Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Tomball Rehab & Nursing during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including acute kidney failure, chronic pain, paraplegia, and Type 2 DM, had a new Levaquin 500 mg PO HS order entered by an NP into the EMR, scheduled to start that night. The order was not confirmed within the facility’s expected 2-hour timeframe and was instead confirmed after midnight the following day, resulting in the first dose being given a full day late. The LVN responsible did not recall receiving the order or knowing it required confirmation, and both the DON and Administrator stated that EMR orders were expected to be promptly confirmed and administered as written, consistent with facility policy to administer meds per MD orders.
A resident with severe cognitive impairment, acute kidney failure, and other comorbidities had STAT lab and imaging orders entered into the EMR that were not confirmed in a timely manner, causing delays in further assessment and treatment. One STAT lab order entered in the morning was not confirmed until early afternoon by an LVN, and a STAT KUB imaging order entered by an NP in the morning was not confirmed until late that night. The administrator stated STAT orders should be confirmed immediately, while the LVN reported a high volume of orders and not always being notified when new orders were entered. The facility’s STAT lab policy described time frames for follow-up on lab technician arrival but the delays occurred at the order confirmation stage.
Infection prevention and control was cited after the facility failed to maintain an adequate water management program for legionella prevention for all 89 residents. The Legionnaires Monitoring Protocol did not include an ASHRAE- or CDC-based risk assessment, procedures for using control measures, control limits or parameters, environmental testing protocols, or intervention steps when limits were not met or when healthcare-associated legionellosis occurred. The RDO, IDON, and Maintenance Director stated they were not aware the LWMP was inadequate, and the Administrator stated the Water Management Program team should have established and maintained an adequate program.
Opened insulin glargine pens for two residents were found in the med cart beyond the 28-day limit after first use. An LVN and the DON stated nurses should check pen dates before each administration and discard them after 28 days, and the facility policy and manufacturer guide both addressed the required handling of opened meds.
Medication administration errors exceeded the allowed rate when staff made 3 errors during 26 observed med passes. An MA mixed polyethylene glycol for two residents without clarifying the missing water amount in the order, and an RN administered IV vancomycin to a resident without documented flush orders, despite the MAR lacking those instructions and staff acknowledging the orders should have been verified.
Food was not stored, prepared, distributed, and served in accordance with professional standards in the kitchen. Surveyors observed dialysis lunch bags past their used-by dates, multiple unlabeled food items, frozen ground beef stored on the freezer floor, soft mechanical sausage held at 130.1 degrees Fahrenheit in the steam table, and a scoop stored in the salt bin. The dietary food service manager stated that leftover food stored for later use should be discarded before the use-by date and that food in the danger zone of 40 degrees Fahrenheit to 140 degrees Fahrenheit should have been discarded.
A resident with incontinence, moderate cognitive impairment, and multiple medical diagnoses had two soiled briefs left on the floor in her room, along with trash on the floor and multiple bed pads in the trash bin. The resident said she usually left used briefs on the floor because staff would pick them up and that staff did not respond when she used the call light. Staff stated the expectation was for aides and EVS to complete regular rounds, keep rooms clean, and ensure items were not left on the floor.
A resident with dementia, dysphagia, malnutrition, and other serious diagnoses had a care plan that was not updated after assessment findings and a change in condition showed decreased appetite, pocketing food, lethargy, and inability to swallow medications. The chart showed mechanical soft/thin liquid diet orders, poor intake, and nutrition monitoring, but no revised IDT care plan reflecting the resident’s decline, despite SBAR documentation, nursing notes, and staff awareness of the change.
Failure to supervise a resident while smoking. A resident with diagnoses including epilepsy, weakness, and atrial fibrillation was observed leaving through the back door in a wheelchair, lighting his own cigarette, and smoking outside by himself despite care plan directions that he be supervised and that smoking paraphernalia be kept at the nurse’s station. Staff interviews confirmed residents were not allowed to smoke unsupervised and that smoking items were to be locked away and controlled by staff.
The facility was found deficient in food storage and dishwashing practices. Foods were stored past their use-by dates, and drinks were unlabeled, contrary to policy. The dish machine operated below required temperatures, and the Dietary Aide was inadequately trained, leading to improper sanitization. The Dietary Manager admitted to not conducting competency checks on staff.
A resident with a G-tube did not receive medications as per physician's orders and facility policy. An LVN administered undissolved powder medications directly into the G-tube, leading to a clogged syringe. The facility's policy required medications to be mixed with water before administration, which was not followed, resulting in a deficiency.
A facility failed to administer and document a crucial insulin injection for a resident with type 2 diabetes, leading to a deficiency in pharmaceutical services. Despite the resident's severe cognitive impairment and multiple health issues, the medication was not given or recorded on the specified date. Interviews with nursing staff revealed inconsistencies in documentation practices, with some staff reporting no issues with the electronic systems. The facility's policy mandates immediate documentation of medication administration, which was not followed in this case.
A resident with multiple health conditions was not properly documented for blood sugar levels, vital signs, or adverse drug effects during a shift. LVN A, responsible for the resident's care, failed to document in the electronic records, citing possible service issues. Other staff reported no system problems, highlighting the importance of documentation per facility policy.
The facility failed to accurately assess a resident's hearing loss and use of hearing aids, leading to an incomplete care plan. Despite progress notes indicating the resident had hearing aids, the Admission MDS assessment inaccurately reflected normal hearing. The resident reported poor hearing without his aids, and the DON could not explain the discrepancy.
Delayed Confirmation and Administration of New Antibiotic Order
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for a cognitively intact male resident with multiple diagnoses, including acute kidney failure, major depressive disorder, chronic pain syndrome, paraplegia, insomnia, muscle weakness, and Type 2 diabetes mellitus without complications. The resident’s physician order, entered by a Nurse Practitioner for Levaquin 500 mg PO at bedtime on 04/02/26 at 11:34 AM, was scheduled to begin that same night at 9:00 PM. However, the order was not confirmed in the electronic medical record until 12:39 AM on 04/03/26, and the first dose was not administered until bedtime on 04/03/26, resulting in a missed initial dose on 04/02/26. The LVN responsible for receiving the order on 04/02/26 reported not recalling receiving the order and was unaware that the medication required confirmation that day. The DON stated that physician orders entered into the EMR should be confirmed within two hours and acknowledged there was no justification for the delay in confirming this order. The Administrator similarly stated that orders entered into the EMR were expected to be confirmed within two hours and carried out as prescribed. The facility’s medication treatment administration and documentation policy directed staff to administer medications according to the physician order, which did not occur in this case, as the Levaquin was not administered as prescribed. The facility identified that this failure placed residents at risk of experiencing worsening conditions, infection, and further decline.
Delayed Confirmation of STAT Lab and Imaging Orders
Penalty
Summary
The facility failed to ensure timely processing and communication of STAT laboratory and imaging orders for a resident, resulting in delays in further medical assessment and treatment. The resident was an elderly female admitted with diagnoses including urinary tract infection, acute kidney failure, cognitive communication deficit, and delusional disorder. Her Quarterly MDS showed a BIMS score of 1, indicating severe cognitive impairment, and she required supervision and one-person assistance with multiple ADLs, including bed mobility, transfers, toileting, dressing, and personal hygiene. She was care planned for falls with interventions such as keeping the bed in the lowest position and using a fall mat. Record review showed a STAT laboratory test entered into the electronic medical record on one date at 10:21 a.m. was not confirmed until 1:30 p.m. by an LVN. In a separate incident, a NP reported issuing a STAT KUB imaging order at 10:29 a.m. on another date, which was not confirmed until 10:09 p.m., representing a significant delay in processing a STAT order. The administrator stated that STAT physician orders should be confirmed right away and acknowledged that the delay in confirming the STAT KUB order was not acceptable. The LVN involved stated she did not recall the NP issuing the STAT order and reported receiving a high volume of orders and not always being notified when orders were entered into the electronic medical record. The facility’s policy on STAT laboratory services outlined specific time frames for follow-up when a lab technician does not arrive, but the documented delays occurred at the order confirmation stage in the electronic medical record.
Inadequate Water Management Program for Legionella Prevention
Penalty
Summary
Provide and implement an infection prevention and control program was cited because the facility failed to establish and maintain an infection prevention and control program for all 89 residents. Record review showed the facility had an Infection Prevention and Control Program dated 11/06/2024 that stated a water management program had been established, control measures and testing protocols were in place, and the Maintenance Director served as the leader of the water management program. However, review of the facility's Legionnaires Monitoring Protocol dated 10/19/2015 showed the water management program did not consider the ASHRAE industry standard or the CDC toolkit. The facility did not have a risk assessment to identify where legionella could grow and spread in the water system, did not have procedures for using control measures, did not include control limits or parameters, did not specify environmental testing protocols for legionella, and did not establish ways to intervene when control limits were not met or when there was a case of healthcare-associated legionellosis. During interview, the Regional Director of Operations, IDON, and Maintenance Director stated they were not aware the LWMP was inadequate, and the Administrator stated the Water Management Program team should have established and maintained an adequate program.
Opened insulin pens were kept beyond the 28-day use limit
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when nurses did not date opened insulin glargine pens and did not discard them within 28 days of opening for 2 of 7 residents reviewed for medication storage and labeling. Resident #33 had an active order for insulin glargine 100 units/ml multiple-dose pen, 15 units SQ at bedtime for diabetes, and Resident #85 had an active order for insulin glargine 100 units/ml multiple-dose pen, 10 units SQ every 12 hours for diabetes. During an observation of Hall A's medication cart and interview, surveyors found two opened and dated insulin glargine pens kept in the medication cart beyond 28 days of the opening date. One pen belonged to Resident #33 and had been opened and dated on [DATE], and the second belonged to Resident #85 and had been opened and dated on [DATE]. An LVN stated nurses should check pen dates before each administration and discard them after 28 days of opening. The IDON stated nurses were expected to check insulin pen opening dates before each administration and discard them after 28 days of opening. The facility's Storage of Medications Policy stated opened drugs are acceptable to use until the manufacturer's expiration date unless the manufacturer specifies a usable duration after use, and the manufacturer's guide for insulin glargine pens stated opened pens must be thrown away after 28 days of first use.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5% during medication administration observations. Surveyors observed 26 medications administered with 3 errors, resulting in an 11.54% medication error rate for 3 of 7 residents reviewed. The deficiency involved Resident #41 and Resident #46, whose active polyethylene glycol 3350 orders did not specify how much water to use when mixing the powder, yet MA A mixed and attempted to administer the medication to both residents on observation dates without first obtaining clarification of the missing instructions. The deficiency also involved Resident #96, an [AGE]-year-old female with diagnoses including sepsis, respiratory failure, pneumonia, aphasia, and enlarged lymph nodes, and a BIMS score of 8 indicating moderate cognitive impairment. Her MAR showed an order for Vancomycin HCI IV solution 500 mg/100 mL every 12 hours for IV ABT related to pneumonia, but no flushing orders were documented. During observation, RN O administered the IV medication and flushed the line with 10 mL of 0.9% sodium chloride before and after the infusion. In interview, RN O stated she would obtain an order because there was no flushing order, and the IDON stated medication administration should follow the doctor order and that the flushing order should be verified before administering.
Food Storage and Labeling Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in 1 of 1 kitchen reviewed for food procurement. During observation on 2-17-26 at 7:45 AM, surveyors found two dialysis lunch bags with used-by dates of 2-11-26 and 2-13-26, a pan of corn niblets with no used-by date, a package of breakfast sausage with a used-by date of 2-14-26, a package of shredded cheese with no used-by date, and a package of sliced Swiss cheese with no used-by date. Surveyors also observed a case of frozen ground beef stored on the freezer floor, a pan of soft mechanical sausage at 130.1 degrees Fahrenheit in the steam table, and a scoop for the salt bin stored in the food bin. The dietary food service manager stated that leftover food stored for later use should be discarded prior to the use-by date and that leftover food in the danger zone of 40 degrees Fahrenheit to 140 degrees Fahrenheit should have been discarded.
Soiled Briefs Left on Floor in Resident Room
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable interior for Resident #91 by leaving two soiled briefs on the floor in the resident’s room on the 200 hall. Observation of the room also showed trash on the floor and multiple bed pads in the trash bin. Resident #91 was a female with diagnoses including lack of coordination, polyneuropathy, abnormal posture, absence of the left leg above the knee, congestive heart failure, anxiety, and major depressive disorder, and her MDS showed a BIMS score of 9, indicating moderate cognitive impairment. Her care plan identified her as incontinent of bowel and bladder and directed staff to check frequently for wetness and soiling and change as needed. During interview, Resident #91 stated she had just returned from the hospital, normally threw used briefs on the floor because staff would come pick them up, and said she had a problem with her hands and could not fold them. She also stated that when she pressed the call light, staff would not come, which was why she left the brief on the floor and cleaned herself up. Staff interviews stated the expectation was for aides and housekeeping to conduct rounds every two hours, clean up resident rooms, ensure nothing was left on the floor or in trash, and maintain cleanliness and infection control. The EVS staff member stated resident trash was emptied once daily and rooms were expected to be cleaned daily, including mopping and disinfecting.
Failure to Update Care Plan After Change in Condition and Assessment Findings
Penalty
Summary
The facility failed to ensure Resident #94’s comprehensive care plan was reviewed and revised by the interdisciplinary team after assessment findings and changes in condition were identified. The resident was a male with diagnoses including protein-calorie malnutrition, dysphagia, dementia, GERD, muscle weakness, epidural hemorrhage without loss of consciousness, and Alzheimer’s disease. His care plan, initiated on 07/15/2025, addressed a mechanical soft diet with thin liquids and nutritional/hydration risk, but it was not updated after later assessments and documented changes. The quarterly MDS showed severe cognitive impairment with a BIMS score of 01 and substantial/maximal assistance needed for eating. A nutrition assessment documented no added salt, mechanical soft texture, thin liquids, extensive assistance with eating, and oral intake of 26-50%, with monitoring for weight and meal intake. These nutrition findings were signed by the RD on 12/20/2025, but they were not updated into the care plan. The MAR also showed supplement and medication orders, including Med Plus 2.0 and medications that later were documented as unable to be swallowed, yet these changes were not reflected in the care plan. On 01/18/2026, an SBAR documented decreased appetite, pocketing food, and lethargy, and the resident’s condition was noted to have worsened. Subsequent progress notes documented poor appetite, weakness, lethargy, inability to swallow medications, and low oxygen and pulse before the resident expired on 01/21/2026. Interviews with the RD, NP, LVN, DON, ADMN, ST, and DOR showed that staff were aware of the resident’s decline or were expected to be notified through the change-in-condition process, but the record did not show updated diet recommendations, speech therapy follow-up, or revised care plan interventions after the assessment and change in condition. The facility policy stated that comprehensive care plans generated by MDS-CAAs were to be completed in the electronic system and that acute problems or changes in intervention or goals were to be developed or modified by nursing staff.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 23 residents reviewed, Resident #43. Resident #43 was identified as a male with diagnoses including intermittent explosive disorder, epilepsy, lack of coordination, weakness, muscle spasm, transient ischemic attack, and atrial fibrillation. His smoking evaluations varied over time, with one evaluation indicating he was dependent and required assist/supervision to smoke, another indicating he was independent and required no supervision, and a later evaluation again indicating he was dependent and required assist/supervision to smoke. Resident #43’s care plan identified him as a smoker at risk of injury and stated that all cigarettes, lighters, matches, and smoking paraphernalia were to be kept at the nurse’s station and that he was to be supervised while smoking on facility property. Despite this, on observation the resident was seen in his wheelchair exiting the back door with a cigarette in hand, going toward the end of the building past the no smoking sign, lighting his own cigarette with a lighter, and placing the lighter in his pocket while the cigarette remained lit. During the observation, the resident stated he was always smoking outside by himself. Staff interviews indicated residents were not allowed to smoke by themselves and were to be supervised, with smoking paraphernalia kept locked away and accessible only to staff. The LVN stated she was not aware the resident had gone out the unlocked back door to smoke until told by the surveyor, and the ADMN, ADON, IDON, CNA, and AD all stated residents were not to smoke unsupervised and that smoking paraphernalia was to be locked in a medication storage room or otherwise controlled by staff.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Foods were found stored past their use-by dates, with mandarin oranges and butterscotch pudding dated well beyond the recommended storage period. Additionally, a tray of drinks was found without proper labeling, which is against the facility's policy that requires all ready-to-eat foods to be labeled with preparation and use-by dates. The Dietary Manager admitted to not knowing the appropriate storage duration for these items and acknowledged that the drinks should have been labeled, attributing the oversight to a dietary staff member in training. Further deficiencies were noted with the facility's dishwashing practices. The low-temperature dish machine was observed operating below the required temperature for effective sanitization, with the wash cycle at 98 F and the rinse cycle at 104 F, contrary to the facility's policy that mandates a minimum of 120 F. The Dietary Aide responsible for operating the machine was found to be inadequately trained, as she was unaware of how to properly check and record the machine's temperature. The Dietary Manager confirmed that the aide had not been in-serviced on the dish machine's operation, despite her six years of employment, and had never conducted a competency check or audit on the staff's use of the dishwasher.
Failure in Proper Medication Administration via G-tube
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident with a gastrostomy tube (G-tube), specifically in the administration of medications. The resident, a male with a history of difficulty swallowing, dementia, and gastrostomy status, was observed receiving medications in a manner that did not comply with the physician's orders or facility policy. The Licensed Vocational Nurse (LVN) responsible for administering the medications poured dry powder medication directly into the resident's G-tube, followed by water, instead of mixing the medications with water as required. The resident's medical records indicated that medications should be crushed or opened and mixed with at least 5 milliliters of water before administration through the G-tube. Additionally, the G-tube was to be flushed with 10 to 15 milliliters of water between each medication. However, during the observation, the LVN continued to administer undissolved powder medication directly into the G-tube, which led to the syringe becoming clogged. This method was contrary to the facility's policy and the physician's orders, which were designed to prevent blockages and ensure the resident received the therapeutic effects of the medications. Interviews with the LVN and other staff members, including the Director of Nursing (DON), confirmed that the facility's procedure was not followed. The DON stated that medications should be dissolved in water before administration to prevent clogging of the G-tube. The LVN admitted to not following the correct procedure and acknowledged having been in-serviced on the proper method within the last 60 days. The facility's policy on medication administration via enteral tube feeding was clear in its requirements, yet the failure to adhere to these guidelines resulted in a deficiency in the care provided to the resident.
Failure in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the administration of a 6:30 am Lantus Solution-Insulin injection. This medication was crucial for managing the resident's type 2 diabetes, a condition that affects glucose metabolism. The resident, who had severe cognitive impairment and multiple health issues including hypertension, chronic kidney disease, and peripheral vascular disease, did not receive the prescribed insulin injection on the morning of June 8, 2024. This lapse in medication administration was not documented in the resident's electronic medical records, indicating a failure in both the administration and documentation processes. Interviews with the nursing staff revealed discrepancies in the documentation process. LVN A, who was responsible for administering the medication on the specified date, acknowledged the importance of following physician orders and documenting medication administration but could not explain the lack of documentation. She suggested there might have been an issue with the electronic system in the 500 hall area. However, other staff members, including LVN B and LVN C, reported no issues with the electronic systems during their shifts and emphasized the necessity of proper documentation to ensure continuity of care. The facility's policy on medication administration and documentation requires that medications be administered according to physician orders and documented immediately in the electronic medical records. The failure to document the administration of the insulin injection, as well as the absence of vital signs and adverse medication effect monitoring on the specified date, highlights a significant deficiency in the facility's pharmaceutical services. This deficiency could potentially place residents at risk for medication errors and adverse health outcomes.
Failure to Document Resident Care and Monitoring
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident, leading to incomplete and inaccurate documentation. Specifically, the facility did not document the resident's blood sugar levels, vital signs, or monitoring for adverse drug effects during a specific shift. The resident, who has a history of type 2 diabetes mellitus, hypertension, chronic kidney disease, and peripheral vascular disease, was not properly monitored or documented for various medical needs, including insulin therapy, anticoagulant monitoring, and catheter care. Interviews with staff revealed that LVN A, who was responsible for the resident's care during the shift in question, did not document the necessary medical information in the electronic medical records. LVN A acknowledged the importance of documentation and monitoring for adverse reactions but could not explain the lack of documentation, suggesting a possible issue with service in the area. However, other staff members, including LVN B and LVN C, reported no issues with the electronic systems and emphasized the critical nature of documentation in nursing practice. The facility's policy on medication and treatment administration requires immediate documentation following administration, and any medications or treatments not administered should be documented with a reason. The absence of documentation for the resident's care during the specified shift represents a significant deviation from these guidelines, potentially affecting the quality of care provided to the resident.
Inaccurate Assessment of Resident's Hearing Status
Penalty
Summary
The facility failed to complete an accurate assessment for a resident, specifically regarding the resident's hearing loss and use of hearing aids. The resident, an elderly male with a primary diagnosis of a left femur fracture and other conditions including diabetes type 2, anemia, and anxiety, was admitted to the facility. Despite progress notes indicating the resident had hearing aids in both ears, the Admission MDS assessment inaccurately reflected that the resident had normal hearing and did not use hearing aids. This discrepancy was further compounded by a care plan that noted a communication problem but did not specify the nature of the problem or include hearing aids as an intervention. During an interview, the resident reported poor hearing without his hearing aids and mentioned that one hearing aid was lost and the other had a dead battery. The Director of Nursing (DON) was unable to explain the inaccuracies in the MDS assessment, as the nurse responsible for MDS accuracy was on bereavement leave. The failure to accurately document the resident's hearing status and use of hearing aids placed the resident at risk of not receiving appropriate care and services to meet his needs.
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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.
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Nursing homes near Tomball
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Manor Of Tomball | 1.3 mi | ★★★★★ | 13 | 0 |
| Lawrence Street Health Care Center | 1.3 mi | ★★★★★ | 9 | 1 |
| The Heights Of Tomball | 1.9 mi | ★★★★★ | 0 | 0 |
| Willow Creek Lodge | 5.4 mi | ★★★★★ | 1 | 0 |
| The Broadmoor At Creekside Park | 6.8 mi | ★★★★★ | 11 | 1 |
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