Cycle 1
Health 2025-01-15 · Fire 2025-01-15
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Baytown, TX
Rollingbrook Rehabilitation And Healthcare Center
3-star overall rating with 4-star inspections with $23,676 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
750 Rollingbrook Dr, Baytown, TX
(832) 572-7575
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
92
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Momentum Skilled Services
Operator or chain grouping
Approved since
2018-03-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 1 staffing / 3 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
0.22
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.10
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
0.23
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
80%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,535
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.24% · Performance 21.44% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.47% · Performance 8.58% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 58.54% · Performance 75.76% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.58
Baseline 3.15 hours · Performance 3.53 hours · Measure score 1.58 · Achievement 1.58 · Improvement 0.93
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 174 · Observed rate 12.07% · Lower 95% interval 7.78% |
| Discharge to community | 54.84% |
50.57%
4.3 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 45.95% · Lower 95% interval 47.39% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 72.81% |
95.27%
22.5 pts worse
|
Numerator 83 · Denominator 114 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 114 |
| Discharge self-care score | 58% |
53.69%
4.3 pts better
|
Numerator 29 · Denominator 50 |
| Discharge mobility score | 48% |
50.94%
2.9 pts worse
|
Numerator 24 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 6.14% |
2.29%
3.8 pts worse
|
Numerator 7 · Denominator 114 · Adjusted rate 5.88% |
| Healthcare-associated infections requiring hospitalization | 8.58% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 11.22% · Lower 95% interval 5.71% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 127 |
| Staff flu vaccination coverage | 13.53% |
42%
28.5 pts worse
|
Numerator 23 · Denominator 170 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 30 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 74 · Denominator 74 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 11.9% |
25.2%
13.3 pts worse
|
Numerator 5 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.5 · 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 | 1.4% |
3.3%
1.9 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
3.3%
2.4 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
18.9%
5.5 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 15.0% · Q3 12.7% · Q4 10.3% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
10.8%
7.1 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.7% · Q3 5.5% · Q4 0.0% · 4Q avg 3.7% · 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 | 7.1% |
15.4%
8.3 pts better
|
16.3%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 14.5% · Q3 8.2% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
16.1%
6.9 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 6.9% · Q3 11.5% · Q4 10.7% · 4Q avg 9.2% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 2.6% |
15.0%
12.4 pts better
|
19.8%
17.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.0% · Q3 4.2% · Q4 1.5% · 4Q avg 2.6% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.2%
1.7 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.2% · Q3 6.4% · Q4 5.3% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
89.7%
8.8 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 98.7% · Q3 98.7% · Q4 98.9% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.5% |
12.0%
5.5 pts worse
|
12.0%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 18.0% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.4% |
88.0%
11.4 pts better
|
79.7%
19.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.3% |
25.9%
5.4 pts worse
|
23.9%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 34.4% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-17 · Fire 2023-11-17
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
10 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-15
E · Potential for more than minimal harm
2023-11-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-20
D · Potential for more than minimal harm
2022-08-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-15
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 2025-01-31
D · Potential for more than minimal harm
2025-01-15
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-01-31
J · Immediate jeopardy
2023-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-12
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 2024-01-05
E · Potential for more than minimal harm
2023-11-17
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 2023-12-15
D · Potential for more than minimal harm
2023-11-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-10-06
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 2023-10-26
D · Potential for more than minimal harm
2023-03-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-03-08
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 2023-03-22
E · Potential for more than minimal harm
2022-08-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-15
E · Potential for more than minimal harm
2022-08-18
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 2022-09-28
D · Potential for more than minimal harm
2022-08-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-09-15
Penalties and ownership
What sits behind the stars
$23,676
2023-11-17
Fine
Fine · fine $23,676
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Broad River Healthcare, LLC
5% Or Greater Mortgage Interest · Organization
Compton, Charles
5% Or Greater Mortgage Interest · Individual
Compton, James
5% Or Greater Mortgage Interest · Individual
Compton, Kris
5% Or Greater Mortgage Interest · Individual
Harris Lt Investments, LLC
5% Or Greater Mortgage Interest · Organization
Martel Healthcare Management LLC
5% Or Greater Mortgage Interest · Organization
Martel, Michael
5% Or Greater Mortgage Interest · Individual
Rollingbrook Rehab LLC
Operational/Managerial Control · Organization
The Smithers Management Trust
5% Or Greater Mortgage Interest · Organization
Thompson, Johnny
Corporate Officer · Individual
Threadgill, Sharlyn
Operational/Managerial Control · Individual
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