Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Tomball during CMS and state inspections, most recent first.
Medication Administration and Order Compliance Failures: The facility failed to provide ordered meds as prescribed for three residents. One resident did not receive Levothyroxine when it was unavailable, another received a full 25 mg Metoprolol tablet instead of the ordered 12.5 mg dose via G-tube, and a third resident had multiple SBP readings over 150 without receiving PRN Clonidine as ordered. Interviews with the LVN, unit manager, DON, and MD confirmed the orders were not followed.
Unsecured medications were found with a resident and on an unlocked med cart. A resident with ESRD, dialysis dependence, diabetes, cirrhosis, and moderately impaired cognition was observed eating breakfast with two Sevelamer tablets on the tray and no staff present, despite the med being ordered with meals and no self-administration order. In a separate event, an LPN left an IV med on top of an unlocked 200 Hall med cart while stepping away into a resident room, allowing two residents to pass by the unsecured cart.
The facility failed to ensure two residents were fully informed and able to communicate their health status, care, and treatments in languages they could understand. A Spanish-speaking resident said she could not effectively tell staff about complaints, medications, meals, or other needs, and staff were observed providing care while speaking only English and using gestures. A Vietnamese-speaking resident with dementia and other diagnoses was not identified in the care plan as speaking Vietnamese, relied on family or a translation line to express needs, and staff initially missed her report of a sore throat and pain because communication was handled in English or through informal methods.
A resident with dementia, stroke-related impairments, incontinence, and a history of UTI had an active order for Macrodantin 50 mg HS for UTI prophylaxis, but the care plan did not address the resident's UTI history or the prophylactic antibiotic intervention. The MDS Nurse and DON stated that UTIs and the antibiotic treatment should have been included in the plan of care, but the care plan lacked those elements.
Failure to Verify GT Placement Before Medications and Feeding: An LVN administered crushed meds and bolus tube feeding via a resident’s GT without first confirming tube placement as ordered and per facility policy. The resident had severe cognitive impairment, dysphagia, malnutrition, and a history of pneumonitis, and the DON stated staff were expected to check placement by aspirating gastric contents before giving meds or formula.
Loose Bedrails Not Maintained or Checked: A resident with dementia, weakness, and a history of falls was observed using both bedrails to turn in bed, but both rails were loose and one was wobblier than the other. The resident stated the rail was loose, a CNA reported the issue as a safety hazard, and Maintenance later tightened the rails after receiving the work order. Records showed the rails were to be checked each shift, while the bed manual required quarterly inspection of rail bolts and the side rail policy required periodic safety checks.
Failure to Wear Hairnet in Kitchen: The Dietary Manager was observed cleaning kitchen floors without a hairnet after returning from bringing in a water hose. She acknowledged she should have worn a hairnet due to the risk of hair contaminating food. The Administrator stated staff are expected to wear hairnets immediately upon entering the kitchen, and the facility policy requires hair to be secured under a hair net or cap.
The facility did not report allegations of drug theft and misappropriation of resident property by a medication aide, nor did it report the theft of controlled substances left unattended by an LVN. Despite receiving multiple anonymous complaints and evidence of possible misappropriation, the facility failed to notify the State Survey Agency as required, and did not suspend the accused staff during the investigation. Facility policies for reporting and investigating such incidents were not followed.
The facility did not thoroughly investigate or report allegations of drug theft and misappropriation involving a medication aide, nor did it report the theft of controlled substances intended for the automated dispensing system. Required interviews, documentation, and notifications to the state agency were not completed, and not all staff with access to the medications were drug tested.
A nurse failed to log 80 controlled substance tablets into the automated dispensing system after signing for their delivery, leaving them unattended on the nursing station counter. The medications, which included narcotic pain, anti-seizure, anxiety, and sleeping medications, were never secured or properly documented, resulting in their disappearance. Staff interviews revealed a lack of training and common practice of leaving medications unattended, and the facility was unable to reconcile the missing drugs.
A nurse failed to secure a delivery of controlled substances, leaving 80 tablets of various medications unattended on the nursing station counter overnight. The medications were not logged or placed in the automated dispensing system as required, and were subsequently stolen. Staff interviews confirmed that leaving medications unattended was a common practice, and the nurse involved had not received training on proper procedures.
The facility did not update or post daily nurse staffing information as required, leaving the Direct Care Report outdated on multiple occasions. This occurred when the designated staff responsible for updating the report were absent, and the task was overlooked by others, resulting in the lack of current staffing details being available for review.
A resident with multiple comorbidities experienced a significant decline, including shortness of breath, rapid heart rate, and low O2 saturation. Nursing staff attempted interventions and delayed contacting the NP, resulting in a late response and hospital transfer. The physician was not promptly notified as required by policy.
Two residents experienced significant changes in condition—one with respiratory distress and another with worsening leg wounds—without timely physician notification or appropriate interventions by staff. Delays in escalation and lack of adherence to facility protocols resulted in both residents being transferred to the hospital after their conditions deteriorated.
Dietary staff failed to check expiration dates and freshness of milk before serving, resulting in a resident with cognitive impairment consuming expired chocolate milk. Further review found expired milk had been distributed to multiple residents, with some milk having a sour odor. Staff interviews confirmed that required food safety checks were not consistently performed.
The facility reported a medication error rate of 6.9% due to two incidents involving incorrect medication administration. One resident received Multivitamins with Minerals instead of plain Multivitamins, and another was given the wrong type of eye drops. Both LVNs involved acknowledged the errors, which were contrary to the facility's medication administration policy.
A resident with a stage 4 sacral pressure ulcer was not repositioned for four hours, contrary to their care plan. Despite being at risk for skin breakdown, the resident was observed lying flat on his back multiple times. Staff interviews revealed a lack of adherence to repositioning protocols, with refusals not being documented. The facility's policy required repositioning every two hours and documentation of any refusals, which was not followed, potentially hindering wound healing.
A resident with a diagnosis of Bipolar Disorder was admitted to the facility without a proper PASRR Level II assessment, as the initial screening incorrectly indicated no mental illness. The MDS coordinator did not audit previous assessments, and the DON confirmed the risk of missing services due to inaccurate screenings.
Medication Administration and Order Compliance Failures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of 3 of 9 residents reviewed. One resident with hypothyroidism, hypertension, heart disease, and protein calorie malnutrition had a physician order for Levothyroxine Sodium 75 mcg by mouth each morning starting 03/23/2026. On 03/24/2026, the eMAR showed a nurse note instead of a medication check mark, and the nurse note stated the medication was awaiting pharmacy. The resident stated he had not received Levothyroxine for the past two days because staff reported the medication was unavailable and needed to be ordered. The LVN stated the medication was scheduled for administration between 4:00 a.m. and 6:00 a.m., but when she found it unavailable she did not notify the physician and instead notified the DON and reordered the medication. A second resident with hemiplegia, hemiparesis, dementia, malnutrition, hypertension, and atrial fibrillation had an order for Metoprolol tartrate 25 mg, give 0.5 tablet via G-tube twice daily for hypertension, hold if SBP <110 or HR <60. During observation of the medication pass, the LVN administered a full 25 mg tablet through the G-tube rather than the ordered half tablet. Review of the medication administration record and the medication pass confirmed the full tablet was given. The LVN stated she was not aware the full tablet had been administered, and the Unit Manager confirmed the order was for half a tablet and that the administering nurse was expected to split the scored tablet before giving it. A third resident with ESRD, dialysis dependence, diabetes, and cirrhosis had orders for scheduled antihypertensive medications and a PRN Clonidine 0.1 mg every 8 hours when systolic blood pressure was over 150. Review of March 2026 vital signs showed multiple blood pressure readings above 150 systolic, including readings of 152/69, 174/73, 155/86, 159/89, 159/68, 156/75, 177/80, 154/69, 168/74, 151/76, 151/65, 156/58, and 159/73, with no corresponding PRN Clonidine administration for those elevated readings. Staff interviews showed that nurses were rechecking blood pressures and sometimes deciding not to give the PRN medication even when the parameters were met. The physician stated the order was not being followed if the PRN Clonidine was not given when the resident's systolic blood pressure was over 150.
Unsecured Medications Left With Resident and on Unlocked Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored securely for one resident and one medication cart. Resident #86, who had ESRD, dependence on renal dialysis, diabetes, cirrhosis of the liver, and moderately impaired cognition with a BIMS score of 10, was observed eating breakfast with two large white oblong tablets in a clear medication cup on the tray and no nursing staff present in the room. The tablets were identified as Sevelamer 800 mg, which was ordered to be given with meals, and there were no orders for self-administration of medications. During interviews, MA A stated she was responsible for administering scheduled medications to Resident #86 and said she watched the resident swallow the Sevelamer. LVN A stated it would be against policy and procedure to leave medications with a resident and that staff should remain with the resident until the medication was consumed. The DON stated medications should never be left alone with a resident and should be witnessed until swallowed unless refused. When interviewed with a Spanish interpreter, Resident #86 stated she took her morning dose of Sevelamer, first saying it was given before her meal came and staff watched her take it, then stating staff were not in the room when she took it. The facility also failed to secure the 200 Hall nurse medication cart during medication preparation. An LVN was observed preparing medications, then leaving the cart unlocked with an IV medication on top of it while entering a resident's room and closing the door. Two residents walked past the cart during this time, and there was no direct line of sight to the unsecured cart. The LVN later stated the cart should have been locked and that leaving the medication out was accidental, and he knew the cart needed to be secure to prevent a resident from walking by and taking medication left there.
Failure to Communicate Resident Health Needs in Preferred Languages
Penalty
Summary
The facility failed to ensure that two residents were fully informed in a language they could understand of their health status, care, and treatments. One resident’s care plan did not include any plan for addressing communication needs, and during interviews she stated that she was Spanish speaking, had some ability to understand and speak English, but could not effectively communicate complaints about care, medications, meal preferences, medication timing, diagnoses, and clothing. She said she had stopped asking for help with many needs because of the language barrier. During an observation of care, two CNAs assisted the Spanish-speaking resident with toileting and dressing while speaking only in English and using hand gestures. The resident did not speak in English or at all to staff during the interaction. The CNAs stated they generally communicated with her using Spanish-speaking staff or internet translation services, and said they were unaware of the facility’s translation line. The DON stated the facility had a translation line and that staff were expected to use it, not internet translation services or family members. The second resident’s record identified dementia, diabetes, and chronic respiratory failure. Her care plan addressed communication problems related to dementia, but did not include that she spoke Vietnamese. Although the annual MDS listed English as her preferred language and indicated she did not need an interpreter, the resident told the surveyor through a translation line that she spoke Vietnamese and could not communicate her needs to staff without a family member. She reported a sore throat for over a week and asked that staff be told she needed medication. A nurse initially spoke to her in English and did not identify the concern until the surveyor used the translation line. Staff interviews showed inconsistent knowledge of the resident’s language needs, limited use of the translation line, and reliance on family members, gestures, and single English words to communicate with her.
Failure to Include UTI History and Prophylactic Antibiotic in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident, identified in the report as Resident #9, that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #9 had diagnoses including dementia, hemiplegia, hemiparesis, stroke, urinary tract infection, atrial fibrillation, hypertension, and depression. The quarterly MDS showed moderately impaired cognition with a BIMS score of 9 out of 15, one-sided upper and lower extremity impairment, use of a manual wheelchair, total incontinence of bowel and bladder, and dependence for multiple activities of daily living. The MDS also indicated an active diagnosis of urinary tract infection during the last 30 days and that the resident was receiving antibiotics. Record review showed an active physician order for Macrodantin 50 mg by mouth at bedtime for prophylactic UTI prevention, and the March 2026 MAR/TAR documented the medication as administered daily at bedtime. However, the resident's undated care plan did not address the history of UTI or the use of prophylactic Macrodantin. During interview, the MDS Nurse stated that UTIs should be addressed in the care plan and that the nursing team should use the care plan as a guide, but she did not know why the resident's history of UTI and prophylactic antibiotic intervention were not included. The DON stated that the resident's UTI and antibiotic treatment should have been part of the plan of care and identified the MDS Nurse as responsible for making the additions.
Failure to Verify GT Placement Before Medications and Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition and medications via gastrostomy tube received the ordered tube placement check before administration. The resident had diagnoses including hemiplegia, hemiparesis, pneumonitis due to inhalation of solids and liquids, malnutrition, dementia, hypertension, and atrial fibrillation. The admission MDS showed a BIMS score of 3 out of 15, indicating severe impaired cognition, and the resident was dependent on staff for most activities of daily living and had a feeding tube for nutritional support. The resident’s physician orders required GT bolus feedings of Isosource 1.5 cal five times per day, with 30 mL water flushes before and after each bolus, and required GT placement to be checked prior to feeding and/or medication administration by aspiration of gastric contents every shift. The care plan also directed staff to check tube placement and gastric content/residual volume per facility protocol. During observation, an LVN prepared and administered multiple crushed medications and the tube feeding through the GT, but did not check for tube placement before giving the medications or formula. The LVN stated she was unsure of the amount of residual fluid to be concerned about and stated she believed residual checks were only for continuous feedings, not bolus feedings. In interview, the DON stated it was the facility policy to check proper GT placement by drawing back on the syringe to check for residual fluids and that nurses were expected to check placement before giving medications or formula feedings. The DON also stated nurses had received in-services regarding GT care during skills checks in December 2025, and that the LVN may not have been part of that training because she returned to work full time in January 2026. The facility policy for administering medications through an enteral tube required confirming tube placement by aspirating stomach contents and, if improper positioning was suspected, not administering feeding or medication and notifying the physician.
Loose Bedrails Not Maintained or Checked
Penalty
Summary
The facility failed to ensure that Resident #14’s bedrails were maintained and checked regularly to make sure they were installed correctly. Resident #14 had diagnoses including fracture of the left femur, sepsis, dementia, muscle weakness, and depression, and the quarterly MDS showed a BIMS score of 6 out of 15, indicating severe impaired cognition. The resident used a manual wheelchair, required supervision for transfers and bed mobility, needed moderate assistance with bathing and dressing, was frequently incontinent, and had a fall with a major injury since admission/re-entry. Record review showed that Resident #14 had a bedrail evaluation stating the resident was currently using bedrails, could not physically release them, could get in and out of bed without assistance, and had a history of falls. The informed consent for bed rails documented verbal consent from the representative and recommended 1/4 partial rails on both sides to be used whenever the resident was in bed. The MAR/TAR also directed that the bed rails be checked every shift. During observation, Resident #14 was in bed using both rails to self-turn, and both bedrails were loose, with the right rail wobblier than the left. The resident stated the bedrail was loose. CNA F stated the loose bedrails were a safety hazard and had been reported to Maintenance through an electronic work order sometime between 3/16/26 and 3/21/26. Maintenance stated he learned about the loose bedrail on 3/19/26 but did not receive the work order until 3/24/26, and he then tightened the bedrails. The DON stated nursing staff were responsible for entering work orders and that bedrails could become loose from wear and tear. The facility’s bed manual required quarterly inspection of bed and rotating assist bars/rails bolts, and the side rail policy stated residents would be checked periodically for safety relative to side rail use.
Failure to Wear Hairnet in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the Dietary Manager was observed cleaning the kitchen floors without wearing a hairnet. During the observation on 03/24/2026 at 8:11 am, the Dietary Manager stated she had just returned from bringing the water hose inside to clean the floors and acknowledged that she should have worn a hairnet because of the risk of hair contaminating food. During an interview on 03/25/2026 at 8:30 am, the Administrator stated that staff are expected to wear hairnets immediately upon entering the kitchen and that failure to wear hairnets poses a risk for food contamination. Record review of the facility's Staff Hygienic Dress Code Policy stated that hair must be secured under a hair net or cap.
Failure to Timely Report Alleged Abuse, Neglect, and Drug Diversion
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—were reported immediately, or within the required timeframes, to the administrator and appropriate authorities. Specifically, the facility did not report to the State Survey Agency allegations of drug theft and misappropriation of resident property by a medication aide (MA A), nor did it report the theft of 80 controlled substance tablets that occurred when a licensed vocational nurse (LVN A) left medications unattended at the nursing station. Multiple anonymous complaints were received alleging that MA A was misappropriating resident medications and items, and a video surfaced showing MA A injecting herself with medication in the facility’s central supply closet. Despite these allegations and evidence, the facility did not submit any Facility Reported Incidents regarding MA A to the state agency, and MA A was not suspended or restricted from medication access during the investigation. In the case of the missing controlled substances, LVN A signed for a delivery of 80 controlled substance tablets, left them unattended at the nursing station, and later discovered them missing. The facility did not report this drug diversion to the State Survey Agency. Interviews revealed that the medications were left out for an extended period, and the facility’s investigation included drug testing only certain staff, searching common areas, and reviewing the incident, but did not include a comprehensive search or assessment of all individuals who may have had access. The facility’s leadership, including the Administrator and Regional Clinical Director, believed that the incident was not reportable because the medications were intended for the automated dispensing system and not for a specific resident. Facility policies required prompt and thorough investigation of theft or misappropriation of resident property, including notification of appropriate agencies within 24 hours and suspension of accused employees pending investigation. However, these policies were not followed in the cases involving MA A and LVN A. The Administrator and other leaders acknowledged that reporting requirements were not met, and that the facility did not fully investigate or report the incidents as required by federal and state regulations.
Failure to Investigate and Report Alleged Drug Diversion and Misappropriation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, and injury of unknown origin were thoroughly investigated and reported to the State Survey Agency within five working days, as required. Specifically, the Administrator did not conduct a comprehensive investigation or report the results to the state agency following multiple allegations of drug theft and misappropriation of resident property by a medication aide. Despite receiving numerous anonymous complaints and law enforcement involvement, there was no documentation of staff or resident interviews, medication audits, or evidence of law enforcement notification. The accused staff member was not suspended or reassigned during the investigation, and the facility did not submit any Facility Reported Incidents regarding the alleged misappropriation. Additionally, the facility failed to report and thoroughly investigate the theft of 80 controlled substance tablets intended for the automated dispensing system. The medications were left unattended at the nursing station and subsequently went missing. The facility's response included limited drug testing of certain staff, but not all individuals with access to the area were tested, and there was no assessment of residents for potential ingestion or side effects. The investigation did not include a thorough search of personal belongings or interviews with all relevant parties, and the incident was not reported to the state survey agency because the medications were not assigned to a specific resident. Facility policies required prompt and thorough investigation of all allegations of theft or misappropriation, including interviews with all involved parties and notification of appropriate agencies. However, these procedures were not followed in the cases described. The Administrator acknowledged that the investigation and documentation were incomplete and that reporting requirements were not met, resulting in a lack of thorough investigation and failure to notify the state agency as required.
Failure to Secure and Account for Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the accurate acquiring, receiving, dispensing, and administering of controlled substances. Specifically, a nurse (LVN A) signed for a delivery of 80 controlled substance tablets, including narcotic pain medications, anti-seizure medications, anxiety medications, and sleeping medications. Instead of immediately logging these medications into the automated dispensing system as required by facility policy, LVN A left the medications unattended on the nursing station counter for several hours while attending to other duties, including managing a resident death. The medications remained unsecured and were later reported missing. Multiple staff interviews confirmed that it was common practice to leave medications unattended at the nursing station, and LVN A stated she had not received training on medication delivery or stocking the automated dispensing system. The missing medications were never located despite searches of the facility, and the incident was reported to facility management. The facility's policies required that controlled substances be counted upon delivery, logged into the automated dispensing system, and stored securely, but these procedures were not followed in this instance. The investigation revealed that the lack of proper documentation and secure storage led to the loss of the controlled substances. Staff did not conduct a search of resident rooms or personal belongings, nor did they assess residents for potential ingestion of the missing medications. The facility's failure to maintain an accurate inventory and secure storage of controlled substances resulted in the inability to reconcile the missing drugs and prevent drug diversion.
Controlled Substances Left Unsecured and Stolen
Penalty
Summary
A nurse (LVN A) failed to properly secure controlled substances after signing for a pharmacy delivery, leaving 80 tablets of various controlled medications unattended on the nursing station counter for several hours. The medications included narcotic pain medications, anti-seizure medications, anxiety medications, and sleeping aids. The medications were left out overnight while the nurse attended to a resident death and related responsibilities, and were not placed in the automated dispensing system or behind a double lock as required by facility policy and federal regulations. Multiple staff interviews confirmed that it was common practice for medications to be left unattended at the nursing station, and that on this occasion, the medications remained unsecured from the time of delivery in the evening until early the next morning. The medications were discovered missing when the nurse attempted to secure them at the end of her shift. Despite searches of the facility and drug testing of nursing and medication aide staff, the missing medications were never recovered, and the responsible nurse was terminated following the incident. Facility policies required that all controlled substances be immediately logged, counted, and stored in a locked container or automated dispensing system upon receipt, with access limited to authorized personnel. The nurse involved reported not having received training on medication delivery or stocking the automated dispensing system. The incident was confirmed through interviews with the administrator, DON, and other nursing staff, all of whom acknowledged that the medications were left unsecured and that this was a violation of both facility policy and regulatory requirements.
Failure to Post and Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted and readily accessible for review, as required. Observations on two separate days revealed that the Direct Care Report, which should display current staffing information, was not updated and still reflected information from a previous day. The posting included details such as the facility census, staff types (RN, LVN, CNA, CMA, Restorative Aide), and total hours worked for all shifts, but was not current on the days reviewed. Interviews with the Staffing Coordinator and the Administrator confirmed that the responsibility for updating the Direct Care Report was not fulfilled on the days in question due to staff absences and oversight. The facility's policy requires daily posting of staffing numbers for each shift in a prominent location, with specific information to be included and updated within two hours of each shift's start. However, on the identified days, the required updates were not made, resulting in the absence of current staffing information for residents, visitors, vendors, and emergency personnel.
Failure to Promptly Notify Physician After Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a resident's physician following a significant change in the resident's condition. The resident, who had a history of osteomyelitis, peripheral vascular disease, and atherosclerotic heart disease, was admitted on antibiotic therapy. Over several days, the resident's oxygen saturation levels gradually declined. On the morning of the incident, the resident experienced blurry vision, shortness of breath, and a rapid heart rate, with oxygen saturation dropping to 76%. Despite these acute symptoms, the nurse initially attempted interventions such as elevating the head of the bed and administering supplemental oxygen, but the resident's condition did not return to baseline. The nurse increased oxygen delivery and eventually placed the resident on a non-rebreather mask, which temporarily improved oxygen saturation. However, the nurse did not immediately notify the physician or nurse practitioner upon recognizing the severity of the resident's symptoms. The first attempt to contact the nurse practitioner was made by text over an hour after the initial assessment, and there was a delay in response. During this period, the resident continued to deteriorate, and only after further desaturation and lack of improvement was the decision made to send the resident to the hospital. The nurse practitioner ordered the transfer after finally responding to the nurse's message. The resident was transported to the hospital several hours after the onset of symptoms. Interviews with staff and review of documentation confirmed that the physician was not promptly notified as required by facility policy when a significant change in condition occurred.
Failure to Provide Timely Physician Notification and Care for Changes in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two residents. In the first case, a male resident with a history of osteomyelitis, peripheral vascular disease, and atherosclerotic heart disease experienced a significant change in condition, including blurry vision, increased heart rate, shortness of breath, and a drop in oxygen saturation below baseline. Despite these symptoms and unsuccessful interventions to improve his oxygenation, the physician was not notified at the onset of symptoms. The first attempt to contact the nurse practitioner was made over an hour later, and the resident was not transported to the hospital until three hours after the initial complaints, during which time his condition continued to deteriorate. Interviews with staff revealed delays in both notification and escalation of care, with confusion about when to contact emergency services in the absence of a physician's order. In the second case, a female resident with end-stage heart failure, atherosclerotic heart disease, chronic kidney disease, dementia, and hypertension developed open wounds on her lower legs. The wounds were first identified by a family member, who reported them to nursing staff. Despite the progression of the wounds and visible deterioration, there was no documentation of physician notification, no new treatment orders, and no interventions initiated by the facility. The resident was eventually admitted to the hospital with a diagnosis of cellulitis affecting both lower limbs. Record reviews confirmed the absence of timely physician notification and lack of appropriate wound care interventions. The facility's own policy required prompt notification of the attending physician for significant changes in a resident's condition, including the need to alter medical treatment or transfer to a hospital. However, in both cases, there was a failure to follow this policy, resulting in delayed medical intervention and escalation of care. Interviews with staff and review of documentation confirmed that these deficiencies were due to lapses in communication, assessment, and adherence to established protocols for managing changes in resident condition.
Expired Milk Served to Resident Due to Lapses in Food Safety Checks
Penalty
Summary
Dietary staff failed to ensure that all perishable food items, specifically milk, were fresh before serving them to residents. During a lunch service, a resident with moderately impaired cognition and multiple medical conditions, including type 2 diabetes and GERD, was served a carton of chocolate milk with an expiration date that had already passed. The resident noticed the expired date after taking a sip and reported the issue. Upon further inspection, it was found that expired milk had been distributed to multiple residents, with some milk poured into cups and covered with plastic wrap, while others were left uncovered. The milk in at least one cup was found to have a sour and pungent smell. Interviews with dietary aides and the dietary manager revealed that the process for checking expiration dates on perishable items was not consistently followed. One aide admitted to not checking the date or the freshness of the milk before serving it, and the dietary manager acknowledged that expired milk had been separated but not discarded, possibly due to oversight by the night shift. The facility's policy required oversight of food storage and preparation, but this was not adhered to, resulting in expired milk being served to residents.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.9% due to two errors out of 29 opportunities. The errors involved two residents. One resident, a male with end-stage kidney disease and other health issues, was administered Multivitamins with Minerals instead of the prescribed plain Multivitamins via G-tube by LVN L. This error was observed during a morning medication round. The resident's care plan required medications to be given as ordered, but this was not adhered to. Another resident, a male with diabetes and mild non-proliferative diabetic retinopathy, was given the wrong eye drops by LVN M. Instead of the prescribed Carboxymethylcellulose Sodium for dry eyes, the resident received Tetrahydrozoline Hydrochloride, a decongestant for redness. Both LVNs acknowledged their errors during interviews, stating they should only administer medications as ordered by the physician. The facility's policy on medication administration emphasizes the importance of verifying the right medication, dosage, and method before administration, which was not followed in these instances.
Failure to Reposition Resident with Sacral Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with a stage 4 sacral pressure ulcer, as observed during a survey. The resident, who had end-stage renal disease and a history of pressure injuries, was not repositioned off his sacral wound for a span of four hours. Despite having a care plan that included interventions such as turning and repositioning during rounds, the resident was observed lying flat on his back multiple times over several hours, indicating a lack of adherence to the care plan. Interviews with staff and family members revealed that the resident was not being repositioned as required. A CNA responsible for the resident admitted that while she had offered repositioning in the past, the resident often refused, and she did not document these refusals. The LVN and Wound Care Nurse also confirmed that they did not monitor or ensure that repositioning was being done, and the Wound Care Nurse was unaware of who was responsible for rounding to ensure compliance with repositioning protocols. The facility's policy required documentation of repositioning efforts, including any refusals by the resident, but this was not being followed. The DON confirmed that aides were expected to reposition residents every two hours and that refusals should be documented and reported. The lack of repositioning and documentation could prevent the healing of the resident's sacral wound, as confirmed by the Wound Physician, who noted no improvement in the wound's condition over several days.
Failure to Conduct PASRR Level II Assessment for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that all Pre Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Level II assessment. This deficiency was identified for a resident who was admitted with a diagnosis of Bipolar Disorder, yet the pre-admission screening incorrectly reflected no indicators of a mental illness. The resident's medical records, including the Minimum Data Set (MDS) and care plan, documented the presence of bipolar disorder, but the PASRR Level I screening did not indicate this, and no further PASRR evaluations were performed. Interviews with facility staff revealed that the MDS coordinator, who started in July 2024, was responsible for revising PASRR Level I screens for new admissions but did not audit previous assessments. The Director of Nursing (DON) confirmed that the MDS Nurse was responsible for auditing her own work and acknowledged the risk of residents missing out on services they could be eligible for due to inaccurate screenings. The facility's policy outlined the need for accurate PASRR screenings to ensure residents receive necessary services, but this was not adhered to in the case of the resident with bipolar disorder.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 454 citations issued within 25 miles in the last 12 months — including the 40 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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tomball
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lawrence Street Health Care Center | 0.4 mi | ★★★★★ | 9 | 1 |
| The Heights Of Tomball | 0.7 mi | ★★★★★ | 0 | 0 |
| Tomball Rehab & Nursing | 1.3 mi | ★★★★★ | 10 | 0 |
| Willow Creek Lodge | 4.1 mi | ★★★★★ | 1 | 0 |
| The Broadmoor At Creekside Park | 7.6 mi | ★★★★★ | 11 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.