Health inspection·November 25, 2025

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 observation, interview, and record review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care services for one of two residents (Resident #1) reviewed for PASARR. The facility failed to submit a request through the simple LTC portal for a customized manual wheelchair for Resident #1 within the time frame set by PASARR. This failure could place residents at risk of not having their PASARR specialized service needs met.Findings included:Record review of Resident #1's face sheet dated 11/25/25 revealed an [AGE] year-old female admitted on [DATE]. Her diagnoses included developmental disorder of speech and language, dementia, and rhabdomyolysis (a serious condition characterized by the breakdown of skeletal muscle tissue leading to the release of myoglobin [iron- and oxygen-binding protein] and other harmful substances into the bloodstream).Record review of Resident #1's quarterly MDS assessment, dated 10/29/25, revealed a BIMS score of 0, which indicated severe cognitive impairment. She was dependent on staff for toileting and oral hygiene, and required assistance with showers, dressing, and personal hygiene.Record review of Resident #1's care plan, dated 11/5/25, revealed Resident #1 was PASRR positive and received services with the local authority related to a diagnosis of developmental disorder of speech and language. Interventions were: initial PASSR meeting held on 4/21/25. PASSR services ST, PT, OT, habitation coordinator, and independent living skills with date initiated 7/18/25. 7/18/25, 10/22/25 - quarterly PASSR meeting held. Continue PT/OT/ST, and PASSR services provided, date initiated 7/18/25.Record review of Resident #1's PASRR Level 1 Screening, dated 4/14/25, revealed Resident #1 had intellectual and developmental disability. Record review of Resident #1's PASRR Comprehensive Service Plan Form initial IDT/SPT meeting, dated 4/21/25, revealed the IDT recommended a customized manual wheelchair as a new specialized service for Resident #1. The Nursing Facility Comments read, PASSR meeting held with resident, Tri country (sic) Coordinator, and IDT team members listed above. Resident and case worker agreed to habitation coordination. PT, OT, ST and independent living skills training. Will remain on psych services provided in house. Case worker verbalized understanding and will participate in PASSR provided services. Customized Manual Wheelchair to be provided.Record review of Resident #1's progress note, dated 4/21/25 at 4:18 p.m. written by the previous MDS Coordinator, read in part, OT service and customized wheelchair added to initial PASSR.Record review of Resident #1's undated Form Activity from the Simple LTC portal revealed there was no NFSS submitted for Resident #1's customized manual wheelchair. Record review of Resident #1's PASRR Comprehensive Service Plan Form quarterly meeting, dated 7/18/25, revealed the customized manual wheelchair was ongoing.Record review of Resident #1's PASRR Comprehensive Service Plan Form quarterly meeting dated 10/22/25 revealed the customized manual wheelchair was received.An observation on 11/25/25 at 11:09 a.m., revealed Resident #1 was sitting in the TV room in her customized wheelchair. In an interview on 11/25/25 at 11:28 a.m., the Page 1 of 2 675739 675739 11/25/2025 Ridgewood at the Woodlands 10450 Gosling Rd The Woodlands, TX 77381

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DOR said Resident #1's customized manual wheelchair was ordered when he started working for the facility in June of 2025. He said the company set a delivery date for the wheelchair for 10/16/25. The DOR said the company was unable to send it prior due to the resident's Medicaid not being renewed. He said the customized manual wheelchair was for positioning and pressure relief and he did not see in the portal that a NFSS was submitted for the wheelchair. He said the previous DOR was responsible for submitting the NFSS request within 30 days from the quarterly meeting.In an interview on 11/25/25 at 11:54 a.m., the previous MDS Nurse said Resident #1's initial PASRR IDT meeting was held on 4/21/25 and the previous DOR initiated the NFSS forms for the customized wheelchair but was unsure if she passed the report on to her manager before leaving the facility. She said the NFSS forms were in the process of being signed and were supposed to be uploaded and submitted within 20 days from the meeting date. She said therapy was responsible for submitting the forms but MDS and therapy both had roles in PASRR. She said there was an issue with Resident #1's Medicaid and that would sometimes return the NFSS, but the facility should still submit the NFSS. She said Resident #1 needed the wheelchair for upper trunk adjustment and comfort. In an interview on 11/25/25 at 12:21 p.m., the Administrator said she was not familiar with the PASRR IDT requesting a customized manual wheelchair for Resident #1. She said an NFSS was not sent for the wheelchair. She said the previous DOR probably ordered the wheelchair through the residents Medicaid benefits, instead of through PASRR. She said the difference between ordering through PASRR and insurance benefits would be that PASRR benefits would pay for the wheelchair instead of Medicaid which may be a different approval process. She said Resident #1 did get her wheelchair. She said PASRR training was provided by the MDS nurse, Corporate, and Therapy. She said she believed the previous DOR knew how to submit the PASRR request for the wheelchair because she had submitted PASRR requests in the past. She said the regional DOR would submit PASRR request in the absence of a DOR. In an interview on 11/25/25 at 3:16 p.m. the previous DOR said she ordered Resident #1 a wheelchair when she transitioned off skilled services, which was prior to her being on PASRR. She said she did not recall if the IDT requested a customized manual wheelchair during her initial PASRR IDT meeting in April 2025. She said if a customized wheelchair was requested, she would have to submit the request through the Simple LTC portal, have the therapist complete a packet, and obtain MD and Administrator signatures. She said she did not recall doing that. She said the wheelchair Resident #1 currently had was the same wheelchair she would have if ordered through PASRR. She said she was familiar with the PASRR process and was trained by her regional director. She said no one followed up with her regarding the status of the NFSS request for Resident #1's wheelchair. She said she stopped working for the facility in June 2025.Record review of the facility's Resident Assessment - Coordination with PASARR Program, dated 10/2023, read in part, .Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: . 7. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. 675739 Page 2 of 2