facility
on [DATE] and readmitted [DATE]. Her diagnoses included Vascular dementia (brain damage caused by
multiple strokes causing memory loss ), psychotic disturbance ( A mental disorder characterized by a
disconnection from reality), diabetes mellitus (a group of diseases that result in too much sugar in the
blood) with diabetic neuropathy (nerve damage that can occur with diabetes), Peripheral vascular disease (
A circulatory condition in which narrowed blood vessels reduce blood flow to the extremities) atrial flutter (
the hearts upper chambers (atria) beat to quickly) and major depressive disorder (mood disorder that
causes persistent feeling of sadness).
Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed sometimes Resident #1
made herself understood. Resident #1 sometimes understood others. Resident #1 BIMS (Brief interview for
mental status) was three which indicted her cognition was severely impaired. The resident required
extensive physical assistance from one staff for bed mobility and personal hygiene. Resident #1 had limited
range of motion (limited movement) to her BLE ( both lower legs). The resident was always incontinent of
bladder and bowel.
Record review of Resident #1's care plan initiated 05/16/2023 revealed the following:
Problem: Resident was at risk for pressure ulcers related to decreased mobility, incontinence, cognitive
deficit, and diabetes mellitus.
Goal: Resident's skin will remain intact.
Approach: Start dated 05/16/2023 Use Prevalon boots (specialized boots with cushioned bottoms that keep
the heels off the surface of the mattress) to relieve pressure on the heels while in bed.
Record review of Resident #1's physician's orders dated 08/16/2023 revealed Apply Prevalon boots to
prevent pressure sores on heels bilaterally. Special Instructions: Apply while resident in bed. Every Shift;
Day, Evening, Night. Start date 09/22/2023. No end date.
Observation on 08/16/2023 at 10:41 AM, assisted by LVN A revealed Resident #1 in bed. Resident #1 was
not wearing the prevalon boots to her BLE. Resident was confused and unable to be interviewed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676021
If continuation sheet
Page 4 of 6
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
676021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clarewood House Extended Care Center
7400 Clarewood Dr
Houston, TX 77036
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Observation on 08/16/2023 at 11:33 AM during wound care, assisted by RN C, revealed Resident #1 in
bed. Resident #1 was not wearing prevalon boots to her BLE. No wounds observed to Resident #1's heels.
Observation on 08/16/2023 at 2:23 PM revealed Resident #1 in bed without prevalon boots.
Observation on 08/17/2023 at 9:25 AM, assisted by LVN A, revealed Resident #1 was in bed not wearing
prevalon boots. Interview at the time of the observation LVN A stated Resident #1 did not have prevalon
boots on now or yesterday when we looked at the resident. LVN A looked around Resident #1's room and
closet. LVN A was unable to find the prevalon boots. LVN A stated Resident #1 should have the boots on to
prevent sores on her heels. The LVN stated she did not know why she did not have them on. The LVN
continued and stated the risk of not following the care plan could result in harm to the resident. The LVN
stated the risk of not wearing the prevalon boots was the development of pressure wounds to her heels.
LVN A stated the resident's care plan should have been followed for the resident's plan of care. As the
interview continued LVN A stated the CNA can put the boots on. It was the treatment nurse's responsibility
for monitoring every shift that the boots were on the resident.
Observation and interview on 08/17/2023 at 9:37 AM, CNA B stated she did not know why Resident #1 was
not wearing the boots. CNA B looked in the resident's room and closet. No boots were observed. CNA B
stated maybe the boots were in the laundry. CNA stated the boots would stop Resident #1 from getting
sores on her heels.
Interview on 08/17/2023 at 10:15 AM, RN C stated the nurse was responsible for making sure Resident #1
had her boots on. RN C stated the boots may be in the laundry. RN C stated she did not know for sure why
they were not on. RN C stated the purpose of the care plan was to make sure the resident received the
individualized care needed. She stated the risk of not following the care plan was the resident may not
receive the proper care.
Interview on 08/17/2023 at 11:02, the MDS Coordinator stated he was responsible for development of the
care plan. The coordinator stated the approach for the prevalon boots came from Resident #1's physician's
order. MDS Coordinator stated the care plan approaches were important to follow; they were the steps to
achieve the resident's goal. He continued and stated the care plan was monitored daily and changed daily
as needed. He stated the risk of not wearing the prevalon boots was skin break down to the resident's heels
due to her decreased mobility and cognitive decline
Interview on 08/17/2023 at 11:43, the DON stated she expected the care plans to be followed. The DON
stated the care plan identified the resident's needs with the steps to reach a goal. The prevalon boots were
to prevent sores. The DON stated the resident needed the boots. She continued and stated the care plan
was monitored and changed as needed for resident changes The DON, ADON, and charge nurses were
responsible for monitoring that the care was provided as needed. The DON stated the staff would monitor
every shift to ensure the care plans were followed.
Interview on 08/17/2023 at 12:35, The ED stated he did not have clinical experience. The ED stated he
expected the care plans were followed. As the ED continued, he stated the care plan was what to do for the
resident's care. He continued and stated if the resident needed to have the boots, she should have had
them. The ED stated he was not able to discuss the risk of not following the care plan. He stated he would
discuss with the DON
Record review of facility policy, Care Plans, Comprehensive Person-Centered revised March 2022
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676021
If continuation sheet
Page 5 of 6
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
676021
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Clarewood House Extended Care Center
7400 Clarewood Dr
Houston, TX 77036
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable
objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed
and implemented for each resident. Policy, Interpretation and Implementation 3. The care plan interventions
are derived from a thorough analysis of the information gathered as part of the comprehensive
assessment. 7. The comprehensive, person-centered care plan: b. describes the services that are to be
furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial
well-being .
Event ID:
Facility ID:
676021
If continuation sheet
Page 6 of 6
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Back to topCitations
2 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.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the August 17, 2023 survey of CLAREWOOD HOUSE EXTENDED CARE CENTER?
This was a inspection survey of CLAREWOOD HOUSE EXTENDED CARE CENTER on August 17, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CLAREWOOD HOUSE EXTENDED CARE CENTER on August 17, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."
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.