Federal inspectors found the 250 School Street facility ignored multiple steps required by law when receiving Schedule II drugs like morphine and fentanyl. The violations create opportunities for drug diversion and put residents at risk of not receiving prescribed pain medications.
The facility's own policy, revised in December 2012, explicitly states that controlled substances "must be counted upon delivery" with both the receiving nurse and delivery person signing off together. Inspectors found this wasn't happening.
Instead of the required two-person count, nurses were accepting narcotic deliveries without proper verification. The policy requires the receiving nurse and delivery agent to "count the controlled substances together" and both sign the designated record.
The facility also failed to follow its medication delivery procedures. Policy requires a nurse to "personally accept each medication delivery" and reconcile all medications with the delivery ticket before signing. Nurses must keep copies of delivery tickets and archive them in a designated location.
These weren't isolated oversights. The inspection revealed a pattern of nurses skipping required safety steps designed to prevent controlled substances from going missing.
Federal law treats Schedule II drugs differently because of their high potential for abuse and addiction. Morphine, oxycodone, fentanyl and similar medications require the strictest handling procedures in nursing homes.
The facility's controlled substance policy acknowledges this reality, stating it "shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances."
Only authorized licensed nursing and pharmacy personnel should have access to these drugs. The policy requires controlled substances be stored in locked containers, separate from other medications, with containers remaining locked except when accessing resident medications.
Charge nurses on duty are supposed to maintain keys to controlled substance containers, with the Director of Nursing Services keeping backup keys for all medication storage areas.
The policy also requires the Director of Nursing Services to investigate any discrepancies in narcotics reconciliation. When controlled substances don't match delivery records, the director must determine the cause, identify responsible parties, and provide a written report to the administrator.
But the inspection found nurses weren't following the initial counting requirements that would catch discrepancies in the first place.
Proper narcotic handling protects both residents and staff. When nurses skip required counts and documentation, controlled substances can disappear without anyone knowing until it's too late. Residents depending on these medications for pain management suffer when doses go missing.
The violations also expose the facility to federal penalties. The Drug Enforcement Administration can impose severe sanctions on nursing homes that fail to properly secure controlled substances, including suspension of their license to handle these medications.
Park Manor of Tomball operates under facility ID 676165 and completed this inspection on November 24, 2025. The complaint-driven inspection focused specifically on medication handling procedures after concerns were raised about the facility's practices.
The facility's December 2012 controlled substance policy shows management understood the requirements. The policy clearly outlines each step nurses must take when receiving, counting, and storing narcotic medications.
Yet inspectors found nurses weren't following these established procedures. The gap between written policy and actual practice suggests either inadequate staff training or insufficient oversight by nursing supervisors.
Controlled substance violations can escalate quickly in nursing homes. What starts as sloppy counting procedures can lead to missing medications, resident harm, and criminal investigations when drugs are diverted for personal use or sale.
The inspection classified this as causing "minimal harm or potential for actual harm" affecting "few" residents. But narcotic control violations often have consequences that extend beyond immediate resident safety, potentially affecting the facility's ability to provide adequate pain management for all residents who need these medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Manor of Tomball from 2025-11-24 including all violations, facility responses, and corrective action plans.