Ridgmar Medical Lodge

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the prior meeting was on 04/16/25. She stated the NFSS form should have been submitted 20 days after

the meeting but was not. She stated the NFSS form was for rehab therapy. She stated she did not know why it had not been submitted. The MDS Coordinator stated it was her responsibility to ensure all forms were submitted in a timely manner. She stated the potential risk if PASRR paperwork was not submitted through the database timely could be a delay in therapy services.Interview on 08/14/25 at 10:36 AM, with

the Director of Rehab revealed Resident #2 was evaluated for a custom wheelchair based on a referral that was made. The Director of Rehab stated from there he sent over the forms to the previous MDS Coordinator to be uploaded in the database and sent to the PASSR unit for approval. The Director of Rehab stated the CMWC was signed 08/23/24 and the vendor came out a few days before that. The Director of Rehab stated he never received any follow-up or heard anything more about Resident #2's wheelchair. The Director of Rehab stated once the CMWC was signed it would usually take about a month or two to receive

the wheelchair. He stated waiting a year for a wheelchair was too long. Interview on 08/14/25 at 11:21 AM, with the Treatment Nurse revealed she was the MDS Coordinator from October 2024 to June 2025. She stated she was involved in the PCSP meetings of Resident #2 and Resident #3. She stated she had submitted the NFSS forms for Resident #2 and Resident #3 back in April 2025 but could not recall the exact dates. However, there was a miscommunication with the residents' Habilitation Coordinator. She stated she had a conversation with the Habilitation Coordinator, and she was made aware that she needed to resubmit the NFSS forms and evaluation needed to be completed to prove that services were being covered. She stated sometime in May 2025 she was made aware that the facility was out of compliance with the NFSS forms, and they were given the opportunity to correct the issue. She stated the corporate MDS Coordinator was assisting at the time and informed her that the NFSS needed to be submitted but by that time she was already out of that position. She stated after she changed positions, she never followed up to ensure the NFSS were submitted. The Treatment Nurse stated there was no potential risk to the resident if the NFSS forms were not submitted timely, residents would still be seen by therapy, and it was more of a payment issue. Interview on 08/14/25 at 1:58 PM, with the Administrator revealed he was not aware Resident #2 and Resident #3's NFSS forms were still pending. He stated he was aware of the request for Resident #2's customized wheelchair, but he stated he was under the impression the forms and assessments were all completed. He stated the previous MDS Coordinator moved positions to be the Treatment Nurse, and they had a corporate MDS Coordinator assisting until the position was filled. He stated he was under the impression all the forms had been submitted for all residents. Record review of the facility's Preadmission and Screening Resident Record review (PASRR) Rules policy, dated 03/15/23, reflected the following: It is the intent of [Management Group] to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Record review (PASRR) Rules .Post IDT Meeting Responsibilities .2. The facility will initiate the request for specialized services within 20 business day of the IDT/PCSP meeting, implement Specialized Services therapy within 3 business days

after receiving approval from HHSC in the online portal and order CMWC and/or DME within 5 business days of receiving approval from HHSC in the online portal.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ridgmar Medical Lodge

6600 Lands End Court Fort Worth, TX 76116

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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

environment for residents. This was determined to be a Past Non-Compliance Immediate Jeopardy on 08/13/25 at 4:25 PM. The Administrator and the DON were notified. The Administrator was provided with

the IJ template on 08/13/25 at 4:38 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of Elopement assessment/Evaluations reflected they were reviewed and completed on Resident #4, Resident #5, Resident #6, and Resident #7 on 07/23/25 and 07/24/25. Record

review of facility invoice from [Door Alarm company] dated 07/24/25 reflected all door alarms were checked.

Record review of facility Elopement binders located on both nurse's stations and reception reflected pictures of residents who were at elopement risk and contained information regarding the residents. Record

review of the facility Elopement Drill/Code Pink Drills reflected drills were completed on the following dates: 07/24/25 - 5:30AM - 5:40AM, 2:45PM 3:05PM 07/30/25 - 6:00AM - 2:00PM, 2:00 PM - 10:00PM, and 10PM - 6:00AM (Facility continued to complete random code pink drills). Record review of facility Shift Exit Door Check forms for all exit doors from July 24 - August 8 reflected door checks were being completed for all three shifts (6AM-2PM, 2PM-10PM, 10PM-6AM). Record review of facility Door Safety and Alarm Check forms from January 2025 - August 2025 reflected they were completed monthly. Record review of Resident #4, Resident #5, Resident #6, and Resident #7 July and August 2025 MARs revealed Wanderguards were being monitored/checked placement and documenting behaviors. Observation on 08/13/25 from 11:00AM through 11:20 AM of Resident #4, Resident #5, Resident #6, and Resident #7 revealed WanderGuards were flashing a red light which indicated the WanderGuards were working properly. Observation on 08/13/25 from 2:36 PM through 2:50 PM revealed the doors on 200 and 300 Halls had two alarms. Alarms were loud enough to be heard from the nurse's station. Wander Guard doors were also checked, and no concerns noted. Record review of in-services dated 07/23/25 reflected all facility staff were in-serviced on Door Alarms, Wander guard, Wandering and Elopement, and Code pink. Objectives of the In-service: Elopement - Identified changes in behaviors of all resident's - notify management of wandering/risk of elopement behaviors. Be watchful of residents at risk and listen for door alarms. Elopement binders for at risk residents can be found at each nurses' station. Elopement Binders include current list of Residents high Risk for wandering. Wander guard - what your orders mean. Check skin around WanderGuard- Means just to make sure band or monitor is not causing pressure or injury. Check placement means to make sure band is not too loose or too tight and make sure is on the body part that the order says it is. Ex. R leg. Check Function - If red light is blinking - Battery is good condition. If the light is SOLID RED, GREEN, half red - cut WG off and replace with new WanderGuard spare will be locked in Medication carts. CALL DON, Code PINK - Missing Resident. The in-services were conducted and signed by all facility staff.Interviews on 08/13/25 from 12:25 PM through 08/14/25 at 1:49PM with CNA D, LVN C, ADON A, ADON B, MA E, CNA F, LVN G, MA H, MA I, MA J, CNA K, Treatment Nurse, Therapy L, Therapy M, Therapy N, CNA O, Dietary Aide, Kitchen Supervisor, Central Supply, LVN P, CNA Q, LVN R, CNA S, MA T, Social Worker, LVN U, CNA V, CNA W, Housekeeping Supervisor, and Housekeeping who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00AM revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize the elopement/code pink in-service, abuse, and neglect, completing head counts before shift change, elopement assessment were reviewed/competed (an evaluation to determine any resident at risk of elopement) , where to locate elopement binders, nurses ensure WanderGuards were checked daily to ensure they were working properly and document on the MAR, alarms added to the 200 and 300 Hall doors, door codes changed and door checks completed on all three shifts.

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