Inspection·August 7, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to coordinate the assessments with the pre admission screening and resident review (PASARR program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort which includes incorporating the recommendations from the PASRR level II determination and the PASARR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 4 residents Resident #1 reviewed for PASARR. Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. The Facility failed to provide Resident #1 specialized services of PT, OT, and ST. Based on record review November 15, 2022 was the date listed in Simple LTC PASARR Portal. The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident#1's OT, PT, and ST specialized services by a specific deadline. This failure could place residents at risk for not receiving specialized PASARR services which could contribute to a decline in physical, [NAME] psychosocial well-being and quality of life. Findings include: Record review of Resident #1's electronic face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included, intellectual disability, Mood disorder, (bipolar disorder and Major depression (A serious mental illness characterized by extreme mood swings, panic, or other severe anxiety disorder.) Record review of Resident #1'sAnnual MDS assessment, dated 01/25/24, reflected Resident #1 was positive for intellectual disability and other related condition. Her cognitive patterns Brief Interview for Mental Status (BIMs ) were coded as 13 out of possible 15, which reflected she was cognitively intact. Record review of Resident #1 care plan, updated on 4/25/24, reflected the resident had a positive PASARR Level II for developmental Disability. Goal Resident #1 will receive all specialized services related to positive PASARR through the next 92 days target date of 05/27/24. Record review of the undated Simple LTC PASARR NFSS Activity Portal History, for Resident #1, reflected the NFSS form was completed and submitted for PT\OT and ST on 06/28/2019 but was rejected. (continued on next page) 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: 675052 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 675052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Ridge Healthcare Center 208 South Utah LA Porte, TX 77571 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)