5201 S Willow Dr, Houston, TX 77035 · Harris County · (713) 721-0297
148 certified beds, about 104 residents a day · For profit - Corporation · Medicare and Medicaid since 1996
CMS Care Compare ratings, data as of September 1, 2026 · CCN 675612 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 30, 2026, inspectors cited 7 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 42 health citations since October 2023, 7 were rated as actual harm or immediate jeopardy to residents (4 immediate jeopardy).
CMS lists 4 fines totaling $108,038 in the last three years; the largest was $52,699, and the latest is dated May 30, 2026.
Nurses and nurse aides worked 3.39 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.36 of those hours.
61.5% of nursing staff left within the year CMS measured (Texas average 55.3%).
CMS links it to Paradigm Healthcare, an affiliated group of 17 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 42 health citations on file.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 2 of 3 residents (Resident #57 and Resident #91) reviewed for nutrition status. The facility failed to identify and verify significant weight loss for Resident #91 who lost 32.4 pounds in 27 days. The facility failed to provide dietary interventions for Resident #91's initially identified weight loss on 5/13/2026 (118.8lbs from 148.6 lbs.), until 5/27/2026. The facility failed to ensure Resident #57 had daily weights obtained per physician order. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 4 (Resident #81, Resident #12, Resident #92 and Resident #101) of 9 residents reviewed for infection control. The facility failed to ensure Resident #81's and Resident #101's urinary catheter bags were not touching or lying on the ground. The facility failed to ensure RN B used a gown when providing enteral feeding to Resident #12 and LVN D used a gown and followed appropriate wound care protocol when providing wound care to Resident # 92. These failures could place residents at risk of infection, decline in health, or cross contamination.
Inspectors wroteBased on interview, observation and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1 (Resident #41) of 6 residents reviewed for care plan. The facility failed to ensure that Resident #41 was care planned regarding refusal to have a privacy cover on his urinary catheter bag. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 12.0% based on 3 errors out of 25 opportunities (Resident #108 and Resident #80) reviewed for medication administration. The facility failed to ensure RN A administered insulin injection at the appropriate site as per physician's order for Resident #108. The facility failed to ensure MA A accurately dispensed and administered oral medication and eye drops as per physician's orders for Resident #80. These failures could place residents at risk for incomplete therapeutic outcomes and decline in health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 (D Hall) of 4 medication aide carts, 2 (B Hall and D Hall) of 4 nurse medication carts and 2 (A Hall and D Hall) of 4 medication storage rooms reviewed for medications storage. -Facility failed to ensure medication aide cart and nurse cart did not have medications that were discontinued. -Facility failed to ensure medication storage room did not have any items stored under the sink. These failures could place residents at risk for drug diversion and contamination of supplies placed under the sink.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 2 of 9 residents reviewed for immunizations. [...]
Inspectors wroteBased on interview and record review , the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 2 of 9 residents who were reviewed for immunizations. (Resident #2 and Resident #115) The facility failed to document, in Resident #2's and Resident #115's medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #1) of 3 residents reviewed for resident rights. This failure could affect the resident who required assistance with her Activities of Daily Living (ADL) from facility staff by placing them at risk for social isolation, loss of dignity, and self-worth. - The facility failed to ensure Resident #1 was provided with personal grooming (changed brief and clean clothing) before her discharge to the hospital on [DATE]. This failure placed residents at risk for embarrassment, at risk of loss of dignity and a decrease in quality of life.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 was provided with personal grooming before her discharged to the hospital on [DATE]. This failure could place residents at risk for discomfort and dignity issues.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care consistent with professional standards of practices for 5 of 5 residents (CR # 1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for respiratory care related to tracheostomy care. The facility failed to train nurses on tracheostomy care, including LVN A. On 8/21/2025, LVN A noticed CR #1's trach appeared to be at an angle and when CR # 1 was repositioned, his entire tracheostomy was out and, on his chest below his chin. Attempts to reinsert the tracheostomy canula were unsuccessful as the stoma was closed. CR # 1 was admitted to the hospital with evidence of prolonged decannulation SNF stay. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, for daily living for residents living on 1 of 4 halls (Hall D) reviewed for resident rights in that: 1. Four rooms on Hall D (westside of building) had room temperatures of more than 81 degrees Fahrenheit (rooms 404, 405, 406, and 407). This failure could have caused hyperthermia, hospitalization, and a diminished quality of life. Findings Included: Hall D Observation of Rooms #404, 405, 406, and 407 on 5/1/2025 at 10:34 a.m. had the following room temperatures: room [ROOM NUMBER] -temperature was 84.0 degrees Fahrenheit. room [ROOM NUMBER]- temperature was 82.4 degrees Fahrenheit. room [ROOM NUMBER]- temperature was 82.2 degrees Fahrenheit. room [ROOM NUMBER]- temperature was 81.5 degrees Fahrenheit. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. -MA J would have administered the incorrect dosage if not for Surveyor intervention. -Five medications for Resident #66 were not available. -The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered 17 times in March to Resident #96 as ordered on 12/01/2024 by the physician. -The facility failed to ensure Resident #72 was not administered insulin outside of the parameters. These failures could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The facility had a medication error rate of 16% based on 6 errors for 37 opportunities. Surveyor intervention was required to prevent one MA from administering the incorrect dose of a blood pressure medication. The errors effected 1 resident (Resident #66) of 6 residents reviewed for medication administration. -MA J would have administered the incorrect dosage if not for Surveyor intervention. -Five medications for Resident #66 were not available: Isosorbide Mononitrate (for blood pressure), Duloxetine HCl for (for depression), Calcium 600 + Vitamin D, Fenofibrate (for cholesterol), and Vitamin D. The medications were not administered on 03/27/25. The failures placed resident at risk for inadequate therapeutic outcomes and a decline in health.
Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 41 residents (Residents #'s 96 and Resident #72) reviewed for significant medication errors. 1. The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered 17 times in March to Resident #96 as ordered on 12/01/2024 by the physician. 2. The facility failed to ensure Resident #72 was not administered insulin outside of the parameters. These failures could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.
Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were labeled and dated. 2. The facility failed to ensure that all kitchen staff were wearing a beard guard. 3. The facility failed to ensure food was safely stored in designated areas at all times. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation on 03/25/25 at 8:15 AM during the kitchen tour with the Dietary Manager revealed the following: 1. There was 1 bag of shredded cheddar cheese in the refrigerator that was open but not dated . 2. There was a 50-pound bag of flour in the kitchen's dry storage room that was not properly sealed . [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 garbage dumpsters reviewed for disposal of garbage. The facility failed to ensure 1 of 1 dumpster lid was secured. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents.
Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (CR#1) of 1 resident reviewed for accidents hazards/supervision. The facility failed to prevent CR#1 from falling from his bed and sustaining a minor head injury on 08/05/24 while CNA A performed a bed bath alone even though the resident required 2-person assist. This failure could place residents at risk of harm, potential accidents, and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for three of three resident hallways (B, C, D) and facility common areas reviewed for environment. 1. The facility failed to maintain two working HVAC units to distribute heat to halls B and C. 2. The facility failed to maintain temperatures in Halls B, C and D (rooms 201, 209, 211, 215, 313, 314, 315, 317, and 401) were above 71 degrees Fahrenheit (61-70 degrees Fahrenheit). An Immediate Jeopardy (IJ) was identified on 1/10/2025. The I.J. template was provided to the facility on 1/101/2025 at 5:14 p.m. [...]
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 residents (CR #1) whose assessments were reviewed, in that: CR#1's admission weight was not accurate on the initial MDS dated [DATE]. CR#1's significant weight loss was not reflected on her quarterly MDS dated [DATE]. This failure could place residents at-risk for weight loss for not receiving the care and services to increase weight loss due to inaccurate assessments. Findings Included: Record review of CR#1's face sheet, dated 10/15/2024, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure the interdisciplinary team reviewed and revised each resident's Care Plan after each assessment, including both the comprehensive and quarterly review assessments for 1 of 5 Residents (CR #1) whose records were reviewed. The facility failed to revise CR #1's Care Plan to reflect her significant weight loss. These deficient practices could result in the residents not receiving the care and services needed to increase weight gain.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 1 of 6 rooms reviewed for homelike environment. The facility failed to ensure Resident #1's and Resident #2's toilet base free was from stains and dirt, bathroom was free from cracked and missing tile, bathroom doorknob was secure to the door, window blinds were in good repair, and room floor was free from dirt and debris. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, uncomfortable, and unsafe.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. 1) Dietary Staff failed to effectively reseal, label and date frozen food items. 2) Dietary Staff failed to effectively reseal, label and date refrigerated food items. 3) [NAME] A failed to handle food with the least amount of contact when she picked up bread with her gloved hand that had touched multiple unclean surfaces and placed the bread onto resident plates for lunch. These failures could place residents at risk for food contamination and foodborne illness.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 staff (CNA A) reviewed for infection control. CNA A failed to perform hand hygiene appropriately while she retrieved ice from the communal ice chest for a resident when she touched high touch areas including the resident door handle, bathroom door handle, resident cup and ice chest lid. This failure could place residents at risk for infection.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 5 (Resident #5, #6, #7, #8, and #9) of thirty-one residents reviewed for ADL care. The facility failed to ensure Residents #5, #6, #7, #8 and #9 received bath/showers three times a week as per their shower schedule. This failure could place residents at risk of skin breakdown, infection and loss of self-esteem. Findings Included: Resident #5 Record review of Resident #5's face sheet undated revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for two residents (CR #40 and CR #41) of five residents reviewed for drug diversion. -CR #40 was discharged , but the resident's controlled medications were not removed from the medication cart. -Controlled medications for CR #40 were diverted from the medication cart. -CR #41 was discharged , but the resident's controlled medications were not removed from the medication cart. The deficient practice increased the risk of drug diversion and increased the risk of having impaired staff.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that. 1. The facility failed to ensure food was properly labeled and dated. 2. The facility failed to ensure that milk temperature was checked at delivery and was at the correct holding temperature. 3. The facility failed to ensure that menu items on the steam table was maintained at the correct holding temperature. 4. The facility failed to ensure that ready to eat foods were not touched with bare hands. These failures could place residents who received meals prepared by the kitchen at risk for food borne illness.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 4 residents (Residents #4 and #5) reviewed for respiratory care. 1. The facility failed to ensure the filter in Resident #4's oxygen concentrator was not dirty and the water reservoir attached to oxygen concentrator was not empty and replaced in accordance with the facility's changing schedule. 2. The facility failed to ensure Resident #5 oxygen humidifier bottle on the oxygen concentrator had enough water in the bottle to function properly. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments for 2 of 2 medication carts reviewed for storage of drugs. The facility failed to ensure medication carts were locked and supervised on two hallways, 100 and 300, reviewed for storage of drugs. This deficient practice could place residents at risk of harm to unauthorized persons for medication misuse and drug diversion.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 4 (301,407,416, 417) of 10 rooms on halls (300 and 400 halls ) reviewed for pests, in that: 1. Numerous gnats were observed in a resident room on Hall 300 (Resident #6-room [ROOM NUMBER]-B). 2. Numerous gnats were observed in a resident room on Hall 400 (Resident #2-room [ROOM NUMBER]-A, Resident #3-417-A, Resident #4 - 407-B and Resident #5 - 407-A). This deficient practice could place residents at risk of residing in an environment with pests.
Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 1 resident reviewed for resident rights. (Resident #1) The facility failed to place a privacy cover over Resident #1's urinary catheter bag. This failure could place residents with urinary catheters at risk for decreased quality of life and self-esteem.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 (Resident #7) of 10 resident rooms reviewed for environment. The facility failed to ensure the window blinds in Resident #7-room [ROOM NUMBER] (bed B next to window) were in good repair. The facility failed to ensure Resident #7 plastic handrail on the bed was in good repair. The failure placed residents at risk of possible injury due to an unsafe environment.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking. 1. The facility failed to secure smoking paraphernalia and supervise smoking for Resident #1, who was paralyzed on one side and had a known history of dropping cigarettes which resulted in multiple burn holes in his clothing and the armrest of his wheelchair. 2. The facility failed to secure smoking paraphernalia and supervise smoking for Resident #2 and Resident #3, who were known to have unsafe smoking habits and were either prescribed oxygen or had a roommate who was prescribed oxygen. An Immediate Jeopardy (IJ) was identified on 02/03/2024 at 8:33 a.m. The IJ template was provided to the facility on [DATE] at 8:33 a.m. [...]
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their own established smoking policy for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking and compliance. 1. The facility failed to effectively intervene or implement their own smoking policy when Residents #1 was known to be non-compliant and continued to store his own smoking paraphernalia. 2. The facility failed to assess Resident #2 for safe smoking upon admission on [DATE] until 02/02/2024. Resident #2 and Resident #3 did not sign smoking contracts until 02/03/2024. 3. The facility failed to implement their smoking policy and allowed Resident #2, who was prescribed oxygen and Resident #3, whose roommate was prescribed oxygen, to store their own smoking paraphernalia. An Immediate Jeopardy (IJ) was identified on 02/03/2024 at 8:33 a.m. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure all areas of the resident call system was functioning for three (Residents #2, 3, and 4) of 114 residents who were able to use the resident call system. The audible alarm of the call system was continuously illuminated on the Tektone system for Resident #2, #3, and #4. This failure could place residents who were not able to use the resident call system at risk for delayed or unmet needs. Findings Included: Observation of the call system located on Unit A on 1/26/2024 at 1:25 p.m. revealed there was a beeping noise and Resident #2, #3 and #4's rooms (Unit C) were illuminating on the call system phone . Observation on 1/26/2024 at 1:35pm, revealed the call light was lit above Residetn #1's room. Observation revealed no staff came to the room to assist Resident #1 by 1:54pm. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure treatment and care in accordance with professional standards of practice was provided to 1 of 8 residents (Resident #83) reviewed for quality of care. The facility failed to check Resident #83's vital signs, including his blood sugar, when he experienced a change in condition on 11/28/23. When emergency personnel arrived, they discovered his blood sugar was 48. Resident #83 was admitted to the hospital for symptomatic hypoglycemia. This failure could place residents at risk of decline in health or hospitalization.
Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission to CMS of staffing information based on payroll data in a uniform format for 103 of 103 residents. The facility failed to submit staffing information to CMS for the 3rd quarter of the fiscal year 2023. The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 28 opportunities, which involved 2 (Residents #26 and #64) of 5 residents reviewed for medication errors. 1. MA E administered Baclofen (used to treat muscle spasms) to Resident #64 in the morning when it was scheduled for bedtime (8PM) and did not administer Buspirone (a medication used to treat anxiety) to Resident #64 as ordered by the physician. 2. MA B did not administer the full dose of Clearlax (a medication used to treat constipation) to Resident #26. These failures could place residents at risk of inadequate therapeutic outcomes.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #1) of 5 residents reviewed for call light access. The facility did not ensure a call light was in reach and could be operated by a visually impaired resident (Resident #1). This failure could place resident at risk for not being able to call for assistance from staff.
Inspectors wroteBased on observations, interviews, and record reviews, failed to provide a therapeutic diet which was prescribed by the attending physician for three residents (Resident #1,#2 and Resident #3) out of 10 residents reviewed for therapeutic diets, in that: The facility failed to provide Residents #1, #2 and #3 with fortified meal plans consistent with the physician's orders. These failures could place residents who received food from the kitchen at risk for decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food items that were open were sealed and dated. 2. The facility failed to ensure that food in the food pantry was not expired. 3. The facility failed to ensure that the microwave, sugar container, pantry floor and walk-in freezer were free from dust, paper, and food particles. 4. The facility failed to ensure that a cup to scoop flour from the flour bin was in a plastic bag. 5. The facility failed to ensure that the refrigerator always had a thermometer in it. 6. The facility failed to ensure that [NAME] B change gloves or use tongs when plating ready to eat foods. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 4 residents (Resident #1) reviewed for privacy -The facility failed to ensure CNA A and CNA B provided complete privacy during incontinent care for Resident #1. This failure could place residents at risk of a lack of privacy, resulting in low self-esteem and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 4 residents (CR #1) reviewed for ADLs. The facility failed to ensure Resident #1 was provided incontinent care in a timely manner, causing her incontinent brief and linen to be saturated with bowel and urine. This failure could place residents at risk for not being provided treatment and care by staff when assistance is needed.
15 fire safety citations on file: 8 on May 30, 2026, 5 on March 28, 2025, 2 on January 7, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| May 30, 2026 | Fine | $26,180 |
| August 28, 2025 | Fine | $14,596 |
| January 15, 2025 | Fine | $52,699 |
| January 7, 2024 | Fine | $14,563 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.39 | 3.39 | 3.86 |
| Registered nurses | 0.36 | 0.43 | 0.69 |
| All nursing staff on weekends | 3.07 | 2.98 | 3.42 |
| Nurse aides | 2.07 | ||
| Licensed practical nurses | 0.96 | ||
| Nursing staff turnover (share who left in a year) | 61.5% | 55.3% | 45.8% |
| Registered nurse turnover | 62.5% | 54.6% | 42.9% |
| Administrators who left | 3 |
CMS expects 4.09 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.52 on weekdays and 3.07 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.29 in April to June 2025 to 3.39 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.39 | 0.36 | 3.52 | 3.07 | 0.0% | 0 of 90 | 104 |
| Oct to Dec 2025 | 3.24 | 0.32 | 3.39 | 2.88 | 0.0% | 0 of 92 | 106 |
| Jul to Sep 2025 | 3.29 | 0.36 | 3.45 | 2.88 | 0.2% | 0 of 92 | 105 |
| Apr to Jun 2025 | 3.29 | 0.46 | 3.50 | 2.76 | 0.0% | 0 of 91 | 110 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 15.5 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.6 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.7 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 11.0 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 9.7 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.1 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 21.5 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 6.6 | 12.3 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Paradigm at Westbury's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (34.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
34.4% this home
Worse than the national rate
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 43 eligible stays.
10.3% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 48 eligible stays.
8.7% this home
No different from the national rate
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 29 eligible stays.
62.5% this home
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 24 residents counted.
0.0% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 38 residents counted.
3.2% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 38 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 15 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: OAKBEND MEDICAL CENTER. CMS links this home to Paradigm Healthcare, a group of 17 nursing homes averaging 2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Oakbend Medical Center | 5% or greater direct ownership interest | Organization | 100% | 02/28/2015 |
| Freudenberger, Joseph | W-2 managing employee | Individual | 06/19/2007 | |
| Beard, Barry | Corporate director | Individual | 01/01/2012 | |
| Council, Jeff | Corporate director | Individual | 01/01/2013 | |
| Crayton, Tom | Corporate director | Individual | 01/01/2013 | |
| Martin, Melissa | Corporate director | Individual | 01/01/2015 | |
| McClamroch, James | Corporate director | Individual | 01/01/2013 | |
| Mefford, Ruthanne | Corporate director | Individual | 01/01/2015 | |
| Murray, Mark | Corporate director | Individual | 01/01/2011 | |
| Petrosewicz, Norma | Corporate director | Individual | 01/01/2013 | |
| Tape, May | Corporate director | Individual | 01/15/2008 | |
| Uthman, Edward | Corporate director | Individual | 01/01/2008 | |
| Freudenberger, Joseph | Corporate officer | Individual | 06/19/2007 | |
| Westbury Place Nursing & Rehabilitation, LLC | Operational/managerial control | Organization | 12/01/2018 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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