Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Clarewood House Extended Care Center during CMS and state inspections, most recent first.
Surveyors found multiple food service deficiencies, including soiled plates, bowls, cups, glasses, and pans stored as clean, and grease and burnt food buildup in ovens and on stove vent covers. A cooked turkey in the walk-in cooler was held above the required cold-holding temperature, and several hot menu items on the steam table, including scrambled eggs, ground beef, and grits, were below the required hot-holding temperature during breakfast service. Staff reported that residents were first served cereal and then the main course, and that food temperatures had been acceptable at the start of service, but observations and temperature checks did not meet the facility’s written policies for food temperatures, cooling, and sanitation.
A resident with multiple chronic conditions, including hemiplegia, COPD, cardiovascular disease, depression, and dysphagia, had an MDS indicating quarterly review and a care plan showing a care conference held in June with the next due in September. Record review found care conference documentation only for March and June, with no EMR entry for the required September conference. The MDS Coordinator, who was responsible for taking notes and uploading care conference minutes, and other IDT members (SW, AD, DON, ADON, Administrator) all confirmed that conferences are held every three months and that the EMR should contain the notes, stating that if it is not documented, it is considered not done. Facility policy required timely, person-centered IDT care planning and documentation when participation is not practicable, but no September care conference record or explanation was present in the EMR, demonstrating incomplete and noncompliant clinical documentation.
A resident was discharged from a facility without a complete discharge summary, missing critical information such as practitioner contact details, advance directives, and care plan goals. The social worker responsible for discharge planning was new and unfamiliar with the resident, and the family took the resident earlier than planned, contributing to the incomplete documentation. Interviews with staff revealed a lack of clarity and communication in the discharge process.
Food Service Sanitation and Temperature Control Deficiencies
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to prepare, distribute, and serve food in accordance with professional standards and facility policy. During an initial kitchen tour, surveyors observed items stored as "clean" that had dried food particles and stains, including plates, bowls, cups, and glasses with water spots and stains. Holding pans stored as clean also contained food particles. The stove air vent covers were observed with dust and grease accumulation, and the double convection oven contained burnt food particles and grease. In the walk-in cooler, a baked turkey cooked the previous evening was found at 44°F, above the facility’s stated cold-holding requirement of 41°F or below and inconsistent with the facility’s cooling policy for cooked turkey. During observation of breakfast meal service, three menu items on the steam table were not maintained at the required hot-holding temperature of 135°F or higher. Scrambled eggs were measured at 120°F, ground beef at 110°F, and grits at 130°F. Dietary staff reported that residents eating in the dining room were first served cereal and then the main course afterward, and that the food temperature on the steam table had been acceptable before service began. The facility’s written policies required hot foods to be held at 135°F or higher with temperatures checked at the start of meal service and every 30 minutes, required cooked turkey to be cooled from cooking temperature to 70°F within two hours and from 70°F to 41°F within an additional four hours, and required ovens and vent hoods to be kept clean and free of grease buildup. Policies also specified that utensils and equipment must be cleaned, sanitized, and air-dried to prevent re-contamination, which was not followed as evidenced by soiled items stored with clean dishware and pans.
Missing Quarterly Care Conference Documentation in EMR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented clinical records for a resident, specifically the absence of a required quarterly care conference report in the EMR. The resident was an adult female with multiple significant diagnoses, including hemiplegia, bladder disorder, COPD, atherosclerotic heart disease, anemia, lack of coordination, osteoporosis, major depressive disorder, generalized weakness, gait and mobility abnormalities, dysphagia, oropharyngeal cancer, and cognitive communication deficit. Her MDS dated 09/14/2025 showed she was cognitively intact with a BIMS score of 15, used a wheelchair, and required assistance with ADLs. Her care plan indicated that a care conference was held on 06/10/2025 and that the next conference was due on 09/10/2025. Record review of the resident’s care conference reports showed documentation only for conferences held on 03/11/2025 and 06/10/2025, with no documentation of a care conference or assessment for the due date in September 2025. The facility’s own records and MDS coding reflected that care conferences were to be conducted quarterly, yet there was no care conference report in the EMR for the September interval. Multiple staff interviews confirmed that care conferences were expected every three months for each resident and that the resident’s schedule would have been June, September, and December. Staff also consistently stated that, from a nursing standpoint, if something was not documented, it was considered not to have occurred. Interviews with the MDS Coordinator, SW, AD, DON, ADON, and Administrator established that the MDS Coordinator was primarily responsible for taking notes during care conferences and uploading the minutes into the EMR, with the DON or ADON serving as backups when the MDS Coordinator was absent. The MDS Coordinator acknowledged responsibility for uploading the minutes but could not explain why the September care conference report was missing. The SW, AD, DON, and ADON all confirmed that care conferences were held quarterly, listed typical attendees, and stated that the EMR should contain the notes as proof that a conference occurred. The DON suggested the missing September record could be due to human error and noted she was newly hired and multitasking at the time, while the ADON stated there was no documentation for September because the DON missed documenting. The facility’s care planning policy required person-centered care plans developed by an interdisciplinary team within specified timeframes and documentation in the medical record when participation was not practicable, but the September care conference documentation for this resident was not present in the EMR. The facility’s written policy on care planning and interdisciplinary team (IDT) care area assessments specified that residents’ care plans are developed according to timeframes, are person-centered, and are created by an IDT including nursing, food and nutrition services, and the resident or representative. It also required that if resident or representative participation is not practicable, an explanation must be documented in the medical record. Despite these requirements, there was no documentation in the EMR to show that the September quarterly care conference for this resident occurred, nor any explanation for lack of participation or rescheduling. Staff interviews repeatedly emphasized that the EMR should be the source to verify whether a care conference was conducted and that missing documentation meant the conference was not done, thereby demonstrating that the facility failed to maintain clinical records in accordance with accepted professional standards and practices for this resident. The Administrator confirmed that care conferences were completed quarterly and that, based on the June date, the next conferences should have been in September and December, and also confirmed that the MDS Coordinator was responsible for uploading the conference reports into the EMR. However, no September care conference report was found in the EMR for this resident during the surveyor’s review. This combination of record review, staff statements, and facility policy established that the facility did not maintain a complete, accurately documented, and systematically organized clinical record for the resident’s September quarterly care conference, resulting in the cited deficiency.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for a resident, identified as Resident #18, who was discharged from the facility. The discharge summary lacked essential information such as the contact details of the practitioner responsible for the resident's care, the resident representative's contact information, advance directive information, special instructions or precautions for ongoing care, and comprehensive care plan goals. This deficiency was identified during a review of closed records for an effective discharge process. Resident #18 was a male with a history of a saddle embolus of the pulmonary artery and chronic obstructive pulmonary disease. He was discharged to an inpatient rehabilitation facility. The discharge summary was incomplete, and the facility's social worker, who was responsible for discharge planning, was new to the facility and unfamiliar with the resident. The social worker admitted that the previous social worker might have forgotten to make a copy of the discharge summary, and there was confusion about the resident's discharge status and the reason for discharge. Interviews with various staff members, including the social worker, Rehab Director, LVN-ADON, Medical Records personnel, DON, and the Administrator, revealed a lack of clarity and communication regarding the discharge process. The social worker and ADON were responsible for different parts of the discharge summary, but there was no clear oversight to ensure the completion of the document. The resident's family took the resident earlier than planned, which contributed to the incomplete discharge summary. The facility's failure to ensure a complete discharge summary could affect the coordination of care and safe transition of residents from one setting to another.
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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.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sharpville Residence And Rehabilitation Center | 0.2 mi | ★★★★★ | 1 | 0 |
| University Place Nursing Center | 1.3 mi | — | 0 | 0 |
| The Lev At Town Park | 1.7 mi | ★★★★★ | 2 | 2 |
| Houston Transitional Care | 1.8 mi | ★★★★★ | 1 | 0 |
| Woodway Nursing & Rehab | 1.9 mi | — | 6 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.