Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park Manor Of Humble during CMS and state inspections, most recent first.
Incomplete post-fall monitoring and documentation: A resident with severe cognitive impairment, fall risk, and multiple orthopedic and neurologic diagnoses had an unwitnessed fall with pain and later bruising, but nursing staff did not consistently assess, monitor, communicate, or document the event across shifts. Interviews showed one nurse did not receive report or complete an assessment, another forgot to document the fall, and the DON and UM acknowledged missing documentation and communication.
Delayed and incomplete fall documentation: A resident with severe cognitive impairment, a high fall risk, and multiple orthopedic and neurologic diagnoses was found on the floor after an unwitnessed fall, but nursing documentation of the event, pain assessment, neuro checks, and fall risk assessment was entered late or was missing. Staff gave inconsistent accounts of the incident, and interviews showed confusion about who was notified, who assessed the resident, and whether the fall was communicated across shifts.
Medication administration errors exceeded the allowed rate, with a 9% error rate found during observation and record review. An MA applied a Lidocaine patch only to one knee instead of the ordered bilateral areas and gave the wrong iron supplement to one resident, while another MA administered only about half of the ordered Clearlax dose to a resident with severe cognitive impairment. The DON stated the patch order required bilateral application and that the full Clearlax dose should have been given.
Improper medication storage and temperature control were found when a resident's eye drops were left on a bedside tray table and in a nightstand drawer despite no order for self-administration, and another resident's Xiidra eye drops were stored in a refrigerator even though the label required room temperature storage. Staff and the DON stated medications were expected to be kept secured in the medication cart or medication room, and the DON confirmed the refrigerated eye drops were not stored as directed.
Infection control was deficient when a CNA performed incontinent care for a resident with multiple serious conditions, including an immunodeficiency and UTI, but did not cleanse the urethral opening during male perineal care. After the care, the CNA also returned used wipes, gloves, and hand sanitizer to a clean linen cart with clean supplies, which the DON and other staff identified as cross-contamination. Facility policy required cleansing the urethral area first and maintaining clean carts free of used items.
The facility failed to report allegations of abuse involving two residents within the required timeframe. A resident with bipolar disorder reported verbal abuse by a roommate, and another resident with severe cognitive impairment reported physical abuse by a staff member. Both incidents were not reported to the State Agency promptly, as required by facility policy.
A resident with multiple health issues sustained an abrasion on his leg, but the facility failed to obtain timely physician orders for treatment. Despite the care plan's directive, staff did not notify the physician or family promptly, leading to a delay in proper care. The wound was not assessed by the NP until several days later, placing the resident at risk of infection.
The facility failed to maintain an effective pest control program, resulting in cockroach sightings in resident rooms and common areas. Interviews with residents and staff confirmed ongoing issues, despite regular pest control services. Observations by surveyors and record reviews highlighted persistent pest presence and sanitation issues, indicating a deficiency in maintaining a pest-free environment.
The facility failed to maintain an effective pest control program, resulting in roach infestations in the rooms of three residents. One resident, with moderate cognitive impairment, reported sleep disturbances due to roaches in her bed. Another resident, cognitively intact, was uncomfortable with roaches on her floor and walls. A third resident, with complex medical conditions, used a fly swatter to kill roaches despite previous pest control efforts. Staff documented sightings, and the facility's pest control policy mandates an ongoing program, but multiple sightings were reported, indicating a deficiency.
A resident experienced severe abdominal pain and difficulty breathing, but the facility failed to provide emergency transportation as requested by the resident's representative. The representative had to push the resident in a wheelchair to a nearby hospital, where the resident was diagnosed with a perforated intestine and severe lung issues, eventually leading to the resident's death. Staff were unclear on protocols and failed to verify the representative's legal authority.
A facility failed to notify a physician and document a resident's change in condition, including diarrhea and trouble breathing. The resident, with a complex medical history, was later admitted to a hospital and died. Staff interviews revealed that the LVN did not follow proper procedures, leading to an Immediate Jeopardy situation.
A resident with multiple serious diagnoses expressed difficulty breathing and abdominal pain with diarrhea. The facility failed to obtain physician orders before treating the resident with loperamide and did not arrange emergency transportation when requested by the resident's representative. The resident was wheeled to a local hospital by the representative and expired while at the hospital.
Incomplete post-fall monitoring and documentation
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple diagnoses including traumatic subdural hemorrhage, Alzheimer’s disease, osteoarthritis of both hips, hip contractures, a history of traumatic brain injury, a prior femur fracture, and osteoporosis was monitored and documented after an unwitnessed fall. The resident’s care plan identified her as high risk for falls due to balance problems and noted an actual fall with no injury on the date of the event. After the resident was found on the floor in her room, nursing documentation stated she was lying on her left side near her bed, reported she had been trying to get back into bed, denied hitting her head, and complained of pain in her left thigh. The note also stated she had no visible injury at that time, was returned to her chair, received pain medication, and that the responsible party, DON, and family member were notified. A later nursing note documented a bruise on the right side of the jaw and that the resident said she fell but did not know who picked her up. Interviews with nursing staff and management showed that the fall monitoring and documentation were incomplete. One nurse said she did not receive report of the fall, did not assess the resident, did not call the provider, and left without giving report to the next shift. Another nurse said she was aware of the fall but forgot to document it and did not know why. The DON and Unit Manager acknowledged that documentation was missing and that the next shift may not have been informed. The facility policy required nursing staff to observe for delayed complications for approximately 48 hours after an observed or suspected fall and to document pain, swelling, bruising, deformity, decreased mobility, and changes in responsiveness or function, but the monitoring and documentation for the resident’s unwitnessed fall on the involved shifts were not completed as required.
Delayed and Incomplete Fall Documentation
Penalty
Summary
The facility failed to maintain complete and timely medical records for a resident with severe cognitive impairment and a high fall risk after an unwitnessed fall. The resident had diagnoses including traumatic subdural hemorrhage without loss of consciousness, Alzheimer’s disease with late onset, bilateral hip osteoarthritis, bilateral hip contractures, cognitive communication deficit, personal history of traumatic brain injury, prior right femur fracture, and osteoporosis. Her quarterly MDS showed a BIMS score of 1 out of 15, and her care plan identified her as high risk for falls related to balance problems. Record review showed that the resident fell while in her room and was found on the floor. Nursing documentation for the fall, including a late-entry note, pain assessment, neurological assessment, and fall risk assessment, was created after the event and entered days later rather than at the time of the fall. The late-entry nursing note stated the resident was lying on her left side near the bed, reported trying to get back into bed, denied hitting her head, and complained of pain in her left thigh. The note also documented that she was placed back in her chair, given pain medication, and that the RP, DON, and family member were notified. Additional documentation showed that on a later date the resident had a bruise on the right side of her jaw and stated that she had fallen, but she did not know who picked her up. During interviews, nursing staff and management gave inconsistent accounts of who knew about the fall, when it was reported, and whether the resident was assessed and monitored. One nurse said she did not conduct an assessment because she believed the ADON already knew about the incident, and another nurse said she forgot to document the fall in the medical record. The DON and Unit Manager acknowledged that some documentation regarding the fall was missing, and the facility policy required observation for delayed complications and documentation of findings in the medical record after a fall.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors identified 3 medication errors out of 31 opportunities, resulting in a 9% error rate, involving two residents and two medication aides. The errors included incorrect administration of a Lidocaine patch and an iron supplement for one resident, and an incomplete dose of Clearlax for another resident. Resident #114 was admitted with diagnoses including displaced fracture of the fifth cervical vertebra, central cord syndrome, and injuries from a motor vehicle accident. His orders included Lidocaine patch 5% to be applied to bilateral hips/knees and Ferrous Gluconate 324 mg daily for anemia. During medication pass, MA C prepared and administered medications, applied the Lidocaine patch only to the left knee after asking the resident where he wanted it, and gave Ferrous sulfate 325 mg instead of the ordered Ferrous Gluconate. MA C stated she was unsure whether Ferrous gluconate and Ferrous sulfate were the same medication and said she was unsure what bilateral meant in the patch order. Resident #29 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, depression, and mental disorder, and had a BIMS score of 7 indicating severe cognitive impairment. Her order was for Miralax 17 gm twice daily for constipation. During medication pass, MA L prepared Clearlax PEG 3350 using only about half of the measuring cup’s white section rather than the full 17 grams, then administered it to the resident. MA L stated she had poured the powder to the halfway line and had not noticed the 17 gm marking and arrows on the measuring top.
Improper Medication Storage and Temperature Control
Penalty
Summary
The facility failed to keep medications and biologicals stored in locked, secure conditions and at the proper temperature for two residents. One resident had four plastic bottles of Eyes Alive (carboxymethylcellulose sodium 0.5%) left on a bedside tray table and additional bottles found in the bottom drawer of the nightstand, even though there was no physician order authorizing self-administration. The resident had diagnoses including cholangitis, hypertension, muscle weakness, kidney failure, and sepsis, and an MDS assessment showed a BIMS score of 14 out of 15. During observation and interview, the resident stated family members and staff left the medication nearby so he could administer it if needed. Staff interviewed stated medications were expected to be kept in the medication cart, medication room, or aide cart, and that the resident was not authorized to self-administer. The medication aide stated she administered the eye drops and denied leaving them accessible in the room or nightstand. The DON also stated medications were expected to be kept in the medication cart or medication room, and that storing medications in a resident's room posed the risk of self-administration without authorization. For another resident, Xiidra eye drops were found in the door of the medication room refrigerator at 40 F, while the medication box instructed storage at room temperature between 68 F and 77 F. That resident had diagnoses including bilateral age-related incipient cataract and a quarterly MDS showing a BIMS score of 11 out of 15 with moderate cognitive impairment and need for staff assistance with ADLs. The DON reviewed the medication insert and stated the drops should not have been refrigerated and that she was unsure who placed them there.
Infection Control Lapses During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when CNA A did not maintain infection control during incontinent care for a resident with multiple medical conditions, including progressive multifocal leukoencephalopathy, other combined immunodeficiencies, a urinary tract infection, hemiplegia, dysarthria and anarthria, chronic kidney disease, hypertension, and muscle weakness. The resident’s admission assessment showed a BIMS score of 13 out of 15, dependence for toileting hygiene, maximal assistance with lower body dressing and showers, moderate assistance with upper body dressing and personal hygiene, wheelchair use, and bowel and bladder incontinence. During observation of incontinent care, CNA A and CNA D provided care in the resident’s room. CNA A cleansed the lower abdomen and groin, then cleansed from the base of the penis toward the urethral opening with one motion, but did not cleanse the opening of the urethra. CNA A later stated she did not realize she had not cleaned the tip of the penis because she was nervous, and stated it was important to clean the area to prevent buildup of germs which could cause infection. The resident also had a small bowel movement during the care, and CNA A completed perineal cleansing and brief change before leaving the room. After the care was completed, CNA A removed the packages of disposable wipes, the box of gloves, and the bottle of hand sanitizer from the room and placed them on the shelf of the linen cart between clean folded linen. CNA A stated she did not think it was a problem to bring the items out of the room and back onto the cart, then later stated the items should not have been placed back onto the clean cart after use because this would be cross contamination. CNA D, the DON, and LVN E all stated the clean cart was for clean supplies only and that used wipes and gloves should not be returned to it because of infection control and cross-contamination concerns. The facility policy for male perineal care required washing the urethral area starting with the urethra and working outward, and the infection control policy stated the facility’s practices were intended to maintain a safe, sanitary, and comfortable environment and help prevent and manage transmission of diseases and infections.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents within the required timeframe. Resident #39, a female with a history of bipolar disorder and major depressive disorder, reported feeling verbally abused by her roommate, Resident #26. Despite expressing her concerns to the Administrator and Social Worker, the facility did not report the incident to the State Agency within the mandated two-hour window. The Administrator was first alerted to the situation by a State Surveyor, and the report was only submitted two days later. Resident #52, a male with severe cognitive impairment due to Alzheimer's disease, reported being physically abused by a staff member during a shower. He claimed that the incident occurred approximately a year ago, but the Administrator was only made aware of the allegation recently. The facility again failed to report this allegation to the State Agency within the required timeframe, submitting the report two days after being informed. The facility's policies on reporting abuse and resident-to-resident altercations were not followed, as both incidents were not reported promptly. The delay in reporting these allegations could place residents at risk of further abuse and neglect, as timely reporting is crucial for the protection and safety of residents.
Failure to Obtain Timely Physician Orders for Resident's Abrasion
Penalty
Summary
The facility failed to ensure that Resident #42 received treatment and care in accordance with professional standards and the comprehensive care plan. Resident #42, a male with severe protein calorie malnutrition, chronic kidney disease, and other health issues, sustained an abrasion on his left leg on 2/1/25. Despite the care plan's directive to notify the physician and family in case of a skin tear, the facility did not obtain physician orders for the abrasion until 2/5/25, four days after the incident. The incident was initially reported by a medication aide to RN K, who cleaned the wound and applied a dry dressing but failed to notify the necessary parties or obtain a physician's order. The wound care nurse and other staff members were not informed of the abrasion in a timely manner, leading to a delay in proper treatment. Observations and interviews revealed that the dressing was changed multiple times without a physician's order, and the wound was not properly assessed until 2/5/25 when the NP was finally informed and provided treatment orders. The facility's policies on skin tears and changes in a resident's condition were not followed, as notifications to the responsible family member, physician, and other relevant parties were not made promptly. The lack of communication and failure to follow established procedures placed Resident #42 at risk of infection, as the abrasion was not addressed according to professional standards and the comprehensive care plan.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in various areas, including resident rooms and common areas. Interviews with residents revealed that they had observed roaches in their rooms, with one resident mentioning that the issue had improved over time but was still present. The facility's maintenance staff confirmed the use of an electronic request system and a logbook to track pest sightings, and pest control services were engaged twice a month, with additional visits as needed. Observations by the survey team confirmed the presence of a roach in the conference room, and the facility's administration acknowledged the issue, noting recent foundation work that might have contributed to the problem. The facility's pest control policy, revised in 2008, outlined measures to keep the building free of pests, including regular pest control services and maintenance interventions. However, the policy's implementation appeared insufficient, as evidenced by the continued sightings of roaches in multiple areas over several months. Record reviews of pest control service inspection reports from the past 90 days indicated repeated treatments in specific rooms and common areas due to live roach sightings. The reports also highlighted issues with sanitation and food storage in some rooms, which may have exacerbated the pest problem. Despite the facility's ongoing efforts to address the issue, the presence of cockroaches persisted, indicating a deficiency in maintaining a pest-free environment.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches in the rooms of three residents. Resident #1, who has moderate cognitive impairment and requires substantial assistance for ADL care, reported being disturbed by roaches crawling in her bed, which affected her sleep. Observations confirmed the presence of a roach on the wall and dead roaches at her bedside. Resident #2, who is cognitively intact but requires moderate assistance for ADL care, also reported seeing roaches on the floor and walls of her room, which made her uncomfortable. Resident #3, who is cognitively intact and has medically complex conditions, used a fly swatter to kill roaches in her room, despite previous pest control measures. Interviews with staff revealed that roach sightings were documented in a pest control binder, and staff were aware of the issue. CNA A confirmed seeing roaches in the rooms of Residents #1 and #2 and documented the sightings. The ADMIN and Dir. of T&L acknowledged seeing roaches in Resident #3's room and reported the issue in morning meetings. The DON noted that food crumbs in resident rooms contributed to the problem and stated that pest control services were conducted monthly and as needed. The facility's pest control vendor service forms indicated reports of German cockroach activity in various rooms, with dead roaches found during inspections. The facility's pest control policy, revised in 2008, mandates an ongoing program to keep the building free of insects. However, the pest control binder showed multiple roach sightings in the residents' rooms, indicating a failure to effectively address the pest issue.
Failure to Honor Resident's Rights and Provide Emergency Care
Penalty
Summary
The facility failed to extend the resident's rights to their representative, leading to a series of events that resulted in a resident's death. The resident, who was alert and oriented, experienced severe abdominal pain and difficulty breathing. Despite the resident's representative requesting immediate emergency transportation to a hospital, the facility staff insisted on following protocol, which involved waiting for a doctor's order for an X-ray and lab tests. The representative, unable to wait, decided to take the resident to the hospital herself, but the staff refused to assist in transferring the resident to her vehicle or to speak with the 911 dispatcher to authorize emergency services on the facility's property. The resident's representative had to push the resident in a wheelchair to a nearby hospital, where the resident was diagnosed with a perforated intestine and severe lung issues. The resident's condition deteriorated, and he was transitioned to comfort care before passing away. Interviews with facility staff revealed a lack of clarity and training on how to handle such situations, with some staff members unaware of the resident's rights and the representative's legal authority to make medical decisions. The facility's policies on resident rights, emergency transfers, and discharges were not adequately followed. Staff failed to establish the resident's wishes or verify the representative's power of attorney. The incident highlighted significant gaps in staff training and understanding of protocols, leading to the resident's inadequate care and eventual death. The facility's failure to act promptly and appropriately in an emergency situation directly contributed to the adverse outcome for the resident.
Failure to Notify Physician and Document Change in Condition
Penalty
Summary
The facility failed to consult with the resident's physician and notify the resident representative for a resident reviewed for a change of condition. Specifically, an LVN did not immediately notify the physician when the resident was observed with diarrhea and when the resident reported having trouble breathing. The resident was later admitted to a local hospital and died while in the hospital. The facility also failed to establish if the resident wanted to leave the facility for the hospital when requested by the resident representative, despite the resident being alert and oriented. The resident had a complex medical history, including metabolic encephalopathy, sepsis, pneumonia, end-stage renal disease, pleural effusion, dyspnea, atherosclerotic heart disease, and atrial fibrillation. The electronic medical records did not reveal any progress notes or SBAR completed by the LVN regarding the resident's change in condition. Additionally, there were no physician orders for anti-diarrhea medication, and the baseline care plan did not indicate that the resident was admitted with diarrhea. Interviews with various staff members revealed that the LVN did not notify the physician about the resident's diarrhea or trouble breathing, and the medication was given without a physician's order. The LVN admitted to being overwhelmed with duties and forgetting to complete the necessary steps. The Director of Nursing and other staff confirmed that a change in condition, such as trouble breathing or diarrhea, should have been reported to the physician, and appropriate documentation should have been completed. The failure to notify the physician and document the change in condition was identified as an Immediate Jeopardy situation.
Failure to Obtain Physician Orders and Arrange Emergency Transportation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not obtain physician orders before treating the resident with loperamide for diarrhea. Additionally, the facility did not arrange emergency transportation to a local hospital when requested by the resident's representative, despite the resident expressing difficulty breathing and abdominal pain. The resident was ultimately wheeled to a local hospital by the representative and expired while at the hospital. The resident, a male with multiple diagnoses including metabolic encephalopathy, sepsis, pneumonia, end-stage renal disease, pleural effusion, dyspnea, atherosclerotic heart disease, and atrial fibrillation, was admitted to the facility. The resident's baseline care plan did not indicate that he was admitted with diarrhea. On the day of the incident, the resident expressed having trouble breathing and abdominal pain with diarrhea. The facility staff failed to document these changes in condition and did not complete the necessary Situation, Background, Assessment, and Recommendation (SBAR) forms. When the resident's representative arrived and requested emergency transportation to the hospital, the facility staff did not assist, citing that they were not allowed to help once the resident was leaving against medical advice (AMA). The representative had to push the resident in a wheelchair to the hospital, where a CT scan revealed a perforated intestine and collapsed lung lobes. The resident's family declined surgical intervention, and the resident was transitioned to comfort measures only, eventually passing away at the hospital.
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Illustrative
What surveyors actually found near you
We read the 585 citations issued within 25 miles in the last 12 months — including the 46 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Humble
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crimson Heights Health & Wellness | 0.2 mi | ★★★★★ | 15 | 0 |
| Deerbrook Skilled Nursing And Rehab Center | 0.5 mi | ★★★★★ | 14 | 3 |
| Focused Care At Humble | 1.1 mi | ★★★★★ | 1 | 0 |
| Oakmont Healthcare And Rehabilitation Of Humble | 1.7 mi | ★★★★★ | 16 | 0 |
| Fall Creek Rehabilitation And Healthcare Center | 4.3 mi | ★★★★★ | 2 | 0 |
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