Paradigm At Westbury
Inspection Findings
F-Tag F0695
F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside.
Observation of Resident # 5 on 8/28/2025 revealed Resident # 5 was lying in bed, and Resident # 5 did not display sign or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. In a telephone interview with LVN B on 8/28/2025 at 11:10 am she stated that she was reeducated
on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent performing tracheostomy care. LVN B stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. In a telephone interview with LVN C on 8/28/2025 at 11:25 am she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent performing tracheostomy care. LVN C stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. In a telephone interview with LVN A on 8/28/2025 at 2:15 pm she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent in performing tracheostomy care. LVN A stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. On 8/28/2025 telephone interviews were conducted with LVN D, LVN, E, LVN F, LVN G, LVN H, LVN I, LVN J, AND RN A. All staff stated they were in-serviced on tracheostomy care and management. All staff reported the completed a returned demonstration and felt competent in performing tracheostomy care. These staff worked various shifts to include morning shift, night shift and weekend shifts. Record review of the facility policies and procedures for Tracheostomy Management, dated 5/2022, revealed Licensed Nurses providing care for residents with tracheostomies will be trained on tracheostomy care. Precautions/Side Effect: accidental decannulation Record review of the facility policies and procedures for Tracheostomy Care, dated 11/22, read in part Tracheostomy care is performed aseptically for cleaning of the tracheostomy tube and soma site, to prevent plugging of the tracheostomy tube, to prevent airway obstruction, to prevent infection of trach site, and to maintain a patent airway for suctioning. Precaution /side effect(s): accidental decannulation. On 8/28/2025 at 4:13 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of potential more than minimal harm that is not immediate jeopardy because all staff had not been trained on 8/26/2025.
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Paradigm at Westbury in Houston, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Houston, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Paradigm at Westbury or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.