Ridgewood At The Woodlands

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.

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