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Complaint Investigation

Paradigm At Westbury

November 24, 2025 · Houston, TX · 5201 S Willow Dr
Citations 2
CMS Rating 1/5
Beds 148
Provider ID 675612
Healthcare Facility
Paradigm At Westbury
Houston, TX  ·  View full profile →
Inspection Summary

Paradigm at Westbury in Houston, TX — inspection on November 24, 2025.

Found 2 citations. 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.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

01:00 a.m. the staff would have been completing rounds and stated maybe the staff were assisting other residents during that time frame and were unavailable to ensure Resident #1 had been properly prepared to discharge to the hospital.

Record review of the facility's staffing schedule dated 10/15/2025 10 p.m. into 10/16/2025 at 6 a.m. reflected that CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F worked and were on shift.

Record review of undated facility policy titled EXHIBIT 4 State Resident Rights.

Texas Human Resources Code Title 6, Section102.003 Rights of the Elderly. (a) An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted.

The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights. (b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment.

This means that the elderly individual: (1) has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits, and services;(2) has the right to be free from abuse, neglect, and exploitation; and (3) if protective measure are required, has the right to designate a guardian or representative to ensure the right to quality stewardship of the individual's affairs. (f) An elderly individual may complain about the individual's care or treatment.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/24/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at Westbury

5201 S Willow Dr Houston, TX 77035

SUMMARY STATEMENT OF DEFICIENCIES

worked and were on shift.

Record review of facility policy revised dated 3/2019 and titled Nursing Policies and Procedures reflected Subject: Activities of daily living - Highest Level of Functioning Policy: It is the policy of this facility to provide care and services to ensure that a resident is able to maintain their ability to self-perform their activities of daily living, at their level of functioning prior to facility admission, unless circumstances of the individual's clinical condition demonstrate that diminishment in ability was unavoidable.

The facility is responsible to provide necessary care to all resident who are unable to carry out activities of daily living on their own to ensure they maintain proper . grooming and hygiene.

Definitions: Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating and communication.

Record review of facility policy revised dated 10/2023 and titled Policies and Procedures Standards of Care.

Policy the purpose of this policy is to establish and maintain acceptable standards of care for all residents, ensuring their safety, well-being, and dignity are maintained.

Procedure: 1.

Health and Safety Standards a.

All care provided will comply with current guidelines, best practices, and Federal/State regulations.

Responsibility: All staff members are responsible for adhering to this policy and for providing care that meets these standards.

The administrator will oversee the implementation and compliance with this policy.

Facility ID:

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.


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