Inspection Reports for Clarewood House Assisted Living
7400 CLAREWOOD DR, HOUSTON, TX, 77036
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide complete discharge information and ensure an effective discharge process for Resident #18.
Complaint Details
The complaint investigation focused on Resident #18's discharge process. Interviews revealed the discharge summary was incomplete, missing critical information. The resident left earlier than planned, and the social worker responsible for discharge planning had recently resigned. The facility staff acknowledged gaps in discharge documentation and coordination.
Findings
The facility failed to provide necessary contact information of the practitioner responsible for the resident's care, resident representative information, advance directive information, special instructions for ongoing care, and comprehensive care plan goals in the discharge summary for Resident #18. The discharge summary was incomplete, potentially affecting safe resident transitions and care coordination.
Deficiencies (1)
Failure to ensure necessary information is communicated to the resident and receiving health care provider at the time of a planned discharge, including practitioner contact, resident representative contact, advance directives, special instructions, and care plan goals.
Report Facts
BIMS score: 10
Discharge date: Jul 15, 2024
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unknown Social Worker | Social Worker | Responsible for resident discharge planning and discharge summary |
| Unknown Rehab Director | Rehab Director | Provided information about Resident #18's discharge timing and family initiation |
| Unknown LVN-ADON | LVN-Assistant Director of Nursing | Responsible for completing nursing part of Post Discharge Plan of Care |
| Unknown DON | Director of Nursing | Commented on family transfer of resident and facility preparedness |
| Unknown Administrator | Executive Director and Administrator | Oversight of discharge planning and facility compliance |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure residents' rights to organize and participate in resident/family groups, and failure to implement a comprehensive person-centered care plan for a resident.
Complaint Details
The complaint investigation revealed that 6 residents were unaware that meeting minutes for the August 31, 2023 resident council meeting were created prior to the meeting. Interviews with the Activity Director (AD), Director of Nursing (DON), Executive Director (ED), and staff confirmed the premature creation of meeting minutes. Additionally, Resident #1's care plan for pressure wound prevention was not followed, as the resident was observed not wearing prescribed pressure-relieving boots, and staff could not locate the boots.
Findings
The facility failed to ensure that residents had the right to organize and participate in resident groups, as meeting minutes were created prior to the actual meetings, affecting 6 residents. Additionally, the facility failed to implement a comprehensive care plan for pressure wounds for one resident, resulting in the resident not wearing prescribed pressure-relieving boots, placing her at risk for skin breakdown.
Deficiencies (2)
Facility failed to ensure residents' right to organize and participate in resident groups; meeting minutes were created before the meeting took place.
Facility failed to implement a comprehensive care plan for pressure wounds for Resident #1, who was not wearing prescribed Prevalon boots.
Report Facts
Residents affected: 6
Residents affected: 1
Resident council members average attendance: 7
Course hours completed: 90
Years employed: 17
Years as AD: 10
Resident BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director (AD) | Interviewed regarding creation of resident council meeting minutes and activities calendar; admitted to creating minutes ahead of meeting. | |
| Director of Nursing (DON) | Interviewed regarding expectations for resident council meeting minutes and care plan monitoring. | |
| Executive Director (ED) | Interviewed regarding expectations for care plans and resident council meeting minutes. | |
| Licensed Vocational Nurse (LVN A) | Observed Resident #1 not wearing prescribed Prevalon boots and interviewed about care plan adherence. | |
| Certified Nursing Assistant (CNA B) | Interviewed about Resident #1's missing Prevalon boots. | |
| Registered Nurse (RN C) | Interviewed about responsibility for ensuring Resident #1 wore Prevalon boots. | |
| MDS Coordinator | Interviewed about care plan development and monitoring. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an armed intruder incident and concerns about the safety and security of the emergency exit door.
Complaint Details
The complaint investigation was substantiated. The facility failed to report an armed intruder incident on 05/12/2023 within the required 24-hour period. The intruder entered through an unsecured emergency exit door, placed a handgun in a nurse's station cabinet, and was later arrested. The facility was found to have inadequate security measures and lack of staff training on active shooter/intruder protocols prior to the incident.
Findings
The facility failed to report an armed intruder incident within the required 24-hour timeframe and failed to ensure the emergency exit door was properly locked, allowing the intruder access. An Immediate Jeopardy was identified but later removed after corrective actions including door repairs and staff training on active shooter/intruder protocols were implemented.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft involving an armed intruder incident within 24 hours.
Failure to provide a safe, functional, sanitary, and comfortable environment due to malfunctioning emergency exit door lock allowing armed intruder access.
Report Facts
Incident date: May 12, 2023
Incident report delay: 5
Duration of intruder presence: 18
Date Immediate Jeopardy identified: May 19, 2023
Date Immediate Jeopardy removed: May 22, 2023
Training dates: 4
Emergency door repair date: May 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Responsible for reporting the incident and overseeing corrective actions |
| Director of Nursing | Director of Nursing | Involved in staff training and facility safety oversight |
| Maintenance Director | Maintenance Director | Repaired emergency exit door and trained maintenance staff on door inspections |
| Nurse G | Certified Nurse Aide | Witnessed intruder, called 911, and received active shooter training |
| CNA M | Certified Nurse Aide | Stayed near intruder, took picture of handgun, involved in incident |
| CNA P | Certified Nurse Aide | Witnessed intruder, hid during incident |
| CNA J | Certified Nurse Aide | Expressed concern about door security and safety |
| Nurse L | Nurse | Used emergency exit door prior to incident, unaware of door issues |
| CNA N | Certified Nurse Aide | Reported no prior active shooter training |
| Security Officer A | Security Officer | Received active shooter training and monitored door security |
| Security Officer B | Security Officer | Checked emergency exit door after police arrived |
| Human Resources Director | Human Resources Director | Reported no active shooter training in new hire orientation prior to incident |
| CNA A | Certified Nurse Aide | Received active shooter training and reviewed locked door policy |
| CNA B | Certified Nurse Aide | Received active shooter training and verbalized understanding |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 23, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including baseline care planning, RN coverage, and medication storage practices.
Findings
The facility failed to develop and implement baseline care plans for residents, maintain required RN coverage for 8 hours daily on weekends, and ensure medications in the medication room were properly labeled and not expired. These deficiencies posed risks to resident care and safety.
Deficiencies (3)
Failed to develop and implement a baseline care plan for resident CR #41 including goals, interventions, treatments, and psychosocial needs.
Failed to ensure registered nurse coverage for at least 8 consecutive hours a day, 7 days a week on 8 of 54 days reviewed.
Failed to ensure drugs and biologicals were labeled according to professional principles and stored properly; expired medications were found in the medication room.
Report Facts
Days without RN coverage: 8
Medication expiration dates: Jun 15, 2022
Medication expiration dates: Apr 26, 2022
Medication expiration dates: May 6, 2022
Medication expiration dates: Jun 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding baseline care plan responsibility and RN coverage issues |
| ADON | Assistant Director of Nursing | Interviewed regarding medication room expired medications and medication checks |
Viewing
Loading inspection reports...
