Paradigm at Westbury
5201 S Willow Dr, Houston, TX 77035 · Harris County · 148 certified beds · avg 104 residents/day · certified since Jul 9, 1996
Part of chain: PARADIGM HEALTHCARE (17 facilities, chain avg rating 1.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Aug 28, 2025 · F-0695 · triggered by a complaint
The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Why it matters: Mistakes in breathing care can quickly become life-threatening for residents who depend on oxygen or equipment.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Sep 17, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, facility-wide · Jan 15, 2025 · F-0584 · triggered by a complaint
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Why it matters: An unsafe or unclean environment affects residents' health, comfort, and dignity every single day.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Jan 25, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Feb 5, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 7, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Feb 5, 2024 · F-0926 · triggered by a complaint
The facility did not have policies on smoking.
Why it matters: Without clear smoking rules, residents face fire hazards and unwanted secondhand smoke.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Feb 7, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 30, 2026 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 25, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 28, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 30, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 7, 2024 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 8, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (42)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 30, 2026 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| May 30, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 30, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 30, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 30, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 30, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| May 30, 2026 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Nov 24, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Nov 24, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Aug 28, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 28, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 28, 2025 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Mar 28, 2025 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Mar 28, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Mar 28, 2025 | D · Potential for harm, one-off | The facility did not dispose of garbage and refuse properly. · from a complaint |
| Jan 28, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 15, 2025 | ▲ L · Immediate jeopardy, facility-wide | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Oct 15, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Oct 15, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jul 3, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jun 27, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Jun 27, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Apr 30, 2024 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Apr 30, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Apr 30, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Feb 5, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 5, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not have policies on smoking. · from a complaint |
| Jan 29, 2024 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Jan 7, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 7, 2024 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. · from a complaint |
| Jan 7, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Nov 7, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Nov 3, 2023 | E · Potential for harm, repeated | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. · from a complaint |
| Nov 3, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Oct 17, 2023 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Oct 17, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | E |
| 2024 | 19 | 3 | K ▲ |
| 2025 | 11 | 3 | L ▲ |
| 2026 | 7 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $108,038.
| Date | Type | Amount / length |
|---|---|---|
| May 30, 2026 | Fine | $26,180 |
| Aug 28, 2025 | Fine | $14,596 |
| Jan 15, 2025 | Fine | $52,699 |
| Jan 7, 2024 | Fine | $14,563 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.17 | 3.46 | 3.95 | bottom 37% in Texas; bottom 20% in the U.S. |
| Registered Nurse hours | 0.34 | 0.44 | 0.69 | bottom 38% in Texas; bottom 14% in the U.S. |
| Weekend total nurse staffing | 2.87 | 3.04 | 3.50 | bottom 46% in Texas; bottom 24% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.34 | 0.34 | 0.48 | top 38% in Texas; bottom 39% in the U.S. |
| Total nursing staff turnover (%) | 61.5 | 55.3 | 45.8 | bottom 30% in Texas; bottom 14% in the U.S. |
| RN turnover (%) | 62.5 | 54.6 | 42.9 | bottom 38% in Texas; bottom 19% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.39, RN 0.36, weekend 3.07. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Oakbend Medical Center | Organization | 5% or Greater Direct Ownership Interest | 100% | 02/28/2015 |
| Beard, Barry | Individual | Corporate Director | NOT APPLICABLE | 01/01/2012 |
| Council, Jeff | Individual | Corporate Director | NOT APPLICABLE | 01/01/2013 |
| Crayton, Tom | Individual | Corporate Director | NOT APPLICABLE | 01/01/2013 |
| Freudenberger, Joseph | Individual | W-2 Managing Employee | NOT APPLICABLE | 06/19/2007 |
| Freudenberger, Joseph | Individual | Corporate Officer | NOT APPLICABLE | 06/19/2007 |
| Martin, Melissa | Individual | Corporate Director | NOT APPLICABLE | 01/01/2015 |
| McClamroch, James | Individual | Corporate Director | NOT APPLICABLE | 01/01/2013 |
| Mefford, Ruthanne | Individual | Corporate Director | NOT APPLICABLE | 01/01/2015 |
| Murray, Mark | Individual | Corporate Director | NOT APPLICABLE | 01/01/2011 |
| Petrosewicz, Norma | Individual | Corporate Director | NOT APPLICABLE | 01/01/2013 |
| Tape, May | Individual | Corporate Director | NOT APPLICABLE | 01/15/2008 |
| Uthman, Edward | Individual | Corporate Director | NOT APPLICABLE | 01/01/2008 |
| Westbury Place Nursing & Rehabilitation, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What are your smoking rules, and how do you keep residents who smoke — and everyone around them — safe?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Seven Acres Jewish Senior Care Services | 2.4 mi | Houston, TX | ★★★★☆ | 3/5 | |
| Bayou Manor | 2.7 mi | Houston, TX | ★★★★★ | 5/5 | |
| Avir at Orem | 3.0 mi | Houston, TX | ★★★★☆ | 4/5 | |
| Houston Transitional Care | 4.0 mi | Houston, TX | ★★★☆☆ | 4/5 | |
| Holly Hall | 4.6 mi | Houston, TX | ★★★☆☆ | 3/5 | |
| Clarewood House Extended Care Center | 4.6 mi | Houston, TX | ★★★★★ | 5/5 | |
| Sharpview Residence and Rehabilitation Center | 4.8 mi | Houston, TX | ★☆☆☆☆ | 2/5 | |
| Garden Terrace Healthcare Center of Houston | 5.3 mi | Houston, TX | ★★☆☆☆ | 1/5 | |
| Brookdale Galleria | 5.7 mi | Houston, TX | ★★★☆☆ | 2/5 | |
| The Methodist Hospital SNF | 5.7 mi | Houston, TX | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675612.