Park Manor Of Tomball
PARK MANOR OF TOMBALL in TOMBALL, TX — inspection on March 26, 2026.
Found 7 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
interview on 3/25/26 at 4:33 p.m. CNA H said he communicated with Resident #75. He said she spoke
complained of throat pain but had complained of pain to the side and butt. He said the resident would
DON said the facility had translation service.
She said Resident #75 was cognitive for the most part and was able to communicate basic needs such as the need to use the bathroom and pain.
She has called the family member to translate.
The family member had not reported a sore throat to the staff.
The DON said there were also communication boards but did not believe Resident #75 had one.
She said it was important to communicate effectively with the residents to ensure they were taken care of and their needs were met. In an interview on 3/25/26 at 4:53 p.m. the Administrator said staff used google translate and families to help translate. In an interview on 3/26/26 at 1:04 p.m. the MDS nurse said she was under the impression that Resident #75 understood English and that was why she coded it as her preferred language on the annual MDS.
She said the resident spoke single words in English and her needs were met.
She said she could update the MDS assessment.In an interview on 3/26/26 at 10:55 a.m. CNA W said Resident #75 spoke Vietnamese and he used hand signals to communicate with her. He said he was trained on using hand gestures to communicate with the resident and was going to ask about a chart with pictures but did not know where it was. He said she never communicated pain to him.
Record review of the facility's Resident rights policy revised October 2009 read in part, .1.
Federal and state laws guarantee certain basic rights to all residents of this facility.
These rights include the resident's right to: 1. Be informed about what rights and responsibilities he or she has;. 2.
Residents are entitled to exercise their rights and privileges to the fullest extent possible.
- Our facility will make every effort to assist each resident in exercising his/her rights to assure that
the resident is always treated with respect, kindness, and dignity.
676165 03/26/2026
Park Manor of Tomball 250 School Street Tomball, TX 77375
Identify the professional services that are responsible for each element of care.
676165 03/26/2026
Park Manor of Tomball 250 School Street Tomball, TX 77375
tube placement by drawing back on the syringe and that more than 100ml of residual would be too
continuous feedings and not for bolus feedings. LVN B stated she was nervous. LVN B stated she
#1 for nausea and vomiting. Resident #1 was observed to cough a few times and LVN B stated the cough was not new for Resident #1 because he had a history of PNA. LVN B stated the risk of not checking for placement of the tube, would be the tube may not be in the stomach and may be in another space in the abdomen which would not be where it should be. LVN B checked the exit site of the Gtube and said there was nothing unusual. LVN B palpated Resident #1's abdomen and stated it was soft. Resident #1 was not in any distress. LVN B replaced the abdominal binder . LVN B stated that when she started working full time on 01/12/2026, she had in-service on medication administration and Gtube at the time.In an interview on 03/25/26 at 10:00 AM, the DON stated it was the facility policy to check proper GT placement by drawing back on the syringe to check for residual fluids.
The DON stated she expected all nurses to check for placement before giving any medications or giving formula feedings.
The DON stated the nurses received in-services regarding care of the GT during skills checks in December 2025 and that LVN B may not have been part of the training as LVN B returned to work full time starting January 2026 .
Record review of the facility policy and procedure of Administering Medications through an Enteral Tube, revised on March 2015 read in part: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube.
Preparation: 1.
Verify that there is a physician's medication order for this procedure.Steps in the Procedure.18.
Confirm placement of feeding tube per physician's order. By aspirating stomach contents, if no residual is aspirated check for bowel sounds, bloating, vomiting and pain. If no changes are noted proceed to administer medications/formula. 19. If you suspect improper tube positioning, do not administer feeding or medication and notify the Physician.
676165 03/26/2026
Park Manor of Tomball 250 School Street Tomball, TX 77375
was received on 3/24/26 at 2:04PM.
Maintenance stated the bedrails would get loose from being used
DON stated it was the responsibility of the nursing staff to always make workorder notifications
every day would be another opportunity for staff to check bedrails.
The DON stated bedrails can become loose from wear and tear.
The DON stated the risk of loose bedrails would be injury to residents and that all bedrails were a potential for injury.
The DON stated moving forward, in-services on bedrails had been started.
Record review of logs for Ambassador Room Rounds dated 3/19/26 to 3/24/26 revealed there were no issues with Resident #14, or the environment of the resident's room.
The log checklist did not include bedrails.
Record review of the facility's Owner's Manual for the Long-Term Care Bed, revised 04/01/2018 read in part: .Quarterly inspection.inspect bed and rotating assist bars/rails bolts, if loose tighten and if missing replace.
Record review of the facility policy for Proper Use of Side Rails, revised on December 2007 read in part: The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms.10.
The resident will be checked periodically for safety relative to side rail use.
676165 03/26/2026
Park Manor of Tomball 250 School Street Tomball, TX 77375
would make that determination and give it. In an interview on March 26, 2026 at 10:05 am, LVN A,
that he will recheck it in an hour. If it is still out of range at that point he will give a PRN medication
86, LVN A stated that she is on dialysis and a lot of times her blood pressure is out of parameters so he keeps an eye on it. He said that when Resident 86?s blood pressure is high he rechecks it after an hour. LVN A said Resident 86 gets dialysis and scheduled medications for blood pressure so LVN A won't give PRN medication right then, but if it gets really high then LVN A will give it. In a telephone interview on March 26, 2026 at 11:31 am, MD C, stated that the order was not being followed if the PRN clonidine was not given when Resident #86's systolic blood pressure was over 150. He stated that the nurse should follow the order rather than make the decision if Resident #86 gets that medication or not. MD C said that he would review Resident #86's chart and may make Clonidine a scheduled medication in order to prevent a nurse from attempting to make that decision themselves .
In an interview on March 26, 2026 at 12:50 pm, the DON, stated that the expectations for staff are to take the resident's blood pressure, follow up in an hour by rechecking the blood pressure, and then give the PRN clonidine 0.1 mg if the blood pressure was still over 150 systolic.
She stated that a nurse should not neglect to give the PRN after a 1 hour recheck when the vital sign meets the required parameters for that medication.
Record review of the facility's policy for Administering Medications revised December 2012 read.Policy StatementMedications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation3.
Medications must be administered in accordance with the orders, including any required time frame.
Record review of the facilities policy for Emergency Medications Revised April 2007 read.Policy StatementThe facility shall maintain a supply of medications typically used in emergencies.Policy Interpretation and ImplementationThe emergency medication kit will include medications and biologicals that are essential in providing emergency treatment.
Record review of the facility policy for Administering Medications, revised December 2012, read in part: .Medications shall be administered in a safe and timely manner, and as prescribed.
Policy Interpretation and Implementation.3.
Medications must be administered in accordance with the orders, including any required time frame.7.
The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medications.
676165 03/26/2026
Park Manor of Tomball 250 School Street Tomball, TX 77375
During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide.No medications are kept on top of the cart.
The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.24.
Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.
Record review of the facility policy for Storage of Medications, revised on April 2007 read in part: .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.
676165 03/26/2026
Park Manor of Tomball 250 School Street Tomball, TX 77375
serve food in accordance with professional standards.
serve food in accordance with professional standards for food service safety reviewed for 1 of 5
appropriate hair nets while in the kitchen and food was being prepared.This failure had the potential to contaminate food and affect residents' health and safety.
Findings included:During an observation and interview on 03/24/2026 at 8:11 am the Dietary Manager was cleaning the kitchen floors without wearing a hairnet.
The Dietary Manager stated she had just returned from bringing the water hose inside to clean the floors.
She stated she knew she should have word a hairnet due to the risk of hair contaminating food.
During an interview with the Administrator on 03/25/2026 at 8:30am The Administrator stated that staff are expected to wear hairnets immediately upon entering the kitchen.
The Administrator stated that failure to wear hairnets poses a risk for food contamination.
Record review of the facilities policy for Staff Hygienic Dress Code Policy Statement undated, read.Policy StatementThis policy mandates that all employees adhere to an approved dress code tailored for their specific job functions to ensure safety, hygiene, and professionalism.Dress Code GuidelinesHair and Facial Hair: Staff must keep hair tied back or off shoulders and secured under a hair net or cap.
Facial hair should also be neatly restrained to prevent contamination.