Paradigm At Westbury
Paradigm at Westbury in Houston, TX — inspection on May 30, 2026.
Found 7 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.
Inspection Findings
During an interview on 5/29/2026 at 11:10 a.m., RN Y said Resident #41 refused to have a privacy cover on his urinary catheter bag. RN Y said Resident #41 said it was ok referring to the urinary catheter bag without the privacy cover and said leave this one like this referring to the urinary catheter bag without a privacy cover.
During an interview on 5/29/2026 at 11:45 a.m., RN Y said regarding Resident #41 refusal of the privacy cover to the urinary catheter bag that she told them in the office this information.
When asked who she told in the office, RN Y said Unit Manager B. RN Y said I don't know regarding this information being on the resident's care plan.
Record review of the facility's policy titled, Care Plan Revisions, with revision date 5/2022, revealed, Care plans will be modified as needed by the MDS Coordinator or other designated staff member.
675612 05/30/2026
Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035
During an interview with Unit Manager A on 5/28/26 at 11:55 am she said she was responsible for monitoring resident weights and maintaining weight lists for residents under 100 lbs., with significant weight loss, residents with congestive heart failure, and residents that required dialysis pre and post weights.
Unit Manager A said residents should be weighed upon admission or readmission within 24-48 hours, and dialysis residents should have a post dialysis weight that should be recorded on the dialysis communication sheets before and after each dialysis visit.
Unit Manager A said Resident #57 should have dialysis weights at least 3 times per week post dialysis and did not know why there were no dialysis weights on at least 2 dates for Resident #57 and why she had no daily weights as ordered.
Attempts made to contact NP and MD for residents #57 and #91 on 5/28/26 at 11:14 am and at 1:55pm and did not receive return calls prior to facility exit.
Interview with RNA B on 5/28/26 at 1:10 pm she said there were no weekly weights obtained or logged for any resident including Resident #57 because she had been working the floor as a CNA the entire month of May and had not had time to complete any daily weights. RNA B said Unit Manager A and the DON were aware the RNAs could not complete daily weights.
Repeatedly requested facility policy and procedure on weight management on 05/27/2026 at 6:30 pm from Administrator and DON, 05/28/2026 at 09:27 am from the DON and again on 5/30/2026 at 4:00pm and was informed via email, by the DON that the facility had no Policy specifically titled Weight Management.
Record review of undated facility policy and procedure titled, Weights-Obtaining revealed in part: It is the policy of this facility that resident weights will be recorded and monitored at least monthly.
Procedures:1) Weigh Residenta.
Upon admission / Readmissioni.
Then weekly x 3 weeksii.
Monthly and/ or per physician orders. 3) Record all weights on the Vitals tab in (EMR).4) If there is an actual 5% or more gain or loss in one month, notify the resident/family, physician, and Clinical Dietitian.
Document this notification per facility protocol. 6) Review significant, unplanned changes and insidious gradual weight loss or gain trends in weightsduring weekly at risk and QA meetings.
675612 05/30/2026
Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035
During an interview on 5/27/2026 at 4:45 pm, DON stated her expectations were for the nurses and Med Aides to audit their carts and replenish the cart accordingly. DON stated the Med Aide should notify the nurse or let the unit manager know if they need OTC medications so that they can get it for the Med Aides.
Record review of facility's policy on Medication Administration and Management read in part .Administering the Medication Pass, # 5: The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member reads the label on the medication 3 times; a) before removing the medication from the drawer; b)before pouring the medication; c) after pouring the medication.
675612 05/30/2026
Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035
During an interview on 5/28/2026 at 1:30 p.m.,
exit.
675612 05/30/2026
Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035
During an interview on 5/29/2026 at 2:31 p.m., the DON said, regarding urinary catheter bags not being on the floor, it was nursing knowledge and nothing should be on the floor as the floor was dirty.
During an observation on 5/26/2026 at 11:25 a.m., LVN B provided wound care to Resident #92 without wearing a gown as per EBP protocol. LVN B removed all three dirty dressings at the same time and discarded the dirty gloves. LVN B donned (put on) clean gloves and cleaned wound #1 with wound cleanser and applied a clean dressing to wound #1 using the same gloved hands. LVN B discarded the dirty gloves, donned clean gloves to clean wound #2 and using the same gloved hands applied a clean dressing for wound #2. LVN B repeated the same for wound #3.
During an interview on 5/26/2026 at 11:47 a.m., LVN B stated he should have changed gloves after cleaning the wound. He said he should have sanitized his hands and donned clean gloves when applying a clean dressing to each wound. LVN B stated the negative outcome was cross contamination and infection if the infection prevention protocols were not followed. LVN B did not respond as to why he did not use a gown while providing wound care for Resident #92.
During an observation on 05/27/2026 at 8:56 a.m., RN B provided medication administration through the g-tube to Resident #12 without wearing a gown as per EBP protocol.
During an interview on 5/27/2026 at 12:41 pm, RN B said she was not familiar with the EBP protocol.
After reading the poster posted by a resident's bed, RN B stated EBP was used as a precaution to prevent transmission of infections to others and herself. RN B stated she did not wear a gown while administering medication via g-tube to Resident # 12 this morning.
Record review of the facility's policy titled, Catheter Care, dated 2/2024, revealed catheter management positioning that included to ensure the catheter bag was positioned below the level of the bladder to allow for proper drainage and avoid reflux of urine.
Record review did not reveal any information regarding urinary catheter bags and their relation to the ground.
Record review of the facility's policy titled, Enhanced Barrier Precaution, revised 03/2024, read in part, .
Policy: Enhanced Barrier Precaution is an infection control intervention designed to reduce the transmission of multidrug-resistance organism and employs targeted gown and glove use during high-contact resident care activities.Guidance/Procedure: EBP are indicated for residents with the following: wounds and /or indwelling medical devices. examples of indwelling medical devices: central lines, urinary catheters, feeding tubes.
675612 05/30/2026
Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035
During interview on 5/29/2026 at 2:31 p.m., the DON said obtaining
and the admitting nurse could also input information.
The DON said the effect it could have on the
looked up to see if they have had immunizations and if not then immunizations were offered to see if they want the immunization.
The DON said not all people believe in immunizations so she could not say it was a high risk.
During interview on 5/29/2026 at 2:31 p.m., the ADON said regarding Resident #2 she was not able to find the admission paperwork.
The ADON said she had called Resident #2's family member to get her immunization information and was entering that information now.
The ADON said that not having immunization information could put residents at risk of infectious diseases and spreading of things.
The ADON said she was not sure who was responsible for completing the admission paperwork that included the immunization paperwork, but she would find out.
The ADON said the Administrator would check in the morning meetings that things had been completed when asked if anyone checked that the admission paperwork was completed.
During interview on 5/29/2026 at 2:59 p.m., the DCE (Director of Customer Engagement) said in the admission packet residents were given information regarding flu, pneumonia and COVID vaccinations.
The DCE said there were also consents for flu, pneumonia and COVID vaccinations that the resident could either accept or decline the vaccination.
The DCE said she was the person responsible for completing the admission packets.
The DCE said had been in contact with Resident #2's family member this morning and would email the admission paperwork to the family member to sign as Resident #2 was unable to sign the admission paperwork herself.
The DCE said she had just started 5/26/26 at the facility and a DCE from another location had been helping and training her.
The DCE said the facility did not have a DCE prior to her starting at the facility but did not know for how long.
The DCE said her training regarding her position was the training she received from the other DCE.
Regarding Resident #115, the DCE said she did not see him on her unresolved list of things that should be completed.
The DCE said she received the list of items that needs to be completed on the application reside.
During interview on 5/29/2026 at 3:15 p.m., the Administrator said the DCE (Director of Customer Engagement) or Admissions was responsible for completing the admission paperwork.
The Administrator said the current DCE started this week.
The Administrator said the last day for the previous DCE was 4/30/26.
The Administrator said that they had a DCE from a sister facility who came out and assisted but was not at the facility full time during the time the facility was without a DCE.
The Administrator said there was a corporate employee that pulled information and did audits weekly to check that admission packets were completed.
Record review of the facility's Infection Control Policies and Procedures with the subject of Immunizations: Resident/Employees with revision date of 2/2022 revealed federal and state regulations are followed regarding immunizations for residents and The facility offers pneumococcal immunizations to residents at risk for pneumococcal disease.
675612 05/30/2026
Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035
During an interview on 5/29/2026 at 2:31 p.m., the ADON said she was not able to find Resident #2's admission paperwork.
The ADON said she had called Resident #2's family member that morning to get her immunization information and was entering that information now .
The ADON said that not having immunization information could put residents at risk of infectious diseases.
The ADON said she was not sure who was responsible for completing the admission paperwork that included the immunization paperwork, but she would find out.
The ADON said the Administrator checked during the morning meetings that the admission paperwork was completed.
During an interview on 5/29/2026 at 2:59 p.m., the DCE (Director of Customer Engagement) said in the admission packet residents were given information regarding flu, pneumonia and COVID vaccinations.
The DCE said there were also consents for flu, pneumonia and COVID vaccinations that the resident could either accept or decline the vaccination.
The DCE said she was the person responsible for completing the admission packets.
The DCE said had been in contact with Resident #2's family member this morning and would email the admission paperwork to the family member to sign as Resident #2 was unable to sign the admission paperwork herself.
The DCE said she had just started 5/26/26 at the facility and a DCE from another location had been helping and training her.
The DCE said the facility did not have a DCE prior to her starting at the facility but did not know for how long.
The DCE said her training regarding her position was the training she received from the other DCE.
Regarding Resident #115, the DCE said she did not see him on her unresolved list of things that should be completed.
The DCE said she received the list of items that needs to be completed on the app reside.
During an interview on 5/29/2026 at 3:15 p.m., the Administrator said the DCE (Director of Customer Engagement) or Admissions was responsible for completing the admission paperwork.
The Administrator said the current DCE started this week.
The Administrator said the last day for the previous DCE was 4/30/26.
The Administrator said that they had a DCE from a sister facility who came out and assisted but was not at the facility full time during the time the facility was without a DCE.
The Administrator said there was a corporate employee that pulled information and did audits weekly to check that admission packets were completed
Record review of the facility's policy titled, Infection Control Policies and Procedures: Immunizations: Resident/Employees, revised 2/2022, revealed federal and state regulations were followed regarding immunizations for residents.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.