Resident #1 at Ridgewood at the Woodlands needed the specialized wheelchair for "upper trunk adjustment and comfort," according to inspection records. The facility's interdisciplinary team requested the equipment during an April 21, 2025 meeting under the federal PASRR program, which coordinates care for residents with intellectual disabilities and mental disorders.
But nobody filed the necessary forms.
The previous Director of Rehabilitation said she "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 stopped working there in June 2025.
The current Director of Rehabilitation, who started in June, said he didn't see that any federal screening request was submitted for the wheelchair. Instead, he said "the company set a delivery date for the wheelchair for 10/16/25" through regular Medicaid benefits, claiming delays were because "the resident's Medicaid was not being renewed."
The MDS nurse explained that the screening forms "were in the process of being signed and were supposed to be uploaded and submitted within 20 days from the meeting date." Federal regulations require facilities to submit these requests within 30 days of quarterly meetings for residents in the PASRR program.
The wheelchair was finally delivered in October, nearly six months after the initial team meeting.
The Administrator said she "was not familiar with the PASRR IDT requesting a customized manual wheelchair for Resident #1." She acknowledged that "an NFSS was not sent for the wheelchair" and suggested the previous director "probably ordered the wheelchair through the residents Medicaid benefits, instead of through PASRR."
This created a significant difference in the approval process. As the Administrator explained, "PASRR benefits would pay for the wheelchair instead of Medicaid which may be a different approval process."
The previous Director of Rehabilitation offered conflicting accounts during her interview. She said she "ordered Resident #1 a wheelchair when she transitioned off skilled services, which was prior to her being on PASRR." But she also said she "did not recall if the IDT requested a customized manual wheelchair during her initial PASRR IDT meeting in April 2025."
When pressed about the proper procedure, she demonstrated knowledge of the requirements. 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."
The facility's own policy, updated in October 2023, explicitly requires coordination with the PASRR program "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."
The policy states that "recommendations, such as any specialized services, from a PASRR level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care."
Multiple staff members claimed training on PASRR procedures. The Administrator said "PASRR training was provided by the MDS nurse, Corporate, and Therapy." The previous Director of Rehabilitation said she "was familiar with the PASRR process and was trained by her regional director."
Yet the system broke down completely for Resident #1.
The current Director of Rehabilitation said "the previous DOR was responsible for submitting the NFSS request within 30 days from the quarterly meeting." The MDS nurse said "therapy was responsible for submitting the forms but MDS and therapy both had roles in PASRR."
The previous Director of Rehabilitation said "no one followed up with her regarding the status of the NFSS request for Resident #1's wheelchair."
She left the facility in June without completing the federal paperwork or ensuring someone else would handle it. The resident continued waiting for equipment designed for positioning and pressure relief while staff sorted out who was responsible for what.
The Administrator 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 added that "the regional DOR would submit PASRR request in the absence of a DOR."
But nobody did.
Federal inspectors found the facility failed to coordinate with the PASRR program as required, leaving Resident #1 without proper equipment for months while staff pointed fingers at each other and claimed confusion over Medicaid renewals.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgewood At the Woodlands from 2025-11-25 including all violations, facility responses, and corrective action plans.