Failure to Act on Ophthalmology Referral and Coordinate Timely Eye Care
Summary
The deficiency involves the facility’s failure to act upon a provider’s ophthalmology referral and to timely coordinate specialty eye care for one resident with a chronic and worsening left eye infection. The resident had a history of schizoaffective disorder, morbid obesity, and prior stroke, with moderately impaired decision-making requiring cues and supervision. In early April 2025, a physician documented bilateral eye irritation and redness consistent with conjunctivitis. On 5/13/2025, an NP/PA documented chronic conjunctivitis and ordered a culture of the left eye drainage before starting antibiotics. A physician order dated 5/17/2025 directed staff to obtain the left eye drainage culture that day, and the 5/22/2025 bacteriology report showed 3+ MRSA in the eye culture. On 6/26/2025, a physician progress note documented continued management of conjunctivitis with recent treatment having no to minimal effect and indicated that new orders and an ophthalmology referral were given. However, review of the EMR showed no corresponding physician order for an ophthalmology referral at that time. The facility’s own staff later acknowledged that the 6/26/2025 referral was not found in the EMR and that there had been an ongoing issue with missed orders around that period. The former scheduler stated he likely was not informed of the June referral, and the Unit Manager/RN stated she was unsure where in the process the June referral broke down, but confirmed that the ophthalmology appointment was not attempted to be scheduled until months later. During the months following the June referral, nursing documentation showed persistent and progressively worsening signs and symptoms of left eye infection. Between early July and mid-September, multiple infection/signs and symptoms notes described green mucus drainage at the inner canthus, crusting despite cleansing and eye drops, bilateral eye redness with drainage, ongoing redness with drainage, repeated scleral injection, increased redness, tenderness, and purulent drainage, the eye being closed shut with thick yellow drainage and pain, and swelling around the eye. On 9/15/2025, a physician order was entered for an ophthalmology appointment “ASAP” related to chronic eye infections. The ophthalmology clinic later confirmed that the first contact from the facility to schedule this resident was not until 9/25/2025, despite the clinic’s ability to see acute eye pain cases within about three days. When the resident was finally transported by EMS to the ophthalmology clinic, staff there documented a months-long history of red, irritated eye with purulent discharge, worsening pain and redness, and immediate concern for bacterial cellulitis and possible sepsis, leading to referral to an ER. The ER documented septic shock and severe eye infection, and the specialty hospital discharge summary confirmed preseptal cellulitis, bacterial keratitis of the left eye, and sepsis present on admission. At the time of the surveyor’s observations in February 2026, the resident’s left eye remained swollen, limiting visualization of the eye and partially blocking vision, and the resident reported that vision in the left eye was still “a little blurry.” The facility’s DON could not explain why there were two separate ophthalmology referrals, one in June and one in September, and acknowledged uncertainty about what happened with the earlier referral. The Unit Manager/RN described the facility’s process as requiring that referrals be transcribed into the EMR as orders so that the transport driver can schedule appointments, but confirmed that the June referral was missed. The ophthalmology clinic’s receptionist confirmed that the facility did not contact the clinic about this resident until late September, despite the chronic and worsening eye condition documented over the preceding months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to arrange ordered retinal specialist follow-up: A resident with DM and cognitive intactness reported fuzzy, burning eyes and said she had been told she needed specialist follow-up for possible edema behind her eyes. Although the physician ordered a routine referral to a retinal specialist, the EMR had no evidence the appointment was scheduled or completed, and staff could not find documentation of follow-up or a consultation report. Interviews showed the HUC was responsible for scheduling outside appointments, but no one could confirm the referral had been carried out.
Failure to obtain prescribed eyeglasses for a resident with a vision deficit. The resident, who had DM and HTN, had an eye exam showing cataracts and blurry vision with glasses prescribed, but the glasses were not received for months. The resident reported barely being able to see out of the current glasses and needing to get very close to the TV, while staff acknowledged no follow-up had been done on the invoice and the facility did not assist with obtaining the glasses in a timely manner.
Failure to Assist a Resident With Eyeglasses Access: A resident with stroke, hemiplegia, myopia, and age-related cataracts requested eyeglasses multiple times and later reported worsening L eye vision and headaches when reading. Records and care notes did not show assistance with obtaining eyeglasses, and staff interviews confirmed they were unaware of resources or any specific policy for residents on EMA to obtain eyeglasses.
Failure to Arrange Audiology Referral for a Resident with Hearing Loss: A resident with dementia and other diagnoses was documented as having diminished/decreased hearing, no hearing aid, and an audiogram showing hearing loss significant enough to qualify for hearing aids under Medi-Cal. The resident stated she could not hear and wanted hearing aids, while CNA and SSD interviews confirmed she had hearing difficulty and that an audiology referral should have been made after ENT wax removal; the SSD also stated the hearing loss affected communication with staff and the resident's ability to communicate needs effectively.
A resident with impaired vision and limited mobility reported that the resident’s only eyeglasses were missing, leaving the resident unable to see well, read, or comfortably do activities. Instead of telling the OPT that the glasses were missing, the SSA emailed that the resident needed replacement glasses because the current glasses were too blurry. The SSA later stated the communication was inaccurate, and the DON confirmed the resident’s vision concern had been misreported.
Failure to Arrange Follow-Up Ophthalmology Care: A resident with severe cognitive impairment, aphasia, and a cerebral infarction developed herpes zoster ophthalmicus with viral conjunctivitis affecting the left eye. The record showed an ophthalmology referral from a retina specialist, but the facility did not evidence arranging, offering, or discussing a follow-up appt with the resident or family. Staff stated family usually scheduled appts, and the DON said the follow-up was not set up because the NP believed it was not needed.
Failure to Arrange Ordered Retinal Specialist Follow-Up
Penalty
Summary
The facility failed to ensure physician-ordered vision services were arranged and provided for one resident who was reviewed for vision services. The resident’s annual MDS dated 4/1/26 showed she was cognitively intact with a BIMS score of 15 and had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD. Her physician orders included a routine referral to a retinal specialist dated 1/19/26, but the EMR had no evidence that the appointment was scheduled or completed and no documentation of follow-up regarding the referral or any consultation report from a retinal specialist. During interviews, the resident stated she needed to see the eye doctor because her eyes were fuzzy and burned, and she reported being told she had edema behind her eyes and needed specialist follow-up. She stated the facility was supposed to make the referral but she had never heard anything further and that her last eye appointment had been over a year ago. Staff interviews showed the LPN stated the HUC was responsible for scheduling outside follow-up appointments, while the HUC assistant said physician orders needing follow-up were highlighted and given to the HUC for scheduling. The HUC assistant, the nurse manager, and the DON were unable to find documentation that the retinal specialist appointment had been scheduled or that the resident had been seen.
Failure to Obtain Prescribed Eyeglasses for Resident With Vision Deficit
Penalty
Summary
The facility failed to ensure that Resident 48 received an assistive device to maintain vision ability. Resident 48 was admitted with diagnoses including diabetes and hypertension, and the care plan dated 4/21/25 identified a vision deficit related to decreased visual acuity with interventions to ensure eyeglasses were clean, appropriate, and being worn. A provider vision progress note dated 12/9/25 documented an eye exam for cataracts and blurry vision in both eyes, and the evaluation indicated glasses were prescribed and would be shipped to the facility two weeks after payment was received. During interviews on 5/18/26 and 5/21/26, Resident 48 stated the eye doctor visit occurred in January, a new glasses prescription was received, but no glasses had been received yet. The resident reported barely being able to see out of the current glasses and needing to get very close to the TV, and stated the resident had been waiting for months and did not know where the new glasses were. A physician progress note on 5/21/26 documented poor vision and noted the resident had an eye exam in January and ordered glasses but did not receive them. Staff stated the facility received an invoice from the optometrist after glasses were needed, that Social Services gave the invoice to the resident to inform them of the cost, and that no invoice from the 12/9/25 vision exam had been received or followed up on. The Administrator stated on 5/22/26 that the invoice for the new glasses had just been received and the facility did not assist with obtaining glasses in a timely manner.
Failure to Assist Resident With Eyeglasses Access
Penalty
Summary
The facility failed to utilize available resources to assist a resident in obtaining eyeglasses. R40’s records showed she had a history of stroke, high blood pressure, hemiplegia, myopia, and age-related cataracts. Her DO visit notes documented that eyeglasses were requested on 2/6/25 and again on 8/15/25, and her NP note on 4/8/26 recorded that she complained of worsening left eye vision and requested to see the eye doctor, resulting in an ophthalmology order on 4/15/26. R40 also stated during interview that her left eye was getting worse, she developed headaches when reading, and she needed eyeglasses. Despite these requests, the progress notes and care conference notes from 2/6/25 through 5/17/26 did not document that R40 was assisted with obtaining eyeglasses. Her communication care plan identified Spanish as her primary language and included a goal that residents’ needs would be anticipated and met, but there were no vision interventions. The HIM stated eyeglasses were not covered on R40’s EMA, the SS-D stated he was not aware of resources for someone on EMA to obtain eyeglasses and was not aware of R40’s request, and the administrator stated social services could look into eyeglasses resources for residents on EMA but had no specific resources or policies. The SS-D later stated there was no specific policy for resources on the acquisition of eyeglasses for residents on EMA.
Failure to Arrange Audiology Referral for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure Resident 65 received proper assistive devices to maintain hearing abilities by not assisting with arranging an audiologist referral consult. Resident 65 was admitted and readmitted with diagnoses including ataxia, spinal stenosis, dementia, and major depressive disorder, and the H&P stated she was not able to make her own medical decisions. The MDS indicated she did not have a hearing aid or other hearing appliances, and she required substantial to maximal assistance with multiple activities of daily living. Record review showed an ENT note documented diminished hearing and recommended an audiogram, another ENT note documented decreased hearing with wax removed from both ears, and an audiogram showed hearing loss significant enough to qualify for hearing aids and that she was eligible for them under Medi-Cal. During interview, Resident 65 stated she was not able to hear, wanted hearing aids, and said no one had come to check her hearing. CNA 11 stated Resident 65 had a hearing problem and did not have hearing aids, and the SSD stated she was responsible for hearing-related referrals and should have made a referral to the audiologist because Resident 65 still had hearing loss after ear wax removal. The SSD also stated Resident 65's hearing loss affected communication with staff and her ability to communicate needs effectively.
Inaccurate communication to OPT about missing eyeglasses
Penalty
Summary
The facility failed to ensure staff provided an accurate description of a resident’s vision concern to the optometrist when the resident’s eyeglasses were missing. Resident 101 had multiple diagnoses, including reduced mobility, generalized muscle weakness, and metabolic encephalopathy, and the admission history and physical stated the resident did not have the capacity to make medical decisions and could not make needs known. The resident’s record also showed impaired vision, use of corrective lenses, and a care plan addressing impaired visual functioning with an optometrist consult as needed. Resident 101 reported that the resident’s only eyeglasses, which were bifocal and transition lenses used every day, were missing after being kept in the nightstand. The resident stated the glasses were noticed missing on 5/07/2026, that an exhaustive search did not find them, and that without the glasses it was very hard to see, the resident’s eyes would get wet, and the resident could not read. The resident also stated that a pair of reading glasses previously made available was too blurry and could not be used to read books. Facility documentation showed the SSA emailed the optometrist’s office stating the resident needed replacement eyeglasses because the glasses were too blurry and the resident was unable to see with them. During interview, the SSA stated this was not an accurate communication and explained the resident had two pairs of glasses, one missing pair used every day and another pair that was too blurry to use. The DON stated the SSA should have included that the resident’s eyeglasses were missing, not blurry, and acknowledged the resident was unable to see the surroundings well without eyeglasses. The facility policy stated it was the facility’s responsibility to assist the resident in scheduling appointments and ensuring arrangements to obtain needed services.
Failure to Arrange Follow-Up Ophthalmology Care
Penalty
Summary
The facility failed to assist in arranging follow-up ophthalmology services for a resident with significant cognitive and communication impairment. The resident’s MDS documented a BIMS score of 2 out of 15, indicating severe impairment in daily decision-making, and listed diagnoses including aphasia and cerebral infarction. Clinical notes showed the resident developed herpes zoster on the left forehead, face, nose bridge, and left eye, with herpes zoster ophthalmicus and viral conjunctivitis, and an ophthalmology consult was ordered STAT along with antiviral treatment and isolation precautions. A retina specialist’s visit summary documented herpes zoster ophthalmicus of the left eye and included a referral to an ophthalmologist. The record did not show that the facility arranged, offered, or discussed a follow-up appointment with the referred ophthalmologist for the resident or the resident’s family. A nursing note stated the resident’s daughter would schedule the eye appointment and transportation, and staff later documented that the resident had been seen by an eye doctor the next day after the initial rash was identified. During interviews, an LPN stated that family members normally scheduled appointments, though she assisted as needed, and that she would usually obtain the physician’s note and coordinate with family for needed follow-up. The DON stated the facility had not set up the follow-up ophthalmology appointment because the NP said the resident did not need it. The NP stated her priority was getting the resident to the eye doctor right away and that she did not think follow-up was necessary because she had been checking the resident’s eyes and the resident reported having vision in the eye.
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