Solera at West Houston

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that resident with pressure ulcers receives treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1(Resident #1) of 5 resident's reviewed for pressure ulcers. -LVN A failed to follow physician orders while changing Resident #1's dressing to right hip. LVN A failed to apply skin prep to peri wound edge and apply Santyl (ointment used to remove dead tissue from skin ulcer) to resident wound bed. This failure could place residents with wounds at risk for delayed healing and tissue damage. Finding Included: Record review of Resident #1's face sheet dated 02/03/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 01/19/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers receive necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for wound care. The facility failed to properly identify the pressure ulcer and provide immediate oversight by a wound care specialist when the wound was first identified as a Stage 2 Pressure Ulcer on 10/15/25. CR#1 was admitted to the hospital on [DATE] with a necrotic pressure ulcer to the right heel and the need for possible amputation of the lower right extremity. On 11/17/25, CR#1's family member stated that CR#1's right leg was amputated above the knee due to an infected pressure ulcer of her heel. An Immediate Jeopardy (IJ) was identified on 11/14/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 (CR#1) of 3 residents reviewed for accuracy of assessments. The WCN failed to accurately document the presence of an existing wound on CR#1's weekly skin assessment after a new skin issue occurred on 10/15/25. CR#1's initial MDS Assessment failed to document the presence of a skin issue. These failures could place residents at risk for delayed treatment, worsening of condition, and hospitalization

Inspectors wroteBased on observation, interview, and record review, the facility must develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and include the minimum healthcare information necessary to properly care for residents for 3 (Residents #139,#140, and #143) of 5 residents reviewed for baseline care plans -Resident #139 had a tracheostomy and an enteral feeding tube that were not baseline care planned. -Residents 139, #140, and #143's baseline care plans did not designate the code status of the residents. The failures could place the residents at risk for not receiving the care and services needed and placed them at risk for deteriorating health.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #9 and #47) of 21 residents reviewed for comprehensive care plans. The facility failed to ensure that Resident #47 has a comprehensive care plan that included all care areas triggered on her assessment. The facility failed to ensure that Resident #9 comprehensive care plan included her hospice service and oxygen. These failures could place residents at risk of not receiving proper care and service to develop and improve their mental, physical and psychosocial well-being. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel for three of five medication carts observed in common areas accessible to staff and residents. -Three unlocked and unattended medication carts were observed in areas accessible to residents, staff, and visitors. This failure could place residents at risk of ingesting medications not prescribed to them and placed the facility at risk for drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that foods are store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen in that:1. Foods were not sealed, labeled, and dated.2. Plates with dried food particles were stored with clean plates.3. Food items on the steam table was not maintained at 135 degrees F and above.4. Equipment were clean.5. Dry storage room free of dented cans. These failures could place residents who ate food prepared by the kitchen at risk for food borne disease and illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 3 of 4 residents (Resident #1 and Resident #2) reviewed for privacy in that: -The facility failed to ensure CNA B provided privacy during incontinent care for Resident #1. -The facility failed to ensure CNA C provided privacy during toilet use for Resident #2. -The facility failed to ensure CNA L provided privacy during incontinent care for Resident #3. These deficient practices could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 3 residents (Resident #1and Resident #3) reviewed for ADLs. - The facility failed to ensure Resident #1 and Resident #3 were provided incontinent care in a timely manner by facility staff. These failures could place residents at risk for not receiving incontinent care needed to maintain personal hygiene which could lead to skin breakdown, pressure injuries or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #1 and Resident #3) reviewed for incontinent care. The facility failed to ensure CNA B properly cleaned Resident #1 during incontinent care when CNA B did not separate Resident #1's labia on 04/22/2025. The facility failed to ensure CNA L properly cleaned Resident #3 during incontinent care when CNA L did not separate Resident #3's labia during incontinent care on 04/24/2025. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/prepared discarded after used date of 2 - 3 days per facility policy. These failures could place residents at risk of food borne illness and disease. Findings Included: Observation of the 1 of 1 facility kitchen freezer on 04/22/2025 at 8:56 a.m., revealed the following: 1. 1-gallon ziplocked sealed bag full of frozen premade waffles unlabeled/undated. 2. 4-single waffles sealed in saran wrap unlabeled/undated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 3 of 4 residents (Resident #1, Resident #2, and Resident #3) and 4 of 5 staff (CNA B, CNA C, CNA L, CNA F) observed for infection control. 1-The facility failed to ensure CNA B followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #1 on 04/22/2025. 2-The facility failed to ensure CNA C followed appropriate infection control and hand hygiene procedure while assisting resident to the bathroom for Resident #2 on 04/22/2025. 3-The facility failed to ensure CNA L followed appropriate infection control and hand hygiene procedure during and after incontinent care for Resident #3 when she was seen leaving a resident's room with gloves on 04/24/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Resident #10 and Resident #22) reviewed. -The facility failed to ensure that Resident #10's status of full code was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #10's status of allergies was a focus area in the resident's comprehensive care plan and no intervention was in place. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #2) reviewed for accidents and for food trays left out in the halls after meals. -The facility failed to ensure CNA C used gait belt when she transferred Resident #2 from bed to walker and walked the resident to the bathroom. -There was a food cart with nine food trays eaten with cutlery left out in the hall observed on 4/23/2025 at 4:43am. This failure could place residents who required assistance from staff to transfer out of bed and ambulatory residents at risk for accidents and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 8 resident halls observed for proper garbage disposal. The facility failed to dispose of garbage when a food tray cart safely and properly with nine trays that were eaten including cutlery laying on the trays were seen outside the Kitchen entrance on 4/24/2025. This failure could place residents at risk of eating food incompatible with their prescribed diet and which could attract pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 (Resident #1) residents reviewed for abuse and neglect. The facility failed to ensure that Resident #1 was free from sexual abuse when staff observed Resident #1 being touched inappropriately by CR #2 on 12/26/2024. The noncompliance was identified as Past Non-Compliance. The IJ began on 12/26/2024 and ended on 12/27/2024. The facility corrected the noncompliance before the survey began. This failure placed residents at risk of experiencing abuse and neglect.

Inspectors wroteBased on record review and interview the facility staff failed to ensure residents with pressure ulcers received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of 5 residents reviewed for wound care. The facility failed to perform wound care for Resident #1 when her bandages became soiled with urine. The facility failed to request a PRN order to change the bandage on Resident #1's sacral wound if it became soiled. This failure could place residents at risk for infection, deterioration of the wound and diminished quality of care.

Inspectors wroteBased on record review and interview the facility staff failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of five residents reviewed incontinent care. The facility failed to address the leakage of urine from Resident #1's urethra, causing her stage VI pressure ulcer to the sacrum to burn. This failure could place residents at risk for infection, deterioration of the wound and diminished quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 6 residents (Resident #141) reviewed for medication administration were free of significant medication errors. Facility failed to administer medications according to physican ordeers: multivitamin with folic acid (medication used to treat or prevent vitamin deficiency due to poor diet, or certain illnesses for 6 Days (was not available in stock) to Resident #14. This failure could place residents at risk of harm, injury, illness or hospitalization.

Inspectors wroteBased on observation, record review and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were not discarded 2. The facility failed to ensure food was labeled and dated. 3. The Ice Scoop was left inside the ice maker These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 06/18/24 at 8:17 AM revealed that the following foods were not discarded prior to the use by date . Highly perishable foods not dated should be discarded due to spoilage and bacterial growth if stored for longer time 1. Rice dated 06/11/24 no used by date 2. Plastic container of Sliced Cheese no label, no use by date. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for three of three residents, (Resident #14, Resident #393 and Resident #397) and three of four staff (LVN C) reviewed for infection control and prevention, in that: 1. LVN C did not follow proper technique in cleaning the accu-check machine (monitor for checking blood sugar levels) between Resident #393 and Resident #397. 2. Resident #14's external urinary catheter tubing was found on the ground and touching the carpet floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #48 ) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Residents #48's urinary catheter leg strap was in place to secure the catheter. This failure could place residents with foley/urinary catheters at risk of catheter pulling causing pain and/or infection due to improper care practices and cross contamination.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 1 of 6 medication carts, and 1 of 2 medication rooms (Medication Room-Hall 500 to 800 and Medication cart 100, 500 and 600) reviewed for medication storage. - There was Azelastine Spray 0.1 % and Fluticasone Propionate 50 mg that were opened, and not dated found ?in the medication cart for Hall 100 - There was Humulin insulin that was opened and not dated in the medication room for halls 500-800 - 1 bottle of Daily Multivitamin formula + iron expired medication found in medication cart for Hall 500/600. - Evencare G2 glucose control solution, 3 bottles Drug buster, Even Care G2: 1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for dumpster A of 2 dumpster reviewed for Food and nutrition services. -The facility failed to ensure dumpster A lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 6 resident rooms (Resident #23): - Sugar Ants were on bedside table and nightstand in Resident #23's room and in a bathroom near the main entrance. These failures could place residents at risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections for 1 of 6 residents (Resident #1) who were reviewed for incontinent care, in that: CNA A did not spread and clean Resident #1's labia and clean around the resident's bottom during incontinent care. These failures could affect residents who received incontinent care performed by facility staff and could result in urinary tract infections. Findings Included: Resident #1 Record review of Resident #1's admission face sheet revealed she was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control as evidence by: CNA A did not wash hands or use hand sanitizer after changing gloves and then applied antiseptic ointment to Resident #1's buttocks. These failures could affect residents who received incontinent care performed by facility staff and could result in urinary tract infections. Findings Included: Resident #1 Record review of Resident #1's admission face sheet revealed she was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents were free from mental and emotional abuse for 1 resident (Resident #1) reviewed for abuse. The facility failed to prevent CNA A from committing emotional and mental abuse by aggressively pulling Resident #1's blanket off of her and using profanity at LVN A outside of the resident's room. This failure placed resident at risk of possible emotional and mental anguish, abuse, and neglect. The noncompliance was identified as past noncompliance (PNC) and began on 04/08/2024 and ended on 04/08/2024. The facility corrected the noncompliance before the investigation began on 05/15/2024 at 11:24 a.m. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's right to be free from abuse for 1 of 6 residents (Resident #1), in that:. CNA C was seen on camera being verbally abusive aggressive towards Resident #1 which resulted in the resident feeling unsafe at the facility. This failure could place residents receiving care at risk of experiencing continued psychological distress and declining mental health.

Inspectors wroteBased on observations and record reviews, the facility failed to ensure that residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) whose care was reviewed in that: CNA F did not transfer Resident #1 using a mechanical lift with two-person assist. CNA F transferred Resident #1 alone. This failure could place residents who required supervision at risk for injury.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 26 opportunity which involved 2 (Resident #250 and Resident # 78) of 7 residents reviewed for medication errors. -RN A left substantial quantity of crushed medications in medication cup. After administered a Seroquel to resident # 78 thus doses of medication ordered were not administered. (Error # 1) -MA A did not administer Sucralfate oral suspension as ordered by the doctor. Zinc Sulfate 50mg., Zinc (220mg) tablet oral one time daily, Citalopram 20mg (tablet) 1 oral time daily were not administering according to physician's order to Resident #250. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: Food items with an expired used by date. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles , included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts ( Medication Aide Cart for 700, and 800 hall) reviewed for medication storage. The facility failed to ensure the Medication Aide Cart for 700 and 800 halls did not contain opened medications that were not labeled with open date. The facility failed to ensure the Medication Aide Cart for 800 hall have medications stored in their original delivery packet. These failures could place residents at risk of not receiving the therapeutic benefit of medication or adverse reactions to medications. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards. The facility failed to ensure RN A follow proper hand hygiene and infection control procedure while providing accucheck for Resident # 70. These deficient practices could affect residents and place them at risk for infection and reinfection.