Health 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 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 . Page 1 of 2 676442 676442 01/15/2025 Rollingbrook Rehabilitation and Healthcare Center 750 Rollingbrook Dr Baytown, TX 77521

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services. The facility failed to label, and date left over food items in walk in refrigerator\freezer. This failures could place residents at risk of foodborne illnesses. Findings included: Observation during initial tour of the kitchen on 01/13/25 at 8:45 AM, revealed a brown substance in a plastic bag which was unlabeled and undated. A bag of a left over whitish looking substances in a plastic bag was undated and unlabeled in the walk in cooler\freezer. The brown substance was identified by the DM as left-over ground beef and the whitish substance as biscuit. During an interview with the DM on 01/13/25 at 10:00 AM, she said, she was responsible to ensure that all left over food items were labeled and dated. The DM said she expected all left over food items in the fridge and walk in cooler\refrigerator to be labeled and dated to prevent cross contamination . Record review of facility's policy on food Storage Titled Date Marking for Food Safety, dated 05/20/23, revised 03/20/24, read in part 1. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 2. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 3. The discard day or date may not exceed the manufacturer's use-by date, or three days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Thursday. 676442 Page 2 of 2