Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Conroe Health Care Center during CMS and state inspections, most recent first.
A resident with severe immobility and cognitive impairment developed a stage 2 pressure ulcer after the facility failed to consistently implement and document standard preventive measures such as regular repositioning and use of positioning devices. Staff interviews and record reviews showed that necessary interventions were not in place prior to the ulcer's development, and documentation of care was incomplete.
The facility did not deliver mail to residents on Saturdays, as confirmed by interviews with alert and oriented residents and multiple staff members. Staff were unclear about who was responsible for weekend mail delivery, and the facility's practice was to hold Saturday mail until Monday, contrary to policy. This resulted in residents not receiving their mail in a timely manner.
Two residents were not accurately assessed in their quarterly MDS, with one resident's lower extremity contractures and another's use of corrective lenses not documented, despite clear evidence from care plans, staff interviews, and direct observation. Staff confirmed these omissions, which resulted in MDS records that did not reflect the residents' actual conditions.
Three residents did not have complete, person-centered care plans addressing all their needs. One resident's care plan lacked documentation of dietary interventions for low body weight, despite being underweight and receiving nutritional supplements. Two other residents with hypertension did not have care plans that included goals or interventions for blood pressure management, even though they were prescribed antihypertensive medications. Staff interviews confirmed these omissions were oversights.
Surveyors found that a resident's seizure medication was stored on a medication cart without an open date, and a bottle of Aspirin on another cart lacked a visible expiration date. Staff and the DON confirmed that medications must be labeled with open and expiration dates, and facility policy requires this information on all medication labels.
Surveyors found that food items in the kitchen freezer, including fully cooked chicken and cheese filling, breaded pork fritter patties, and lasagna sheet pasta, were stored in opened, unsealed, and undated packaging. Dietary staff confirmed the importance of resealing and dating food, and facility policy requires proper storage and date marking to prevent contamination.
A resident with impaired mobility and moderate cognitive impairment was not provided timely assistance with emptying his urinal, leading him to empty it himself into a cup and trash can at his bedside. Staff interviews revealed inconsistent practices and no set policy for urinal emptying frequency, resulting in the resident experiencing backflow and spills, and feeling uncomfortable and disrespected.
A resident with physical and cognitive impairments reported a dislodged bump rail with exposed nails and missing wall trim in her room, which had not been repaired despite her notifications to staff. The issue persisted for an extended period, and facility inspections failed to identify or address the deficiency, leaving the environment unsafe and not homelike.
A resident with a history of falls and impaired mobility reported a possible fall to a surveyor, but the DON did not initiate the required fall protocol, perform assessments, or document the event as per facility policy. No neuro checks or incident reports were completed, despite the facility's procedures for unwitnessed falls.
A resident with multiple health conditions and a history of falls was found with an unexplained bruise on her sternum. Staff interviews and record reviews revealed that the bruise was not documented in any incident or accident reports, and skin assessments failed to note its presence. The facility did not follow its own protocols for documenting and monitoring injuries of unknown origin.
Expired oral Vancomycin solutions for two residents who were no longer in the facility were found in the medication room refrigerator. An LVN confirmed the medications were expired and should have been removed after discharge. The DON stated that daily checks and immediate removal of medications for discharged residents were expected, but these procedures were not followed, resulting in expired medications remaining in the active supply.
Two residents were administered anti-hypertensive medications by a medication aide who used blood pressure and pulse readings taken 1.5 to 2 hours prior to medication administration, rather than immediately before as required by physician orders and facility policy. This practice was confirmed through observation, record review, and staff interviews, and involved residents with complex medical histories and specific medication hold parameters.
A med room insulin refrigerator was found to have a puddle of water with black, powdery mildew on the first shelf. An LVN confirmed that staff are expected to check and clean the fridge during temperature checks, and the DON stated that fridges should be cleaned and monitored every shift. Facility policy requires regular environmental monitoring and immediate correction of issues, but the presence of mildew indicated this was not done.
A resident on hospice care with chronic respiratory failure and COPD did not receive consistent oxygen therapy as prescribed. The resident removed her nasal cannula, and despite multiple staff members entering her room, it was not replaced for over three hours. The resident called out for help repeatedly without response, and was later found unresponsive. This deficiency was identified as an Immediate Jeopardy, indicating a serious risk to the resident's health and safety.
Failure to Implement Timely Pressure Ulcer Prevention Measures
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services to promote healing and prevent worsening of pressure sores for a resident who was at high risk due to immobility, cognitive impairment, and incontinence. Upon admission, the resident was bedbound, had contractures, and was dependent on staff for all aspects of care. Initial assessments documented redness to the coccyx area, but there was a lack of specific documentation regarding whether the area was blanchable or non-blanchable, and no clear follow-up was conducted to clarify or monitor this area of concern. Despite the resident's high risk for pressure ulcers, there were no documented orders for repositioning, turning, or the use of positioning pillows or wedges prior to the development of a stage 2 pressure ulcer. The care plan and order summary did not reflect timely implementation of standard interventions such as regular repositioning or the use of offloading devices. Documentation of bed mobility and repositioning was inconsistent and did not meet the facility's protocol for at-risk residents, with records showing infrequent repositioning events. Interviews with staff, including the admitting nurse, wound care nurse, and DON, revealed that standard preventive measures were expected but not consistently implemented or documented. The wound care nurse and DON both acknowledged that interventions such as diligent repositioning and the use of pillows or wedges should have been in place immediately upon admission. The lack of timely and consistent preventive interventions led to the resident developing a stage 2 pressure ulcer, which later progressed to stage 3, indicating a failure to provide necessary care to prevent pressure injuries.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail in a timely manner on Saturdays, as required. During a confidential group interview, all four alert and oriented residents interviewed reported that mail was not delivered on Saturdays. Multiple staff interviews revealed confusion and lack of clarity regarding who was responsible for delivering mail on weekends. The Administrator stated that the weekend receptionist and Managers on Duty (MODs) were responsible for mail delivery, but the Activities Director, HR staff, and Social Worker, all of whom served as MODs on alternating weekends, stated that delivering mail was not part of their assigned duties. Receptionists also reported that they did not deliver mail on weekends and that it was facility policy to hold Saturday mail for delivery on Monday. A review of the facility's policy on mail and electronic communication indicated that mail and packages should be delivered to residents within 72 hours of delivery, including Saturdays. Despite this policy, staff interviews confirmed that mail arriving on Saturdays was routinely held until Monday, resulting in residents not receiving their mail within the expected timeframe. The Administrator acknowledged that while there was no physical risk to residents, the failure to deliver mail on Saturdays could result in emotional distress.
Failure to Accurately Document Resident Assessments in MDS
Penalty
Summary
The facility failed to accurately assess and document the status of two residents during their quarterly Minimum Data Set (MDS) assessments. For one resident, the facility did not document lower extremity impairment, despite multiple sources of information indicating the presence of bilateral lower extremity contractures since admission. Observations showed the resident was bedbound with contracted knees, and both the admitting nurse and wound care nurse confirmed the contractures were present upon admission and had not changed. The resident's MDS, however, indicated no upper or lower extremity impairment, which was inconsistent with the resident's actual condition and care needs. For another resident, the facility failed to document the use of corrective lenses in the quarterly MDS. The resident's care plan noted impaired vision and the use of glasses due to glaucoma, and observations confirmed the resident wore glasses while reading. Despite this, the MDS stated the resident had impaired vision but did not use corrective lenses. The MDS nurse acknowledged that the resident wore glasses and that this should have been documented in the MDS and care plan. Interviews with facility staff, including the MDS nurse and DON, confirmed that the assessments were inaccurate and did not reflect the residents' actual conditions. The facility's policy requires that qualified staff conduct accurate assessments reflective of the resident's status at the time of assessment, but this was not followed in these cases. The failure to document these conditions in the MDS could result in an inaccurate description of the residents and their care needs.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required. For one resident with a history of high blood pressure, diabetes, kidney failure, and dementia, the care plan did not include any dietary orders or interventions, despite the resident being underweight and receiving a fortified diet and nutritional supplements. Observations and interviews confirmed that the resident was frail and underweight, and that interventions were in place and effective, but these were not documented in the care plan as required by facility policy. For two other residents with a diagnosis of hypertension, their care plans did not document goals or interventions related to blood pressure management, even though both were prescribed antihypertensive medications. Medical records showed that these residents had active diagnoses of hypertension and were receiving medications such as Amlodipine, Carvedilol, and Losartan. However, the care plans lacked any mention of hypertension management, goals, or interventions. Interviews with facility staff, including the MDS nurse and DON, revealed that the omission of dietary interventions and hypertension management from the care plans was an oversight. Staff acknowledged that care plans should include all relevant diagnoses and interventions to guide care, and that the absence of this information could result in staff not being aware of the residents' needs.
Failure to Properly Label and Store Medications on Medication Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards for one resident and two medication carts. Specifically, an open and in-use bottle of Oxcarbazepine liquid, prescribed for a resident with epilepsy and a seizure disorder, was found on the Front Hall Nursing Cart without an open date, despite manufacturer instructions requiring use within seven weeks of opening. The resident's care plan and physician orders confirmed the ongoing use of this medication for seizure management. Staff interviews confirmed that multidose containers should be labeled with the date opened to track expiration, and that medications without an open date should not be used. Additionally, on the Station 1 Med Cart, an open bottle of Aspirin 325 mg was found with no visible expiration date, as the date had been rubbed off. Staff interviews revealed that nursing staff are expected to check carts daily for expired or inappropriately labeled medications, and that medications without legible expiration dates should not be used. The Director of Nursing confirmed that all medications must have expiration dates and that multidose containers must be dated when opened. Facility policy also requires medication labels to include expiration dates and appropriate instructions.
Failure to Properly Store and Label Food in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During kitchen inspections, opened and unsealed bags of fully cooked chicken and cheese filling in flour tortillas, breaded pork fritter patties, and wavy lasagna sheet pasta were found in the freezer. These items were not labeled or dated, and the packaging was not resealed, contrary to food safety protocols. Interviews with the Dietary Manager and Dietician confirmed the importance of resealing and dating food to maintain freshness and prevent contamination. Review of facility policies also indicated requirements for proper storage and date marking to prevent food deterioration or contamination. The failure to follow these procedures was directly observed and acknowledged by dietary staff.
Failure to Timely Empty Urinal Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not emptying his urinal in a timely manner. The resident, an elderly male with muscle weakness, age-related debility, and Alzheimer's disease, required substantial assistance with toileting hygiene and was always continent. Observations revealed that the resident's urinal was often left partially full, and he reported that staff were slow to respond to his requests for assistance with emptying it. As a result, the resident was forced to empty the urinal himself into a cup and then into the trash can at his bedside, sometimes missing and causing spills, which led to staff being upset with him. Interviews with staff confirmed that there was no specific policy or frequency for emptying urinals, though both CNAs and nurses acknowledged it was their responsibility to do so when needed. Staff reported that urinals should be emptied to prevent backflow and contamination, but practices varied, and the resident's behavior of emptying his own urinal was not documented or addressed. The DON stated that urinals should be emptied when half full or less and that staff were expected to check on residents at least every two hours, but there was no formalized schedule or documentation of the resident's difficulties. Facility policies reviewed indicated that residents have the right to dignity and that staff should act upon information regarding resident preferences. However, the lack of timely assistance and failure to document or address the resident's need to have his urinal emptied resulted in the resident feeling uncomfortable and disrespected, as he had to manage the situation himself, sometimes resulting in spills and backflow during use.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment for a resident by not ensuring that the bump rail in the resident's room was properly attached to the wall and free of protruding nails, and by not replacing missing wall trim. The resident, a female with muscle weakness, lack of coordination, anxiety disorder, and mild intellectual disabilities, reported the issues to social services and the DON, but no corrective action was taken. She expressed that the room needed improvement and specifically pointed out the missing trim and dislodged bump rail with exposed nails, which she stated had been in this condition since she began living at the facility a year prior. Despite regular rounds and inspections reported by the Administrator and Maintenance Director, the dislodged bump rail and missing trim were not addressed. The Administrator and Maintenance Director both acknowledged that exposed nails from the bump rail posed a safety risk, but claimed the issue was not previously identified during their inspections. The facility's policy required regular monitoring and immediate correction of environmental issues, but the deficiency persisted, as confirmed by the resident's repeated reports and ongoing observations.
Failure to Initiate Fall Protocol After Suspected Resident Fall
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident identified as high risk for falls. The resident, an elderly female with muscle wasting and impaired mobility, had a history of falls and was on a care plan that included fall prevention interventions such as a low bed and fall mat. During a survey, the resident reported to the surveyor that she thought she had fallen the previous night, but was unsure if she had reported it to staff. The resident was observed to be alert, oriented, and without visible injuries at the time. Upon being notified by the surveyor of the suspected fall, the DON interviewed the resident, who stated the fall might have occurred in a dream. The DON did not initiate the facility's fall protocol, did not treat the event as an unwitnessed fall, and did not perform physical or neurological assessments. There was no documentation of a fall assessment, neuro checks, or incident report for the suspected fall in the resident's clinical records or progress notes for the relevant dates. Facility policy required that any fall, whether witnessed, reported, or presumed, be assessed, documented, and followed by appropriate notifications and interventions, including neuro checks for unwitnessed falls. The DON acknowledged in interviews that she did not follow these protocols after being informed of the suspected fall, and that this failure could place residents at risk for unidentified injuries and other complications.
Failure to Document and Monitor Unexplained Bruise
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for one resident who was reviewed for accidents and supervision. The resident, a female with a history of type 2 diabetes, right-sided paralysis, muscle weakness, difficulty walking, high blood pressure, and a history of falls, was found to have a dark purple bruise with a red edge on her sternum. The resident was unable to recall how the bruise occurred and denied any pain or recent falls. Multiple skin assessments conducted by the Wound Care Nurse over several weeks did not document the presence of a bruise on the sternum, and there was no incident or accident report related to this injury. Interviews with staff revealed that the bruise had been present for some time, but there was no documentation or clear understanding among staff regarding its origin. The LVN stated that the bruise was not documented in any accident or incident reports, and the Wound Care Nurse was unaware of the bruise on the sternum, having only followed a wound on the resident's neck. The DON confirmed that staff are expected to document new bruises and monitor them daily, but acknowledged that there was no documentation of the sternum bruise in the resident's chart. The DON attributed the lack of documentation to staff assuming the bruise was related to a previous fall, but the records did not support this conclusion. The facility's policy requires that all incidents and accidents, including unobserved injuries, be documented and assessed by licensed staff, with ongoing documentation until resolution. In this case, the failure to identify, document, and monitor the resident's sternum bruise represented a lack of adequate supervision and failure to follow established protocols for accident and injury management.
Expired Medications Not Removed from Medication Room
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring that expired oral Vancomycin solutions were removed from the Station 1 Medication Room refrigerator. During an inventory check, an open and in-use bottle of Vancomycin Oral Solution labeled 'Do Not Use After' a past date was found for one resident, and a sealed bottle with the same expiration date was found for another resident. Both residents were no longer in the facility, yet their medications remained in the medication room after their discharge. The LVN present confirmed that the medications were expired and should have been removed immediately after the residents' discharge. Interviews with the LVN and the DON revealed that nurses were expected to inspect medication rooms daily for expired medications and to remove all medications belonging to discharged residents. Facility policy required that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, and that all expired medications be removed from active supply and destroyed. Despite these policies, expired medications remained accessible in the medication room, indicating a failure to follow established procedures for medication storage and removal.
Failure to Obtain Timely Vital Signs Before Administering Anti-Hypertensives
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who were administered anti-hypertensive medications without proper assessment of their vital signs immediately prior to administration. Medication Aide B administered Amlodipine to both residents, and Losartan and Carvedilol to one resident, using blood pressure and pulse readings that had been obtained approximately 1.5 to 2 hours before the medication pass, rather than immediately before as required by physician orders and facility policy. Observations confirmed that the medication aide did not check the residents' blood pressure and pulse at the time of medication administration. One resident had a history of stroke, hypertension, heart disease, and other chronic conditions, and was ordered to receive Amlodipine with specific parameters to hold the medication if blood pressure or heart rate fell below certain thresholds. The other resident, with diagnoses including stroke, dementia, hypertension, and peripheral vascular disease, was ordered to receive multiple anti-hypertensive medications with similar hold parameters. In both cases, the medication aide relied on early morning vital signs rather than obtaining current readings, as confirmed by documentation and direct observation during the medication pass. Interviews with the medication aide, other nursing staff, the Director of Nursing, and the Medical Director revealed a consensus that blood pressure and pulse should be checked immediately prior to administering anti-hypertensive medications, in accordance with physician orders and best practice. The facility's policy also required vital signs to be obtained and recorded when applicable or per physician orders, specifically for medications requiring such monitoring. The failure to follow these procedures resulted in significant medication errors for the two residents reviewed.
Mildew Found in Insulin Refrigerator in Med Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the Station 1 Med Room, specifically regarding the insulin refrigerator. During an observation, a puddle of water with a black, powdery, flat growth resembling mildew was found on the first shelf of the insulin fridge. LVN E confirmed that nursing staff are expected to check the cleanliness of the insulin fridge when monitoring its temperature, and acknowledged that the presence of mildew or mold could lead to contamination. The DON stated that med rooms and refrigerators should be organized, cleaned, and monitored every shift, and that nurses and med aides are responsible for cleaning the fridge when moisture builds up. Review of the facility's policy indicated that environmental services are to be regularly monitored and any issues corrected immediately, but the presence of mildew in the fridge demonstrated a failure to follow these procedures.
Failure to Provide Consistent Oxygen Therapy
Penalty
Summary
The facility failed to provide consistent respiratory care to a resident who was on hospice and had a Do Not Resuscitate (DNR) order. The resident, who had a history of acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and heart failure, was not given continuous oxygen therapy as prescribed. The resident removed her nasal cannula, and despite multiple staff members entering her room, the nasal cannula was not replaced for over three hours. During this time, the resident repeatedly called out for help, but staff did not respond to her requests. Observations from video footage showed that the resident removed her nasal cannula at approximately 11:46 a.m., and it remained off until she was found unresponsive at 3:28 p.m. Several staff members entered and exited the room during this period without addressing the missing nasal cannula. The resident was observed gasping for air and calling out for help multiple times, yet no staff responded to her distress. Interviews with staff revealed a lack of awareness and monitoring of the resident's oxygen therapy needs, with some staff members unaware of the resident's requirement for continuous oxygen. The facility's failure to monitor and respond to the resident's oxygen therapy needs resulted in the resident being without necessary oxygen for an extended period. This deficiency was identified as an Immediate Jeopardy, indicating a serious risk to the resident's health and safety. The facility's policies on oxygen administration and quality care were not adhered to, leading to the resident's death without appropriate intervention.
Removal Plan
- Conduct an immediate physical assessment of all residents receiving oxygen therapy to verify device placement, functionality, and settings.
- Audit all records of residents with oxygen therapy orders to ensure each order matches the current oxygen delivery setup, including flow rates and frequency.
- Conduct an audit of all oxygen equipment to ensure functionality, clean cannulas, and confirm that oxygen tanks and concentrators are operational.
- Provide training to all nursing staff on the importance of promptly responding to resident calls and monitoring oxygen therapy.
- Require return demonstrations from staff on proper oxygen device placement, O2 concentrator operation and protocols for checking and monitoring residents.
- Schedule in-depth training sessions for all nursing and CNA staff on respiratory care, focusing on the monitoring and maintenance of oxygen therapy devices and prompt response protocols.
- Develop a resident monitoring log to be kept in each room, with sections for oxygen checks documented in resident's EHR.
- Conduct a QAPI meeting to review the incident, corrective actions, and policy updates.
- Schedule weekly audits to ensure compliance with oxygen monitoring and response protocols.
- Nurse A, B and CNA's B, C and D will receive 1:1 in servicing and a skills validation test.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 127 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Conroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodland Manor Nursing And Rehabilitation | 1.4 mi | ★★★★★ | 10 | 3 |
| The Brightpointe | 3.5 mi | ★★★★★ | 0 | 0 |
| Park Manor Of Conroe | 3.5 mi | ★★★★★ | 3 | 0 |
| Willis Nursing And Rehabilitation Lp | 7.1 mi | ★★★★★ | 9 | 0 |
| Park Manor Of The Woodlands | 8.5 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.