CONROE HEALTH CARE CENTER

Nursing Home Inspector

2019 N FRAZIER
CONROE, TX 77301
Montgomery County
Phone: 936-441-2120
Provider Number: 675648
Last Inspection: 12/15/2016

About the Nursing Home

Number of Beds: 108
Number of Residents: 70
Beds Available: 38
Percent Occupancy: 65%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

8

Facility
19

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

8

2016
25

2016
0

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

12/15/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that special or therapeutic diets are ordered by the attending doctor. Pattern : Minimal 4 1/2/2017
 
Failed To: Put firmly secured handrails on each side of hallways. Pattern : Minimal 4 1/2/2017
 

1/28/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 2/26/2016
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Pattern : Minimal 4 2/26/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 2/26/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 2/19/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 2/26/2016
 
Failed To: Put firmly secured handrails on each side of hallways. Pattern : Minimal 4 2/1/2016
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

5/15/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Immediate 6 6/9/2017
 
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Pattern : Immediate 6 6/9/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Immediate 6 6/9/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Immediate 6 6/9/2017
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Pattern : Immediate 6 6/9/2017
 

4/7/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 4/10/2017
 

11/5/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 11/28/2016
 

9/21/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide routine and 24-hour emergency dental care for each resident. Isolated : Minimal 3 10/5/2016
 

4/12/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 5/9/2016
 
Failed To: Give or get x-rays and other tests in a timely manner to meet the needs of residents. Isolated : Actual 4 5/6/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 70 78.60 75.11
Registered Nurses 0.61 0.56 0.59
Licensed Practical / Vocational Nurses 1.16 0.80 0.94
Certified Nursing Assistants 2.03 2.00 2.20
Total Staff Hours 3.79 3.35 3.73

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
of high risk long-stay residents with pressure ulcers 6 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 90 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 90 92
of long-stay residents experiencing one or more falls with major injury 11 3 3
of long-stay residents who have depressive symptoms 12 3 3
of long-stay residents who lose too much weight 6 6 5
of long-stay residents who received an antianxiety or hypnotic medication 26 24 26
of long-stay residents who received an antipsychotic medication 8 15 17
of long-stay residents who self-report moderate to severe pain 4 2 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 22 20 20
of long-stay residents whose need for help with daily activities has increased 16 16 18
of long-stay residents with a catheter inserted and left in their bladder 4 2 2
of long-stay residents with a urinary tract infection 9 3 3
of low risk long-stay residents who lose control of their bowels or bladder 46 49 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 90 72 77
of short-stay residents who had an outpatient emergency department visit 18 13 13
of short-stay residents who made improvements in function 60 59 59
of short-stay residents who newly received an antipsychotic medication 2 1 2
of short-stay residents who self-report moderate to severe pain 9 8 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 85 69 74
of short-stay residents who were rehospitalized after a nursing home admission 23 27 23
of short-stay residents who were successfully discharged to the community 31 34 46
of short-stay residents with pressure ulcers that are new or worsened 2 0 0