Park Manor Of Tomball
PARK MANOR OF TOMBALL in TOMBALL, TX — inspection on November 24, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. 4.
The administration will keep a copy of written reports on file.
Record review of the facility policy tilted Abuse Investigation revised 04/2010 revealed, no instructions on how to investigate or report drug diversion.
Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances.
Policy Interpretation and Implementation: 1.
Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3.
Controlled substances must be counted upon delivery.
The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together.
Both individuals must sign the designated controlled substance record. 5.
Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications.
This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7.
The Charge Nurse on duty will maintain the keys to controlled substance containers.
The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers.
Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1.
All staff shall follow a consistent procedure in accepting medications. 2.
Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services.
Policy Interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2.
Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt. 4. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket.
Both the receiving nurse and the delivery agent must sign any notations about errors. 5.
The delivery ticket shall be archived in a designated location. 6.
The dispensing pharmacy, consultant pharmacist, and Director of Nursing Services shall be not[TRUNCATED]
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Manor of Tomball
250 School Street Tomball, TX 77375
SUMMARY STATEMENT OF DEFICIENCIES
revised 04/2010 revealed, no instructions on how to investigate or report drug diversion.
Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances.
Policy Interpretation and Implementation: 1.
Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3.
Controlled substances must be counted upon delivery.
The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together.
Both individuals must sign the designated controlled substance record. 5.
Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications.
This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7.
The Charge Nurse on duty will maintain the keys to controlled substance containers.
The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers.
Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1.
All staff shall follow a consistent procedure in accepting medications. 2.
Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services.
Policy Interpretation and Implementation: 1. A nurse shall personally accept each[TRUNCATED]
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Manor of Tomball
250 School Street Tomball, TX 77375
SUMMARY STATEMENT OF DEFICIENCIES
minimal harm
responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 3.
Shift staffing information shall be recorded on the Daily Nursing Hours Posting form for each shift.
The information recorded on the form shall include: a.
The name of the facility. b.
The date for which the information is posted. c.
The resident census at the beginning of the shift for which the information is posted. d.
Twenty-four (24)-hour shift schedule operated by the facility. e.
The shift for which the information is posted. f.
Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g.
The actual time worked during that shift for each category and type of nursing staff. h.
Total number of licensed and non-licensed nursing staff working for the posted shift. 5.
Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form.
The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Manor of Tomball
250 School Street Tomball, TX 77375
SUMMARY STATEMENT OF DEFICIENCIES
Policy Interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2.
Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt. 4. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket.
Both the receiving nurse and the delivery agent must sign any notations about errors. 5.
The delivery ticket shall be archived in a designated location. 10.
The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings.
Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances.
Policy Interpretation and Implementation: 1.
Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3.
Controlled substances must be counted upon delivery.
The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together.
Both individuals must sign the designated controlled substance record.
- Controlled substances must be stored in the medication room in a locked container, separate from
containers for any non-controlled medications.
This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7.
The Charge Nurse on duty will maintain the keys to controlled substance containers.
The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Manor of Tomball
250 School Street Tomball, TX 77375
SUMMARY STATEMENT OF DEFICIENCIES
brought to the attention of the Pharmacist and Director of Nursing Services.
Policy Interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2.
Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt. 4. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket.
Both the receiving nurse and the delivery agent must sign any notations about errors.
- The delivery ticket shall be archived in a designated location. 6.
The dispensing pharmacy, consultant pharmacist, and Director of Nursing Services shall be notified of medication order errors. 10.
The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. 11.
The Director of Nursing Services shall consult with the provider pharmacy and the Administrator to determine whether any further legal action is indicated. 12. In the event there is concern about controlled substances being discharged with the resident and/or resident's representative, the Attending Physician may choose not to discharge the resident with those medications. 13.
The Director of Nursing Services shall maintain and disseminate to appropriate individuals a list of personnel who have access to medication storage areas and controlled substance containers.
Record review of the facility policy titled Storage of Medication revised 04/2007 revealed, Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 2.
The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 7.
Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances.
Policy Interpretation and Implementation: 1.
Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3.
Controlled substances must be counted upon delivery.
The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together.
Both individuals must sign the designated controlled substance record. 5.
Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications.
This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7.
The Charge Nurse on duty will maintain the keys to controlled substance containers.
The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers.
Facility ID: