F0656

D

Failure to Develop Comprehensive Care Plan for Visually Impaired Resident

Glendale, California Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan addressing the needs of a legally blind resident. The resident’s admission record showed diagnoses including bilateral blindness, respiratory failure, and diabetes, and the history and physical documented that the resident had capacity to understand and make decisions. The MDS indicated the resident was cognitively intact and required moderate assistance with oral hygiene, toileting hygiene, dressing, and footwear. During interview, the resident reported being unable to visually identify meals and stated she used her hands to determine what she was eating by feeling the texture and temperature of the food. A nurse confirmed the resident was blind in both eyes and stated that assistance was usually provided for meal set-up, including identifying food items and their location on the tray, as well as for transfers and toileting due to the visual impairment.

Record review with nursing staff revealed there was no care plan initiated to address the resident’s specific diagnosis of blindness. RN 2 acknowledged that a care plan should have been initiated and should have included measurable goals and interventions to address the resident’s behaviors and needs, including measures to decrease stress and anxiety. The MDS nurse also confirmed there was no care plan in place for the resident’s blindness. This was inconsistent with the facility’s written policy on comprehensive, person-centered care plans, which requires development and implementation of a care plan with measurable objectives and timetables for each resident, including after significant changes in status, and ongoing revision as resident conditions change.