The Westbury Place

F-F921: Safe/Functional/Sanitary/Comfortable/Environment and reviewed plan to sustain compliance.

Monitoring of the plan of removal included the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 675612 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675612 B. Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Observation on 1/11/2025 at 7:58 p.m. revealed temporary industrial heating units were being utilized on Units B (2 industrial heaters), Main common area (1 industrial heater), and Unit C (1 industrial heater). Parts Level of Harm - Immediate of Unit B and Unit C had temperatures below 72 degrees Fahrenheit (Thermostat B7 on Unit B was 68 jeopardy to resident health or degrees Fahrenheit, room [ROOM NUMBER] was 71 degrees Fahrenheit, room [ROOM NUMBER] was 65 safety degrees Fahrenheit, room [ROOM NUMBER] was 69 degrees Fahrenheit, Unit C - room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] Residents Affected - Many was 66 degrees Fahrenheit, room [ROOM NUMBER] was 67 degrees Fahrenheit, and room [ROOM NUMBER] was 66 degrees Fahrenheit). Residents were observed to have blankets, appropriate clothing, and small heaters (specific rooms and common areas).

Observations on 1/11/2025 at 8:00 p.m. revealed signs posted at all nursing stations revealed Monitor Resident For: Shivering, Numbness, Change of Skin Color, Decreased Temperature, and Dry Mucus Membranes.

Observations on 1/12/2025 - 1/15/2025 revealed temporary industrial heating units were being utilized on Units B (2 industrial heaters), Main common area (1 industrial heater), and Unit C (1 industrial heater) remained in use until the 2 HVAC units were repaired and the heater for Units B and C were able to maintain

a temperature above 71 degrees Fahrenheit.

Observation and interview on 1/11/2025 at 8:15 p.m. revealed Resident #1 in bed with two blankets over him. He said he was warm. Resident #1 had a small portable heater in the room and the temperature was 76 degrees Fahrenheit.

Observation and interview on 1/11/2025 at 8:19 p.m. revealed Resident #2 had a small portable heater in his room. He said the small heater made a difference, and he was no longer shivering. The temperature was 71 degrees Fahrenheit.

Observation on 1/12/2025 at 5:40 p.m. of Resident #3 and Resident #4's room revealed the temperature was 74 degrees Fahrenheit.

Observation on 1/13/2025 at 10:06 a.m. revealed temperatures in the common areas, resident room ranged from 67 -78 degrees Fahrenheit.

Observation on 1/14/2025 at 3:53 p.m. revealed temperatures in the facility ranged from 73-85 degrees Fahrenheit on Halls A, B, C, and D.

Observation on 1/15/2025 at 10:35 p.m. revealed temperatures in the facility ranged from 73-75 degrees Fahrenheit on Halls A, B, C, and D.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 675612 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675612 B. Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Interviews were conducted on 1/11/2025 - 1/14/2025 with staff on all shifts RN A, RN B, RN C (day), RN D, LVN B (night) - (Nurses 6:00 a.m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m.), CNA A, CNA B, CMA A (day), CNA C, Level of Harm - Immediate CNA D (night), CNA E , CNA F (morning)- (6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - jeopardy to resident health or 6:00 a.m.), the DON, ADON, ADMIN, Maintenance A, Maintenance Dir., Former Acting Maintenance Dir., HK safety Supervisor, and Activity Director to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding Residents Affected - Many related to emergency preparedness heating elements to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance, and reporting failure of HVAC system and temperatures outside of normal range to administrator immediately . Nursing staff reported they monitored residents hourly, checked for signs and symptoms of hypothermia (condition of having a lower body temperature than normal) like shivering, skin color, numbness, offered.

Interview on 1/12/2025 at 5:25 p.m., Resident #6 said she did not have any complaints and the nursing staff came into her room to ensure she was comfortable, warm and they checked her vitals.

Interview on 1/14/2025 at 3:28 p.m., Maintenance A said the 2 new HVAC units were installed, wired and the appropriate breaker to support the wattage was installed. He said he would begin to open the vents in rooms to ensure the warm air was flowing. He said the temperature was set high but would adjust the temperature to an appropriate level.

Record review of the facility's document Ad Hoc QAPI dated 1/10/2025 revealed the following in part:

On 01/10/2025 [Facility] to ensure to maintain safe and comfortable temperatures throughout the building when heating units were not functioning for 3 days.

Root Cause Analysis:

Inclement weather with outside temperatures as low as 38 degrees and high 50 degrees.

On 01/10/2025 residents observed to cold due to vent blowing cold air

Record review of nurses' notes and vitals dated 1/10/2025 - 1/15/2025, for all affected residents revealed nurses documented monitoring of resident vitals which included resident temperatures were within normal range.

Record review of the facility's Temperature logs, dated 1/10/2025 - 1/15/2025, revealed all halls (including Hall B 72, Hall C 70, Hall D 75 (thermostat), room [ROOM NUMBER] room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Common Area B, room [ROOM NUMBER], room [ROOM NUMBER]) temperatures were monitored hourly until the two HVAC heating units were repaired.

Record review of the facility's Education In-Service Attendance Record - Monitoring Temperatures, dated 1/10/2025, by the ADMIN to the HK Supervisor, Maintenance A, and HK A. Summary of training session - Monitor temperature on specified hallways and keep updated logs of monitoring. Notify [ADMIN] [phone number] of any temperature less than 72 degrees Fahrenheit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 675612 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675612 B. Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Record review of the facility's Education In-Service Attendance Record - Emergency Preparedness - Loss of Heating Element, dated 1/10/2025 by RNC to the DON and ADMIN. Level of Harm - Immediate jeopardy to resident health or Record review of the facility's receipt, dated 1/11/2025, for 21 additional blankets. safety

Observation on 1/11/2025 at 7:58 p.m. revealed temporary industrial heating units were being utilized on Residents Affected - Many Units B (2 industrial heaters), Main common area (1 industrial heater), and Unit C (1 industrial heater). Parts of Unit B and Unit C had temperatures below 72 degrees Fahrenheit (Thermostat B7 on Unit B was 68 degrees Fahrenheit, room [ROOM NUMBER] was 71 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 69 degrees Fahrenheit, Unit C - room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 67 degrees Fahrenheit, and room [ROOM NUMBER] was 66 degrees Fahrenheit). Residents were observed to have blankets, appropriate clothing, and small heaters (specific rooms and common areas).

Record review of the facility's email written by the ADMIN, dated 1/13/2025 at 1:53 p.m., in response to the question if there was an update on repairs revealed the following: Yes, just now. Corporate has approved full installation on HVAC units for B, C Hall. This is in addition to the work getting done today. Full installation should be completed today. The goal is to have a fully functional system with zero space heaters and auxiliary heaters in the facility.

Record review of HVAC vendor email, dated 1/10/2025 at 5:52 p.m. revealed the following:

Upon thorough assessment of the system, it was determined that specific parts were required to address the identified issues. These parts were promptly ordered on January 7, 2025. The scheduled installation of the ordered parts is planned for January 12, 2025, to ensure the HVAC system is restored to proper working condition

Record review of HVAC vendor email (dated 1/11/2025 at 4:18 p.m.) revealed the following:

I am writing to provide an update on the measures we have taken to address the heating issues

at [Facility, located at [Facility Address]

On 01/11/2025, I dispatched an HVAC technician to assess and service the two malfunctioning heating units. While the technician was able to keep the units operational, they are not currently functioning at full capacity.

To mitigate the impact on the affected areas, we delivered Four 1.25-ton portable .heat pump units yesterday and placed them in the hallways needing supplemental heat.

Additionally, this morning, we delivered five more portable heaters, strategically placing them in the affected areas to ensure warmth throughout the facility.

This afternoon, the HVAC technician returned to inspect the units again to confirm they are still providing some heat. I will continue to send the technician daily to monitor and maintain the heating units as best as possible while repairs are underway. Furthermore, the portable heaters will remain in place until the issue with the heating units is fully resolved

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 675612 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675612 B. Wing 01/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 The Administrator was informed the Immediate Jeopardy was removed on 1/15/2025 at 4:13 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal Level of Harm - Immediate harm that is not immediate jeopardy and a scope of widespread due to the facility's need to evaluate the jeopardy to resident health or effectiveness of the corrective systems that were put into place. safety

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 675612