Inspection·January 15, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review 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, excluding readmissions in which there was no significant change in the resident's physical or mental condition reviewed for assessments . The facility failed to ensure Resident #35's admission MDS Assessment was completed within 14 days of admission. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services. The findings include: Record review of Resident #35's admission Record, face sheet, dated 01/15/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included Alzheimer's disease (a condition in which nerve cells in the brain drop out, causing a gradual decline in memory and cognitive function). chronic kidney disease (a gradual loss of kidney function), heart disease, type 2 diabetes chronic ( a condition characterized by insulin resistance and high blood sugar levels), muscle weakness, and high blood pressure . Record review of Resident #35's admission MDS revealed the MDS was signed as completed on 03/21/24 and the care summary was signed by RN as completion date on 03/25/24 which was the 17th day after admission. During an interview with MDS coordinator #1 on 01/15/25 at 10:00 AM, she said she was not present at the facility during the time of the MDS. She said all area of the MDS should be completed by the 14th day of admission and transmitted 7 days after completion of the MDS . In an interview with MDS coordinator #2 on 01/15/25 at 2:00 PM, she said she was at the facility and the MDS was completed by the 14th day, but the CAAS was signed late by the RN who was no longer working at the facility. She said she could not explain why. She said the facility followed the RAI manual by CMS for their facility policy . Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676442 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676442 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)