Paradigm at Westbury: Vaccination Records Gap - Houston, TX
The facility's Director of Customer Engagement, the staff member responsible for completing admission packets, left on April 30, 2026. Her replacement started May 26, four days before state inspectors arrived. The new hire told inspectors she had never held the position before. Her training consisted of what she learned from a DCE at a sister facility who had been coming in to help, though not every day and not full time.
When inspectors reviewed records during their May 29 visit, at least two residents were missing completed admission paperwork that included vaccination history and consent forms for flu, pneumonia and COVID immunizations.
One of those residents was Resident 2, who had been at the facility long enough that the 72-hour window for completing admission paperwork had already closed. When inspectors asked the Assistant Director of Nursing about the file, she said she was still looking for it. By early afternoon, she told inspectors she had called the resident's family member that morning to obtain the immunization information and was entering it as they spoke. Resident 2 was unable to sign the paperwork herself.
The newly hired DCE told inspectors she had not seen Resident 115 on her list of unresolved items at all. She learned what needed to be done through an app called Reside.
The Director of Nursing told inspectors that collecting immunization information was primarily the infection control nurse's job, though unit managers, the DON herself and the admitting nurse could also enter the information. She then offered her own assessment of the risk. "Not all people believed in immunizations," she said, "so she could not say it was a high risk." She added that if a resident's immunization history was missing, staff could look it up, and if the resident had not been vaccinated, they could be offered the shots then.
Her assistant saw it differently. The ADON told inspectors that not having immunization information on file "could put residents at risk of infectious diseases."
The Administrator told inspectors that a corporate employee had been pulling information and running weekly audits to check that admission packets were completed during the period the facility had no DCE. She did not explain why those audits had not flagged the missing records for Resident 2 or Resident 115.
The Administrator also confirmed that the DCE position had been vacant since April 30 and that the part-time help from the sister facility was not a full-time presence. She did not say how long the facility had gone without anyone in that role before the previous DCE's final day, and the new DCE told inspectors she did not know how long the position had been unfilled before she started.
What the inspection captured was a facility that had let a key administrative function go unstaffed for weeks, filled it four days before inspectors walked in with someone still in training, and was still catching up on paperwork that should have been done within three days of each resident's arrival. The DON's position, that missing vaccination records were not a high risk, sat alongside her assistant's acknowledgment that the gaps left residents exposed.
Resident 2's family was being emailed forms to sign the afternoon inspectors were on site. Resident 115 had not made it onto anyone's list.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paradigm At Westbury from 2026-05-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Paradigm at Westbury in Houston, TX was cited for violations during a health inspection on May 30, 2026.
The facility's Director of Customer Engagement, the staff member responsible for completing admission packets, left on April 30, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.