Health inspection·September 12, 2024

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few QD. Assess psycho/social needs prn. Break down activities in manageable segments. Encourage to participate in activities. Talk to resident during care explain procedures. Provide cueing & redirection prn. Provide supervision & assist /c ADLS prn. Provide consistent & routine environment QD. Problem: Decline in ADL function R/t BL Extremity weakness and unsteady gait, need extensive assistance from 1-2 person for transfer and 1 person for ADL care. Goal: Will reduce risk of complications over next 90 days. Approach: Assist /c all ADLS x aide QD prn. Staff to gather supplies, shampoo hair, bathe, oral & nail care per schedule & prn. Offer choices for what to wear. Provide assist to stand & transfer to bed/chair x 1-2 aide QD prn. Monitor for incontinence Q2hrs & prn. Assist to toilet Q2hrs & prn. Set up meal tray, open cartons, cut meat prn. Explain all procedures using terms & gestures resident can understand. Be patient & allow time to complete tasks. Provide Foley catheter care as needed, PT/OT if needed . Record review of Resident #18's Discharge summary dated [DATE] noted there was no contact information of the practitioner responsible for the care of the resident; the resident representative information including contact information; the advance directive information; all special instructions or precautions for ongoing care, as appropriate; and comprehensive care plan goals. Record review of an undated blank Post Discharge Plan of Care: Nursing Services given to me by the Social Worker to show what should have been in Resident #18's chart noted a place for the facility name, phone number, address, reason for discharge, nursing needs, personal needs, Level of assistance required with ADLs, and Level of assistance required with IADLs. There was no space for Advance Directives. Record review of Discharge Summary and Plan dated October 2022 read in part . When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. 4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: a. where the individual plans to reside; b. arrangements that have been made for follow-up care and services; 12. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary. Interview on 09/12/2024 at 1:57 PM with the Social Worker revealed she was responsible for resident discharge planning. She said the ADON and herself were responsible for the Discharge Summary. She said she would look at the Progress notes to look for the date of discharge. She said the previous social worker may have forgotten to make a copy of the Discharge Summary. She said she was not sure what his admission status was and was not sure why he was discharged . She said she thought it may have been the resident's decision to discharge from the facility. She said the ADON might know why he was discharged . She said it was her 4th day at the facility. She said her role at the facility was as the social worker was to participate in Care Plan meetings, and discharge planning, and weekly Medicare meetings. She said she was not familiar with Resident #18. She said the policy or procedure for discharge planning was to meet with resident and or family members within 48 hours of admission and ensured everyone knew what the plan was and agreed to it, set up home health, ensured the resident had the proper equipment and she coordinated with therapy on that. She said the information that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 2 of 4 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 09/12/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was required on discharge summary was things like home health or rehab, what equipment and where it was from, community resources, who was doing housekeeping, social support system, who their PCP and pharmacy were as well as their transportation needs, the discharge location, a contact, and the reason for discharge. She said she made 3-4 follow up calls after a discharge, but if the resident was going to another facility she would not make follow up calls. The follow up calls were only if residents were going back home. She said she had training on discharge planning when she previously worked at the facility. She said she would guess the DON or ADON were responsible for oversight to ensure staff was following protocol. She said the risk to residents if policy or procedures were not followed would be residents may not have their needs fully met once they were at their discharge location. She said the worst thing that could happen to a resident if policy or procedures were not followed was the resident may have access to things that would facilitate them to remain in their home. Interview on 09/12/2024 at 2:05 PM with the Rehab Director revealed the resident was always planned to go to another facility from the hospital and stay a while. She said Resident #18 and the family initiated the discharge. He was not set to leave when originally planned and the resident left earlier than what the facility had scheduled . She said Resident #18 was planned to discharge in a week, but the family came to get the resident 3 days later. Interview on 09/12/2024 at 2:011 PM with the LVN-ADON revealed she said when a resident left a facility, it was because they met skilled requirements. She said the social worker wrote the discharge summary. She said she was not aware of a Discharge Summary document. She was shown a copy of the Plan of Discharge document and she said the charge nurse should write the nursing part of the discharge. She said she had worked at the facility for 5 years in January. She said part of her role was to complete the Post Discharge Plan of Care. She said she was familiar with Resident #18. She said the policy or procedure for discharge summaries/discharge planning was the social worker initiated the Post Discharge Plan of Care and she the ADON completed the nursing part of it including diet. She did not know what the Discharge Summary was incomplete. She said she had not been in-serviced on that before. She said the resident left unexpectedly before she could complete it. She said the social worker was responsible for ensuring the Discharge Plan of Care was complete. She said there was no risk to residents if policy or procedure was not followed. She said staff provided patient teaching, the medication list, and the residents knew who their doctors were. She said there really was no risk. Interview on 09/12/2024 2:16 PM with Medical Records revealed the resident's family member talked about the resident going to another facility, but did not know when he would be going. When the resident left the family just took him without letting them complete the form. Interview on 09/12/2024 at 2:56 PM with the DON said the family was unsure the resident could transfer to the another facility and the facility was caught off guard when the family came to take him to the other facility. Interview on 09/12/2024 at 3:07 with the Administrator revealed he said, with discharge planning, the social worker was in charge of that. He said the Discharge Summary was supposed to have where they were going, what medications they were on, what equipment they needed, did they need home health, what supplies they would need, and whether to continue the care. He said the facility ensured where they were going was appropriate , and they called and followed up a week later to check on them. He said he had worked at the facility for 23 years and his role at the facility was Executive Director and Administrator. He said he was not familiar with Resident #18. He said, routinely, he ensured the facility stayed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676021 If continuation sheet Page 3 of 4 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 09/12/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete in compliance, attended standup meetings, tracked who was being discharged , talked with residents and visited with them, asked how things were going, assisted with ensuring staffing was in place, stood in on all the committees, ensured staff were there and doing their jobs, talked with staff about residents, reviewed incident/accidents, met with all directors, and communicated with families. He said the discharge plan should start as soon as possible. He said the facility needed to determine if a resident was short-term or long-term, ensured their needs were being meet, coordinated with family to get with all outside agencies, ensured the orders were sent, and got the NOMNCs signed. He said he did not know what happened with Resident #18. He said the former social worker was sick and not doing well. He said she had to resign. He said generally the social worker communicated with the team, but as Administrator he knew who was going and coming. The primary staff responsible for ensuring policy/protocol was followed, would be the social worker. He said the risk to residents if policy or protocol was not followed depended on the resident and what needs they had; their needs might not be met. He said the worst thing that can happen to the resident when proper protocols were not practiced was it could result in a lack of needed services. Event ID: Facility ID: 676021 If continuation sheet Page 4 of 4