Conroe, TX

Conroe Health Care Center

2-star overall rating with 2-star inspections with $12,860 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

2019 N Frazier, Conroe, TX

(936) 441-2120

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

108

Certified beds

Average residents

82

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Health Services Management

Operator or chain grouping

Approved since

1996-11-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

16 facilities

Chain averages 3 overall / 3 health / 3 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

0.52

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.13

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.24

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.89

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.64

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.57

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.48

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.53

CMS adjusted RN staffing hours

Adjusted total hours

3.97

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

47%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,949

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

34.49

Composite VBP score used to determine payment impact.

Payment multiplier

0.9884

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.50

Baseline 23.54% · Performance 21.59% · Measure score 2.50 · Achievement 0 · Improvement 2.50

Healthcare-associated infections

5.76

Baseline 11.44% · Performance 7.41% · Measure score 5.76 · Achievement 1.43 · Improvement 5.76

Total nurse turnover

3

Performance 51.43% · Measure score 3 · Achievement 3 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

2.55

Baseline 4.12 hours · Performance 3.80 hours · Measure score 2.55 · Achievement 2.55 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	14.52%	10.72% 3.8 pts worse	Worse than the National Rate · Eligible stays 98 · Observed rate 22.45% · Lower 95% interval 11.04%
Discharge to community	39.27%	50.57% 11.3 pts worse	No Different than the National Rate · Eligible stays 95 · Observed rate 29.47% · Lower 95% interval 28.85%
Medicare spending per beneficiary	1.24	1.02 0.2 pts worse
Drug regimen review with follow-up	98.25%	95.27% 3 pts better	Numerator 56 · Denominator 57
Falls with major injury	3.51%	0.77% 2.7 pts worse	Numerator 2 · Denominator 57
Discharge self-care score	42.86%	53.69% 10.8 pts worse	Numerator 12 · Denominator 28
Discharge mobility score	46.43%	50.94% 4.5 pts worse	Numerator 13 · Denominator 28
Pressure ulcers or injuries, new or worsened	3.57%	2.29% 1.3 pts worse	Numerator 2 · Denominator 56 · Adjusted rate 2.69%
Healthcare-associated infections requiring hospitalization	7.41%	7.12% 0.3 pts worse	No Different than the National Rate · Eligible stays 67 · Observed rate 8.96% · Lower 95% interval 4.38%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 89
Staff flu vaccination coverage	47.37%	42% 5.4 pts better	Numerator 45 · Denominator 95
Discharge function score	57.14%	56.45% 0.7 pts better	Numerator 16 · Denominator 28
Transfer of health information to provider	92.59%	95.95% 3.4 pts worse	Numerator 25 · Denominator 27
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	6.45%	25.2% 18.8 pts worse	Numerator 2 · Denominator 31

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.4	2.1 0.3 pts worse	1.9 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.4 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	2.1 1.3 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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	2.7%	3.3% 0.6 pts better	3.3% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.5% · Q3 1.6% · Q4 3.1% · 4Q avg 2.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.7%	2.7% 5 pts worse	11.4% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 13.3% · Q3 5.7% · Q4 8.2% · 4Q avg 7.7%
Percentage of long-stay residents who lose too much weight	7.3%	3.3% 4 pts worse	5.4% 1.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.4% · Q3 16.7% · Q4 3.5% · 4Q avg 7.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	25.4%	18.9% 6.5 pts worse	19.6% 5.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 27.6% · Q3 26.8% · Q4 20.0% · 4Q avg 25.4%
Percentage of long-stay residents who received an antipsychotic medication	15.5%	10.8% 4.7 pts worse	16.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 16.7% · Q3 17.4% · Q4 12.5% · 4Q avg 15.5% · 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	14.8%	15.4% 0.6 pts better	16.3% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.4% · 4Q avg 14.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.7%	16.1% 5.4 pts better	14.9% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.9% · Q3 8.3% · Q4 7.3% · 4Q avg 10.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	0.8% 0.4 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.4%	15.0% 4.4 pts worse	19.8% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 30.0% · Q3 16.2% · Q4 13.5% · 4Q avg 19.4%
Percentage of long-stay residents with pressure ulcers	6.5%	4.2% 2.3 pts worse	5.1% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.7% · Q3 6.7% · Q4 7.7% · 4Q avg 6.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.9%	89.7% 6.2 pts better	81.7% 14.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 95.6% · Q3 95.3% · Q4 98.4% · 4Q avg 95.9%
Percentage of short-stay residents who had an outpatient emergency department visit	5.8%	12.0% 6.2 pts better	12.0% 6.2 pts better	Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 6.8% · Expected 13.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.1%	1.5% 0.4 pts better	1.6% 0.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 1.5% · Q4 1.9% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	95.2%	88.0% 7.2 pts better	79.7% 15.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.3%	25.9% 4.4 pts worse	23.9% 6.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 37.0% · Expected 29.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-11 · Fire 2025-04-11

13 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-02-01 · Fire 2024-02-01

4 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-11-09 · Fire 2022-11-09

3 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-11

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-05-05

E · Potential for more than minimal harm 2025-04-11

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-02

F · Potential for more than minimal harm 2024-02-01

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-02-23

F · Potential for more than minimal harm 2024-02-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-02-21

E · Potential for more than minimal harm 2024-02-01

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-02-21

C · Minimal harm 2024-02-01

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-02-26

E · Potential for more than minimal harm 2022-11-09

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-11-16

E · Potential for more than minimal harm 2022-11-09

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2022-11-24

Inspection history

Recent health citations

G · Actual harm 2025-04-11

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-05-02

F · Potential for more than minimal harm 2025-04-11

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-04-11

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-04-11

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 2025-05-02

E · Potential for more than minimal harm 2025-04-11

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-05-02

E · Potential for more than minimal harm 2025-04-11

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-05-02