Paradigm At Westbury
Paradigm at Westbury in Houston, TX — inspection on August 28, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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