Failure to Provide Vision and Hearing Services
Summary
The facility failed to ensure proper treatment and assistive devices to maintain vision and hearing abilities for two residents. Resident #54, who was admitted with type II diabetes mellitus and required assistance with various activities of daily living, reported that she could not see out of her glasses and had not been offered an eye exam. Despite her care plan indicating the need for visual aids and consultations with an eye care practitioner, no appointment had been made. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for an eye exam, with the Medical Records Director (MRD) and Director of Nursing (DON) both unaware of the issue until it was brought to their attention during the survey. The Social Service Director (SSD) also did not know the last time the resident had her eyes checked and had not communicated the need for an eye exam to the MRD. This lack of coordination and follow-through resulted in the resident not receiving the necessary eye care services in a timely manner. Resident #40, who had mild cognitive impairment, anxiety, depression, and mild intellectual disabilities, experienced significant hearing difficulties. The resident reported increased anxiety and self-harm behaviors due to his inability to hear properly. Despite having a hearing exam and recommendations for new hearing aids, the resident had not received the necessary devices. The SSD was not aware of the status of the insurance claim for the hearing aids and had not reached out to an organization that provided grants for such services. The resident's care plan indicated the need for hearing aids, but there was no documentation of assistance with these devices. Interviews with staff revealed confusion about the resident's hearing aid status and a lack of consistent support in managing his hearing needs. The DON acknowledged the resident's impaired hearing and the agitation caused by staff having to yell to communicate with him, but there was no clear plan to address the issue. The facility's failure to ensure timely and appropriate vision and hearing services for these residents highlights significant gaps in communication, coordination, and follow-through among staff. The lack of awareness and action regarding the residents' needs resulted in prolonged periods without necessary assistive devices, negatively impacting their quality of life and well-being. Staff interviews consistently pointed to a lack of clarity about responsibilities and procedures for managing ancillary services, contributing to the deficiencies identified in the survey.
Penalty
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A resident with dementia, prior CVA, and ear malformation causing hearing impairment was care planned and ordered to use a right-ear hearing aid during the day, with staff responsible for ensuring its availability, function, and placement. Despite this, the resident was repeatedly observed without a hearing aid, and multiple CNAs and a CMA reported they had never seen one or were unaware of a care plan for its use. Activity and social services staff reported the hearing aid had stopped working months earlier, attempts to reach the DPOA about repair were unsuccessful, and no audiology visit was known to have occurred, while an RN later indicated a replacement hearing aid had been purchased and left charging at the nurse’s desk. The facility did not provide a policy governing hearing aid management.
A resident with multiple vision-related diagnoses, including macular degeneration, dry eyes, suspected glaucoma, pseudophakia, hyperopia, and presbyopia, had a care plan identifying vision impairment and the need for glasses, yet continued to use severely damaged eyeglasses missing a lens and nose piece, with the remaining lens heavily scratched. The resident reported repeatedly requesting new glasses over the course of a year and described difficulty reading, doing preferred activities, and watching television. An eye consult had recommended new glasses, but the billing for these glasses was mishandled, first being sent to a daughter barred from contact and then not successfully completed by the guardian until much later, resulting in the resident not receiving the prescribed eyewear.
A resident with a history of cataract surgery, who required eyeglasses to read and participate in activities, did not receive needed optical services in a timely manner. The resident reported confusion about multiple eye appointments and not knowing the status of obtaining eyeglasses. Review of the EHR and transportation logs showed that the resident had an ophthalmology visit and an eyeglass prescription on file, but no eyeglasses had been ordered or provided. The SSD confirmed that, contrary to usual practice where prescriptions lead to eyeglasses being ordered and delivered within weeks, this prescription was uploaded without follow-up, despite a facility policy stating residents should receive appropriate vision and hearing assistive devices.
A resident with diabetes, glaucoma, and moderate cognitive impairment was referred to an outpatient ophthalmologist for bilateral eye burning and was ordered Refresh Tears QID and PRN Tylenol. A transport requisition was completed and a contracted Transportation Aide took the resident to the eye clinic, but clinic staff reported the resident could not be seen without someone accompanying him. After the facility informed the Transportation Aide that no one would accompany the resident, the appointment was not completed, and the resident experienced a medical emergency at the clinic and was sent to the ED. Facility records showed no evidence that the missed ophthalmology appointment was ever rescheduled, and the staff member responsible for tracking appointments had no record of any upcoming eye visit for this resident, despite leadership expectations that missed specialty appointments be rescheduled.
A resident with nonexudative age-related macular degeneration and other conditions reported being unable to see out of three-year-old glasses, while multiple optometry consults documented that recommended new spectacles, retinal specialist referrals, and eye drops were never implemented. Despite a contract requiring coordination of optometry services and a care plan identifying impaired vision with ophthalmologist/optometrist consults, the facility did not ensure scheduling of the retinal specialist or provision of new glasses over several consults, and the DON acknowledged that these recommendations had been missed.
A resident with bilateral hearing loss, severely impaired cognition, and documented hearing deficits reported difficulty obtaining hearing aids, believing insurance would not cover them. The care plan acknowledged hearing impairment, but the MDS inaccurately documented adequate hearing without devices. Appointment notes showed the facility was waiting on an ENT provider and later a mobile hearing service, while a CMA received a list of contracted hearing aid providers and made calls to the insurer, then forgot to follow up when no return call came. The CMA reported no clear process for communicating insurance barriers, and the Asst Admin, DON, and MDS coordinator all stated they were unaware of the ongoing insurance issue until surveyor interviews, resulting in a failure to effectively assist the resident in accessing needed hearing services.
Failure to Ensure Resident Access and Assistance With Prescribed Hearing Aid
Penalty
Summary
The facility failed to ensure that a dependent resident received staff assistance with the use of a prescribed hearing aid. The resident’s EMR documented dementia with severely impaired cognition, a history of cerebral infarction, and an ear malformation causing hearing impairment. A Significant Change MDS and subsequent Quarterly MDSs showed the resident wore a hearing aid and relied on staff to have needs met, with no change in hearing aid use. The resident’s care plan directed staff to ensure availability and functioning of adaptive communication equipment, including a right-ear hearing aid to be worn during the day, removed at night, and stored and charged at the nurses’ station. Physician orders allowed for specialist care, including an audiologist, as needed. Activity notes documented that the resident was hearing impaired and wore a right-ear hearing aid when available, and that the resident had limited communication. During multiple observations, the resident was seen in a wheelchair and in the dining room without a hearing aid in place. Multiple CNAs and a CMA reported they had never seen the resident with a hearing aid and did not know if the resident was care planned for one. The Activity Director and Administrative Nurse F gave conflicting information, with the Activity Director initially stating the resident did not have a hearing aid and staff had to speak loudly in the resident’s right ear, and later stating the hearing aid had stopped working and would not hold a charge. The Social Service Designee reported the hearing aid had broken months earlier, that attempts to contact the resident’s durable power of attorney about repair had been unsuccessful, that she was unsure about coverage or personal funds for repair, and that she did not think the resident ever had an audiology appointment. Administrative Nurse D stated she expected staff to ensure hearing aids were offered and placed as ordered and reported that an unnamed nurse had purchased a hearing aid for the resident, which had been at the nurse’s desk charging. The facility did not provide a policy for hearing aids.
Failure to Ensure Resident Received Functional Eyeglasses
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. The resident had diagnoses including diabetes mellitus, altered mental status, anxiety, depression, anisocoria, macular degeneration, dry eyes, suspected glaucoma, pseudophakia, hyperopia, and presbyopia. Her care plan identified vision impairment and included interventions such as placing glasses within reach, encouraging their use, consulting with a physician for vision evaluation, and administering eye medications as ordered. An eye care consult documented that new glasses were recommended, with follow-up in 3–4 months and instructions to encourage use of glasses for distance and reading. During an interview, the resident reported that the eye doctor had been in about a month earlier and asked how her new glasses were working, but she had not received them. The surveyor observed that her current glasses were missing the right lens and nose piece, and the left lens was severely scratched. The resident stated that she had been in the facility for a year, had been asking for new glasses because they were severely scratched, and that since admission a lens had fallen out and could not be found, followed by the nose piece falling off. She reported that not having functional glasses affected her quality of life because she could not see to read or do activities she enjoyed and had to sit close to the television and could not watch it while lying in bed. The bill for the new glasses was initially sent to the resident’s daughter, who was not allowed contact with the resident due to a history of exploitation, and later to the guardian, but the guardian did not receive or complete the bill until contacted again, resulting in a delay in obtaining the new glasses.
Failure to Ensure Timely Optical Services for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure timely provision of optical services for a resident with visual impairment. The resident, who had previously undergone cataract removal surgery and still required eyeglasses to read, was observed sitting in her wheelchair with an activity calendar on the wall and a monthly meal menu on her bedside table, but no eyeglasses were present in the room. During interview, the resident reported needing readers to enjoy activities such as coloring and reading and described having been seen by an eye doctor, then referred to a specialist, and then referred back to the regular eye doctor, leaving her uncertain about the status of obtaining eyeglasses. Record review showed that the resident had an ophthalmology visit on 01/16/2026, and a prescription for eyeglasses from that visit had been scanned into the EHR. The Social Services Director (SSD) explained that a company routinely provided on-site ancillary vision services and that, typically, when an eye doctor examined a resident and wrote a prescription, eyeglasses would be ordered and delivered to the facility within a few weeks, after which she would distribute them to residents. Upon reviewing the records and transportation logs, the SSD confirmed the resident’s eye appointment and the presence of the eyeglass prescription in the EHR but was unsure why the prescription had been uploaded without follow-up. The SSD acknowledged that the prescription should probably have been acted on sooner. The facility’s undated policy on vision and hearing services stated that it is the organization’s standard to ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities.
Failure to Reschedule Missed Ophthalmology Appointment After Unaccompanied Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident obtained ordered ophthalmology services after a missed appointment. The resident had diagnoses including type 2 diabetes, glaucoma, and coronary artery disease, and a physician progress note documented bilateral eye burning. On the following day, the physician ordered a referral to an outpatient ophthalmologist, along with Refresh Tears ophthalmic solution four times daily for dry eyes and PRN Tylenol for pain. A quarterly MDS showed the resident had moderate cognitive impairment, was coded as having adequate vision without corrective lenses, and was coded as not having pain or receiving pain interventions. A transport requisition was completed for an eye appointment at an outpatient office, and the contracted Transportation Aide reported picking up the resident and signing him in for the appointment. Shortly after leaving, the outpatient office called the Transportation Aide to report that the resident could not be seen without someone accompanying him. The Transportation Aide called the facility and was told there was no one available to accompany the resident. When the Transportation Aide returned to the outpatient office, she learned the resident was having a medical emergency and had been transported by ambulance to the ED. Later that day, she picked the resident up from the ED and returned him to the facility. Record review showed no evidence that the missed ophthalmology appointment was ever rescheduled. The Medical Supplies Personnel, who maintained a calendar and transportation requisition forms, had no record of any upcoming eye appointment for the resident. The MARs indicated the ordered eye drops were administered four times daily and PRN Tylenol was given once for a reported pain level of 4/10, with all other documented pain assessments at 0. Attempts to interview the resident about his vision and eye appointments were unsuccessful. The Unit Manager confirmed the resident did not receive ophthalmology services on the day of the missed appointment and stated she had called the eye clinic and was waiting for a call back to reschedule, but there was no documentation of a new appointment. The Medical Director and Administrator both stated their expectations that specialty referrals and any missed appointments be scheduled or rescheduled so residents receive needed medical services, which did not occur in this case.
Failure to Implement Vision Service Recommendations and Provide Updated Eyeglasses
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident received proper treatment and assistive devices to maintain vision, despite an existing contract with a vision services company. The contract, effective December 14, 2018, required the company to arrange optometry services, including eye exams, medical eye evaluations, and fitting and ordering of eyeglasses, while the facility was responsible for coordinating necessary physician documentation. One resident with diagnoses including nonexudative age-related macular degeneration, dysphagia, and delusional disorders reported during an interview that his glasses were three years old and that he was unable to see out of them. His comprehensive care plan identified impaired vision with an intervention for ophthalmologist/optometrist consults as per orders. Clinical record review showed multiple vision consults with unimplemented recommendations. A consult dated November 26, 2024, documented bilateral nonexudative age-related macular degeneration and recommended scheduling a retinal specialist consult and obtaining new spectacles to maximize visual function. A February 5, 2025, consult recorded that the resident had not received the glasses from the November order, had not seen a retinal specialist, and was not receiving any prescribed eye drops, and again requested scheduling of the retinal specialist consult. A June 17, 2025, consult noted the resident still had not received new glasses or seen the retinal specialist and again requested scheduling for evaluation and treatment of possible choroidal neovascular membranes. During an interview, the DON acknowledged that the recommendations from the initial and February consults were missed, including during current facility ownership, and stated it was her expectation that contracted service recommendations be implemented or addressed by the physician if there was disagreement.
Failure to Assist Resident in Obtaining Hearing Aids and Coordinate Insurance Barriers
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to assist a resident in obtaining needed hearing devices through available resources. The resident reported being hard of hearing and stated she had been trying to get hearing aids but her insurance would not cover them. Her care plan included a hearing deficit focus with an intervention for staff to validate her messages by repeating them aloud. The MDS assessment documented a BIMS score of 7/15 indicating severely impaired cognition, diagnoses including heart failure, depression, and bilateral hearing loss, and noted she required supervision with several ADLs while being independent with others. Despite this, the MDS documented she had adequate hearing without hearing aids or other appliances, and staff CNAs reported needing to speak to her in an elevated voice because they did not think she could hear well. Appointment notes showed that on one occasion the facility was waiting for the ENT provider to supply a phone number for the insurance company regarding hearing aids, and later was waiting for a response from a mobile hearing service to schedule a hearing test. A CMA reported that the ENT provider had given a list of hearing aid providers contracted with the resident’s insurance and that she made multiple attempts to contact the insurance provider, was told she would receive a call back, and then forgot about the issue when no call was returned. She also stated she did not know of any official process for communicating insurance barrier situations and usually spoke with the DON or MDS coordinator when expecting return calls. The assistant administrator, DON, and MDS coordinator all stated they were unaware of the ongoing hearing aid insurance barrier or process delay until the day of the survey interviews, and the DON later stated staff should have notified her or the MDS coordinator of the ongoing communication attempts, demonstrating a lack of effective follow-through and communication in assisting the resident to obtain hearing devices.
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