Map showing the location of Paradigm at Westbury in Houston, Texas
5201 S Willow Dr, Houston, TX, 77035

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • TexasLowest tier among peers1,167 rated homes · average 2.8★
  • Harris CountyLowest tier among peers94 rated homes · average 2.8★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs TX avg
  • StaffingCan add or remove a star1★−1.1 vs TX avg
  • Quality measuresCan add or remove a star3★−0.8 vs TX avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersTX avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersTX avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 15% of peersTX avg3.8★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.29hrsAbove 51% of peersTX avg3.40Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.36hrsAbove only 44% of peersTX avg0.44Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better63%Above only 19% of peersTX avg51%RN turnover65%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$118,093Above only 15% of peersTX avg$55,368Fines · denials3 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
45citations
19inspection dates
2actual harm (G–I)
4immediate jeopardy (J–L)
Nov 24, 2025most recent

Citations by monthOct 2022 – Nov 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Nov 24, 20252 citationsCycle 1worst D · no actual harm
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Dec 12, 2025
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Dec 12, 2025
Aug 28, 20251 citationCycle 1worst K · immediate jeopardy$22,455
  1. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareK · patternCorrected Sep 17, 2025
May 2, 20251 citationCycle 1worst D · no actual harm
  1. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsD · isolatedCorrected May 6, 2025
Mar 28, 20255 citationsCycle 1worst E · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Apr 23, 2025
  2. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Apr 23, 2025
  3. F814Dispose of garbage and refuse properly.Nutrition and DietaryD · isolatedCorrected Apr 23, 2025
  4. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Apr 23, 2025
  5. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Apr 23, 2025
Jan 28, 20251 citationCycle 2worst G · actual harm$81,075
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jan 30, 2025
Jan 15, 20251 citationCycle 2worst L · immediate jeopardy$81,075
  1. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsL · widespreadCorrected Jan 25, 2025
Oct 15, 20242 citationsCycle 2worst D · no actual harm
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Oct 15, 2024
  2. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 15, 2024
Jul 3, 20241 citationCycle 2worst D · no actual harm
  1. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsD · isolatedCorrected Jul 10, 2024
Jun 27, 20242 citationsCycle 2worst F · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jun 30, 2024
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jun 30, 2024
Jun 6, 20245 citationsCycle 2worst E · no actual harm
  1. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Jun 12, 2024
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Jun 12, 2024
  3. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 12, 2024
  4. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jun 12, 2024
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jun 12, 2024
Apr 30, 20243 citationsCycle 2worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 2, 2024
  2. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsD · isolatedCorrected May 2, 2024
  3. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrected May 2, 2024
Feb 5, 20242 citationsCycle 2worst K · immediate jeopardy
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareK · patternCorrected Feb 7, 2024
  2. F926Have policies on smoking.EnvironmentalK · patternCorrected Feb 7, 2024
Jan 29, 20241 citationCycle 3worst E · no actual harm$14,563
  1. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Feb 5, 2024
Jan 7, 20243 citationsCycle 2worst G · actual harm$14,563
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Jan 8, 2024
  2. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jan 8, 2024
  3. F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.AdministrationF · widespreadCorrected Jan 8, 2024
Nov 7, 20231 citationCycle 3worst D · no actual harm
  1. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Nov 10, 2023
Nov 3, 20232 citationsCycle 3worst E · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Nov 8, 2023
  2. F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Nutrition and DietaryE · patternCorrected Nov 8, 2023
Oct 17, 20232 citationsCycle 3worst D · no actual harm
  1. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Oct 24, 2023
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Oct 24, 2023
May 5, 20231 citationCycle 3worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 9, 2023
Oct 7, 20229 citationsCycle 3worst E · no actual harm
  1. F814Dispose of garbage and refuse properly.Nutrition and DietaryD · isolatedCorrected Oct 21, 2022
  2. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 21, 2022
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareE · patternCorrected Oct 21, 2022
  4. F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and CareD · isolatedCorrected Oct 21, 2022
  5. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Oct 21, 2022
  6. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Oct 21, 2022
  7. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningE · patternCorrected Oct 21, 2022
  8. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 21, 2022
  9. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Oct 21, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.29hrsAbove 51% of peers−0.11 vs TX avg
  • Registered nursesRN hours only0.36hrsAbove only 44% of peers−0.08 vs TX avg
  • Licensed practical nursesLPN hours0.97hrs
  • Nurse aidesCNA hours1.96hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.88hrs
  • Texas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better63%Above only 19% of peersTX avg 51%
  • RN turnoverRegistered nurses only65%Not ranked by CMS
  • Administrators who leftIn the past year2Leadership changed
  • Occupancy148 certified beds · ~105 residents a day71%Above 58% of peersTX avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $118,093In fines
  • 3Fines
  • 0Payment denials
  • $55,368TX avg in fines
Above only 15% of peersFewer fines than 15% of rated homes in Texas

Actions on record

  1. Aug 28, 2025Civil money penalty$22,455
  2. Jan 15, 2025Civil money penalty$81,075
  3. Jan 7, 2024Civil money penalty$14,563

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Paradigm Healthcare18 facilities in the chain2.1★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Oakbend Medical Center
Operational or managerial control
  • Westbury Place Nursing & Rehabilitation, LLC
Corporate directors
  • Barry Beard
  • Jeff Council
  • Tom Crayton
  • Melissa Martin
  • James McClamroch
  • Ruthanne Mefford
  • Mark Murray
  • Norma Petrosewicz
  • +2 more
Corporate officers
  • Joseph Freudenberger
Managing employees
  • Joseph Freudenberger

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 675612 · 5201 S Willow Dr, Houston, TX, 77035.
  • Percentiles compare this facility with every rated nursing home in Texas and Harris County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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