Cycle 1
Health 2025-07-09 · Fire 2025-07-09
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Conroe, TX
The Brightpointe
3-star overall rating with 3-star inspections with $21,037 in total fines with 8 fire-safety deficiencies in the latest cycle
604 S Conroe Medical Dr, Conroe, TX
(936) 494-6600
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Purehealth
Operator or chain grouping
Approved since
2017-02-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 4 staffing / 5 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
0.62
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.66
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.32
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.29
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.50
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,269
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.74
Baseline 24.54% · Performance 22.11% · Measure score 2.74 · Achievement 0 · Improvement 2.74
Healthcare-associated infections
0.67
Baseline 7.39% · Performance 7.63% · Measure score 0.67 · Achievement 0.67 · Improvement 0
Total nurse turnover
2.38
Baseline 59.26% · Performance 53.93% · Measure score 2.38 · Achievement 2.38 · Improvement 1.05
Adjusted total nurse staffing
3.89
Baseline 4.25 hours · Performance 4.18 hours · Measure score 3.89 · Achievement 3.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.38% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 489 · Observed rate 8.79% · Lower 95% interval 7.32% |
| Discharge to community | 63.28% |
50.57%
12.7 pts better
|
Better than the National Rate · Eligible stays 522 · Observed rate 56.51% · Lower 95% interval 58.17% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 276 · Denominator 276 |
| Falls with major injury | 0.72% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 276 |
| Discharge self-care score | 56.19% |
53.69%
2.5 pts better
|
Numerator 109 · Denominator 194 |
| Discharge mobility score | 45.36% |
50.94%
5.6 pts worse
|
Numerator 88 · Denominator 194 |
| Pressure ulcers or injuries, new or worsened | 1.81% |
2.29%
0.5 pts better
|
Numerator 5 · Denominator 276 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 7.63% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 279 · Observed rate 8.6% · Lower 95% interval 5.5% |
| Staff COVID-19 vaccination coverage | 0.79% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 126 |
| Staff flu vaccination coverage | 19.25% |
42%
22.8 pts worse
|
Numerator 36 · Denominator 187 |
| Discharge function score | 60.82% |
56.45%
4.4 pts better
|
Numerator 118 · Denominator 194 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 96 · Denominator 96 |
| Transfer of health information to patient | 99.39% |
96.28%
3.1 pts better
|
Numerator 163 · Denominator 164 |
| Resident COVID-19 vaccinations up to date | 20.95% |
25.2%
4.2 pts worse
|
Numerator 31 · Denominator 148 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
3.3%
0.4 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
18.9%
8.4 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
10.8%
10.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
16.1%
0.6 pts worse
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.5%
0.6 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
0.8%
1.3 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.0% |
15.0%
5 pts better
|
19.8%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% |
| Percentage of long-stay residents with pressure ulcers | 12.2% |
4.2%
8 pts worse
|
5.1%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
89.7%
7.8 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 96.6% · Q3 97.0% · Q4 98.0% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
12.0%
2.1 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 10.2% · Expected 11.5% · 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 0.5% · Q2 0.0% · Q3 1.5% · Q4 2.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.9% |
88.0%
5.9 pts better
|
79.7%
14.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
25.9%
0.4 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 28.8% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-09
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-07-12
F · Potential for more than minimal harm
2025-07-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-07-12
F · Potential for more than minimal harm
2025-07-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-12
E · Potential for more than minimal harm
2025-07-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-07-12
E · Potential for more than minimal harm
2025-07-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-12
D · Potential for more than minimal harm
2025-07-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-12
D · Potential for more than minimal harm
2025-07-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-12
D · Potential for more than minimal harm
2025-07-09
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-07-12
F · Potential for more than minimal harm
2024-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-17
E · Potential for more than minimal harm
2024-05-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-05-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-01
D · Potential for more than minimal harm
2023-03-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-09
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-30
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 2024-05-31
E · Potential for more than minimal harm
2024-03-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-04-20
E · Potential for more than minimal harm
2024-03-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-20
E · Potential for more than minimal harm
2024-03-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-20
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 2024-04-20
D · Potential for more than minimal harm
2024-03-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-20
J · Immediate jeopardy
2023-09-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-22
J · Immediate jeopardy
2023-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-22
J · Immediate jeopardy
2023-09-21
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 2023-09-22
D · Potential for more than minimal harm
2023-09-21
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 2023-12-08
D · Potential for more than minimal harm
2023-09-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-03-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-07
Penalties and ownership
What sits behind the stars
$21,037
2023-09-21
Fine
Fine · fine $21,037
Fine
$0
2023-09-21
Payment Denial
Payment Denial · denial start 2023-10-19 · 50 days
50 day denial
Ownership
Ph Ops Of Conroe LLC
5% Or Greater Direct Ownership Interest · Organization
Bell, Kevin
5% Or Greater Indirect Ownership Interest · Individual
Bell, Kevin
Operational/Managerial Control · Individual
Bell, Kevin
Corporate Officer · Individual
Bgaf Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Campion, Robert
5% Or Greater Indirect Ownership Interest · Individual
Campion, Robert
Operational/Managerial Control · Individual
Campion, Robert
Corporate Officer · Individual
Dwight Mortgage Trust LLC
5% Or Greater Mortgage Interest · Organization
Fraser, Siobaughn
Operational/Managerial Control · Individual
Kccj1 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Lbei Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Punsalan, Tricia
Operational/Managerial Control · Individual
Ratzlaff, Casey
Operational/Managerial Control · Individual
Romney, Christopher
Operational/Managerial Control · Individual
Tx Nm Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Park Manor Of Conroe
Conroe, TX
5-star overall rating with 5-star inspections with $13,627 in total fines with 4 recent health deficiencies
#2
Woodland Manor Nursing and Rehabilitation
Conroe, TX
1-star overall rating with 2-star inspections with $21,530 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Conroe Health Care Center
Conroe, TX
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
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