Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Rollingbrook Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Inaccurate PASRR Level 1 Screening for Resident with PTSD and Dementia: A resident admitted with PTSD, dementia, and other diagnoses had an inaccurate PASRR Level 1 that did not reflect a mental illness or dementia diagnosis. The MDS record showed cognitive impairment and checked yes for Non-Alzheimer's Dementia and PTSD, but the PASRR screening stated no primary diagnosis of dementia, mental illness, ID, or developmental disability. Staff interviews confirmed the screening should have been corrected and that a PASRR Level 2 was indicated.
Incorrect Insulin Pen Attempted During Medication Administration: An LVN attempted to administer Insulin Glargine to a resident using an insulin pen that belonged to another resident. The LVN did not read the label before entering the room and stated she thought the pen was the resident’s because it was Lantus. The resident had COPD, Type 2 DM, and aphasia, and the MDS showed intact cognition. Facility policy required staff competence in infection control and adherence to the six rights of medication administration.
Failure to maintain the infection prevention and control program occurred when an LVN did not use EBP before administering meds via a resident’s G-tube. The resident was a new admission with a G-tube, dysphagia, and cognitive communication deficit, and the facility’s EBP policy identified feeding tubes as a reason for EBP. During observation, the LVN entered the room with meds and gloves, exposed the G-tube, and handled it without gowning up; she later said she forgot. The DON stated the resident should have been on EBP, and no EBP sign or PPE supplies were posted at the room.
The facility did not follow professional standards for food service safety by failing to label and date leftover food items in the kitchen's walk-in refrigerator/freezer. Unlabeled and undated bags containing leftover ground beef and biscuits were found during a survey. The Dietary Manager acknowledged the oversight and the facility's policy requires food to be marked with a label and date for consumption or disposal within three days.
A facility failed to complete a resident's Admission MDS Assessment within the required 14 days, as it was signed on the 17th day. The resident, with multiple health conditions including Alzheimer's and chronic kidney disease, was affected by this delay. Interviews revealed that while the MDS was completed on time, the CAAS was signed late by an RN no longer at the facility.
Inaccurate PASRR Level 1 Screening for Resident with PTSD and Dementia
Penalty
Summary
The facility failed to ensure that a resident with mental illness had an accurate and updated PASRR Level 1 screening. Resident #11 was admitted with diagnoses including unspecified dementia, PTSD, polyneuropathy, mood disorder due to a known physiological condition with manic features, and cognitive communication deficit. The record showed PTSD was present on admission, and the quarterly MDS indicated a BIMS score of 8 with sections marked yes for Non-Alzheimer's Dementia and PTSD. However, the resident's PASRR Level 1 screening dated 12/6/2025 stated that he did not have a primary diagnosis of dementia, mental illness, intellectual disability, or developmental disability. The resident's comprehensive care plan did not reflect a focus, goal, or interventions addressing dementia or PTSD. During interview, the MDS nurse stated the resident did have PTSD on admission and should have had a PASRR Level 2 completed, and the Regional MDS consultant stated the PASRR Level 1 should have indicated dementia and that the facility should have completed a correction or contacted the entity that completed the PASRR Level 1. The facility policy stated that if a resident is admitted without a documented diagnosis of serious mental illness, intellectual disability, or related condition, and such diagnosis is identified after admission, the facility will initiate the PASARR referral process upon identification.
Incorrect Insulin Pen Attempted During Medication Administration
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of each resident when an LVN attempted to administer insulin to a resident using the incorrect insulin pen. The resident had diagnoses including COPD, Type 2 DM, and aphasia, and the quarterly MDS showed a BIMS score of 15, indicating intact cognitive response. The physician order summary included an order for Insulin Glargine 30 units subcutaneously in the morning for DM. During observation, the LVN was seen with an Insulin Glargine (Lantus) pen, alcohol wipe, and gloves, and entered the resident’s room to administer the insulin. Before the injection was completed, the surveyor stopped the LVN and asked her to read the label on the pen; the LVN stated that the pen belonged to another resident and that she had not read the label. The LVN stated she did not have the resident’s insulin pen in her medication cart and that she saw Lantus and thought it belonged to the resident. The DON stated insulin training was conducted annually, nurses received quarterly medication administration training, and random medication administration audits were conducted. Facility policies required staff competence in infection control practices and adherence to the six rights of medication administration, including the right resident.
Failure to Use EBP During G-Tube Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when LVN A failed to follow enhanced barrier precautions (EBP) before administering medications through Resident #100’s gastrostomy tube. Resident #100 was a new admission with diagnoses including gastrostomy status, dysphagia, and cognitive communication deficit. Her admission record and physician orders showed that all medications were to be given via G-tube, and the facility’s EBP policy identified feeding tubes as an indication for EBP and required PPE for high-contact care activities involving device care or use. During observation, LVN A entered the resident’s room with medications, supplies, and gloves, closed the door, donned gloves, and had the resident lift her shirt to expose the G-tube. LVN A leaned forward and grabbed the G-tube without using EBP. When asked about precautions, she did not answer at first and then stated she needed to gown up, adding that she had forgotten because the resident was new to the facility. The DON stated she was the infection preventionist, that Resident #100 should have been on EBP, and that any nurse could initiate EBP for a resident. The facility also observed that Resident #100’s door did not have PPE supplies or an EBP sign posted.
Failure to Label and Date Leftover Food in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not label and date leftover food items stored in the walk-in refrigerator/freezer. During an initial tour of the kitchen, surveyors observed a brown substance in a plastic bag and a whitish substance in another bag, both of which were unlabeled and undated. The Dietary Manager (DM) identified these substances as leftover ground beef and biscuits, respectively. In an interview, the DM acknowledged her responsibility to ensure all leftover food items were labeled and dated to prevent cross-contamination. A review of the facility's policy on food storage, titled 'Date Marking for Food Safety,' indicated that food should be marked with a color-coded label, the date of opening, and the date by which it must be consumed or discarded, not exceeding three days from the date of opening or preparation.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to ensure a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences using the Resident Assessment Instrument (RAI) specified by CMS was completed within 14 calendar days after admission. Specifically, the Admission Minimum Data Set (MDS) Assessment for Resident #35 was not completed within the required timeframe. The resident, an elderly female with multiple diagnoses including Alzheimer's disease, chronic kidney disease, heart disease, type 2 diabetes, muscle weakness, and high blood pressure, was admitted to the facility, but her MDS was signed as completed on the 17th day after admission, which was beyond the 14-day requirement. Interviews with the facility's MDS coordinators revealed discrepancies in the completion process. MDS coordinator #1 was not present during the time of the MDS completion, while MDS coordinator #2 stated that the MDS was completed by the 14th day, but the Care Area Assessment Summary (CAAS) was signed late by a registered nurse who was no longer employed at the facility. This delay in completing the MDS assessment could potentially place residents at risk of not having their assessments completed timely, which could result in denial of services and/or payment for services.
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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.
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Nursing homes near Baytown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Allenbrook | 0.6 mi | ★★★★★ | 4 | 1 |
| Focused Care At Cedar Bayou | 0.7 mi | ★★★★★ | 2 | 0 |
| Mont Belvieu Rehabilitation & Healthcare Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Focused Care At Burnet Bay | 0.9 mi | ★★★★★ | 4 | 0 |
| St James House Of Baytown | 3 mi | ★★★★★ | 9 | 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.