Paradigm at Westbury

In the surveyor’s words

From the most serious findings on record at Paradigm at Westbury, in the surveyor’s own words.

• Immediate jeopardy, widespreadF584Jan 15, 2025

  Based 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 [DATE] at 5:14 p.m. […]

• Immediate jeopardy, patternF695Aug 28, 2025

  Based 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. […]

• Immediate jeopardy, patternF689Feb 5, 2024

  Based 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. […]

• Immediate jeopardy, patternF926Feb 5, 2024

  Based 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 01/22/2024 until 02/02/2024. Resident #2 and Resident #3 did not sign smoking contracts until 02/03/2024. 3. […]

• Immediate jeopardy, isolatedF600Jan 26, 2022

  Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 13 residents (CR#1) reviewed for abuse. The facility failure to prevent abuse of CR#1 when licensed nurse RN A left assigned unit without a licensed nurse coverage. The facility failure to prevent abuse of CR#1 when facility staff failed to immediately initiate emergency life-saving procedures to CR#1 found unresponsive in the unit without a licensed nurse coverage. CR#1 was pronounced dead at the facility by Emergency medical services. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 10:40 AM. […]