Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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The facility did not update or post daily nurse staffing information as required, leaving the Direct Care Report outdated on multiple occasions.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.
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.
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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) |
|---|---|---|---|---|
| Lawrence Street Health Care Center | 0.4 mi | — | 0 | 0 |
| 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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