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F0656
D

Failure to Develop Comprehensive Care Plan for Resident's Visual Needs

Hermiston, Oregon Survey Completed on 04-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive care plan addressing the visual needs of a resident with dementia and severe cognitive impairment. The resident, who required substantial to maximal assistance with activities of daily living, was observed multiple times without eyeglasses, despite having a documented vision impairment. The resident expressed concern about missing eyeglasses, and staff observations confirmed that the resident wore eyeglasses when engaging in activities such as coloring and puzzles, but often needed assistance to locate and use them. Record review revealed that the resident's care plan did not include any information regarding the use of eyeglasses or staff assistance with them. Interviews with CNAs and the Resident Care Manager/LPN indicated that staff relied on the care plan for guidance and were aware of the resident's need for eyeglasses, yet the care plan lacked specific instructions. The Director of Nursing Services confirmed that the care plan should have included directions for staff to assist the resident with eyeglasses as needed.

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