Cycle 1
Health 2024-03-28 · Fire 2024-03-28
3 health deficiencies
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Tomball, TX
The Heights Of Tomball
3-star overall rating with 3-star inspections with $21,908 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
27840 Johnson Road, Tomball, TX
(832) 843-7700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
131
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Touchstone Communities
Operator or chain grouping
Approved since
2013-12-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.22% · Performance 22.65% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.25% · Performance 7.92% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 62.00% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.15 hours · Performance 3.17 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.2% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 204 · Observed rate 12.25% · Lower 95% interval 8.21% |
| Discharge to community | 45.37% |
50.57%
5.2 pts worse
|
No Different than the National Rate · Eligible stays 208 · Observed rate 37.98% · Lower 95% interval 39.01% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.99% |
95.27%
1.7 pts better
|
Numerator 129 · Denominator 133 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 1 · Denominator 133 |
| Discharge self-care score | 57.75% |
53.69%
4.1 pts better
|
Numerator 41 · Denominator 71 |
| Discharge mobility score | 25.35% |
50.94%
25.6 pts worse
|
Numerator 18 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 1.5% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 133 · Adjusted rate 1.48% |
| Healthcare-associated infections requiring hospitalization | 7.92% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 131 · Observed rate 9.92% · Lower 95% interval 5.21% |
| Staff COVID-19 vaccination coverage | 2.8% |
8.2%
5.4 pts worse
|
Numerator 4 · Denominator 143 |
| Staff flu vaccination coverage | 4.74% |
42%
37.3 pts worse
|
Numerator 40 · Denominator 843 |
| Discharge function score | 42.25% |
56.45%
14.2 pts worse
|
Numerator 30 · Denominator 71 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 50 · Denominator 50 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 53 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 6.06% |
25.2%
19.1 pts worse
|
Numerator 4 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
2.1
1.4 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 4.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.3%
0.6 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.1% · Q3 5.6% · Q4 3.5% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.8% |
18.9%
13.1 pts better
|
19.6%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.7% · Q3 4.9% · Q4 5.3% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
10.8%
0.8 pts worse
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 10.6% · Q3 10.3% · Q4 11.8% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.6% |
15.4%
10.8 pts better
|
16.3%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.2% · Q4 8.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.2% |
16.1%
8.9 pts better
|
14.9%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 4.8% · Q3 5.4% · Q4 5.6% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.8% |
15.0%
0.8 pts worse
|
19.8%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 15.6% · Q3 19.6% · Q4 13.4% · 4Q avg 15.8% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.2%
1.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.9% · Q3 1.8% · Q4 1.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
89.7%
8.4 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 97.7% · Q3 98.2% · Q4 98.5% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
12.0%
1.9 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 11.5% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
88.0%
6.6 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
25.9%
0.3 pts better
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 33.3% · Expected 31.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-20 · Fire 2023-01-20
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-10-28 · Fire 2021-10-28
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-02
E · Potential for more than minimal harm
2023-01-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-20
E · Potential for more than minimal harm
2021-10-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-11
Inspection history
Recent health citations
J · Immediate jeopardy
2025-05-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-10
K · Immediate jeopardy
2024-12-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-03-28
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-03-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-02
D · Potential for more than minimal harm
2023-08-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-05-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-01-20
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-20
D · Potential for more than minimal harm
2021-10-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-11-11
D · Potential for more than minimal harm
2021-10-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-11-11
Penalties and ownership
What sits behind the stars
$8,281
2025-05-12
Fine
Fine · fine $8,281
Fine
$13,627
2024-12-03
Fine
Fine · fine $13,627
Fine
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Baidoo, Joseph
Operational/Managerial Control · Individual
Boening, Christopher
Operational/Managerial Control · Individual
Campbell, Leslie
Operational/Managerial Control · Individual
Castillo, Lynnea
Operational/Managerial Control · Individual
Keybank National Association
5% Or Greater Mortgage Interest · Organization
Maire, Sanikqa
Operational/Managerial Control · Individual
Sehlke, Bryon
Operational/Managerial Control · Individual
Stratton, Charles
Corporate Officer · Individual
Touchstone Strategies - Tomball LLC
Operational/Managerial Control · Organization
Zurovec, Darrell
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Park Manor Of Tomball
Tomball, TX
1-star overall rating with 2-star inspections with $21,645 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Lawrence Street Health Care Center
Tomball, TX
4-star overall rating with 4-star inspections with $12,740 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Tomball Rehab & Nursing
Tomball, TX
3-star overall rating with 3-star inspections with $110,495 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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