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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

0.22

Registered nurse staffing

LPN hours / resident day

1.20

Licensed practical nurse staffing

Aide hours / resident day

2.06

Nurse aide staffing

Weekend hours

3.00

Weekend nurse staffing

RN turnover

86%

Annual RN turnover

Total nurse turnover

80%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

100% 96 facilities 2021-05-01
Broad River Healthcare, LLC

5% Or Greater Mortgage Interest · Organization

0% 3 facilities 2021-05-01
Compton, Charles

5% Or Greater Mortgage Interest · Individual

0% 5 facilities 2021-05-01
Compton, James

5% Or Greater Mortgage Interest · Individual

0% 5 facilities 2021-05-01
Compton, Kris

5% Or Greater Mortgage Interest · Individual

0% 5 facilities 2021-05-01
Harris Lt Investments, LLC

5% Or Greater Mortgage Interest · Organization

0% 1 facilities 2021-05-01
Martel Healthcare Management LLC

5% Or Greater Mortgage Interest · Organization

0% 3 facilities 2021-05-01
Martel, Michael

5% Or Greater Mortgage Interest · Individual

0% 8 facilities 2021-05-01
Rollingbrook Rehab LLC

Operational/Managerial Control · Organization

0% 1 facilities 2021-05-01
The Smithers Management Trust

5% Or Greater Mortgage Interest · Organization

0% 5 facilities 2021-05-01
Thompson, Johnny

Corporate Officer · Individual

0% 69 facilities 2024-07-01
Threadgill, Sharlyn

Operational/Managerial Control · Individual

0% 10 facilities 2021-05-01

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