Health inspection·September 23, 2025

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 2565756 and complaint number 2514550. The inspection was limited to the specific facility-reported incident and complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for facility reported incident 2565756 and complaint number 2514550 at F-tag 685/G. F685 §483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- (1) In making appointments, and (2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. 22 CCR § 72301 (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 22 CCR §72311 (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72313 (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 22 CCR § 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 7/3/25, an unannounced visit was conducted at the facility to investigate a complaint regarding a resident who did not receive his eye drops and missed his eye doctor's appointment. Resident 1 is a 62-year-old male who was admitted to the facility on 7/13/23 and has diagnoses of ischemic refractory left eye (is a term that combines two significant medical concepts: ischemia, which is reduced blood flow, and refractory, meaning resistant to treatment. The phrase points to a severe, treatment-resistant eye condition caused by a lack of oxygenated blood reaching the eye's tissues. This can result from underlying vascular diseases and may require a multi-specialty approach to treatment), history of transient ischemic attack (mini stroke, temporary disruption of blood flow to the brain), cerebral infarction (brain tissue death caused by a lack of blood flow to the brain), and tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] through the front of the neck. This opening allows a tube to be inserted to maintain an airway and allow breathing) status, and cerebral infarction (loss of blood flow to a part of the brain resulting in brain tissue death). Based on observation, interview, and record review, the facility failed to provide services to maintain vision for one of three sampled residents (Resident 1) when the facility failed to: Administer Lumigan (prescription medicated eye drops which help reduce intraocular pressure-the fluid pressure in the eyes. If the pressure is too high, it can cause irreversible vision loss) as ordered by the ophthalmologist (OPTH - medical doctor who specialize in all aspects of eye care). Arrange the follow-up appointment with OPTH as ordered for continued eye assessment and eye care management. These failures resulted in Resident 1 experiencing sustained elevated intraocular pressure (IOP is the fluid pressure inside the eye, normal IOP is 10 - 21 millimeters of mercury [mmHg - unit of pressure]) in the left eye, pain, headaches, photosensitivity (sensitivity to light), blurry vision, neovascularization (abnormal blood vessel growth that can result in bleeding, swelling, and vision loss), corneal edema (swelling of the cornea, the clear outer layer of the eye that helps focus light), ischemia (insufficient blood flow), optic nerve (the nerve that sends visual messages to your brain to help you see) damage and permanent loss of vision to the left eye. Findings: During a review of the facility "Resident Appointment Calendar (RAC)," dated 2025, the RAC indicated Resident 1 was seen by OPTH on 2/11/25. During a review of Resident 1's "OPTH Notes (OPTHN)," dated 2/11/25, the OPTHN indicated Resident 1 was to start Lumigan eye drops at night. During a review of Resident 1's "ORDER SHEET (OS)," dated 2/11/25, the OS indicated Resident 1 was to start Lumigan one drop to both eyes for 12 months starting on 2/11/25. During a review of the facility's "Social Services Concern Log (SSCL)," dated 4/9/25, the SSCL indicated Resident 1 wanted all the lights in his room to remain off due to pain in his eyes from the light. The SSCL indicated Social Services Director (SSD) informed Resident 1 that his roommate (Resident 2) had the right to have his side of the room light on. The SSCL indicated Resident 1 requested to be moved to another room where the entire room lights can remain off, but the facility was not able to accommodate this request. The SSCL dated 6/17/25 indicated, "Resident (1] attended [OPTH appointment] on 6/17/25. Found out his (Resident 1) drops (Lumigan) had not been continuous [sic] and did not attend March (2025) f/u [follow up appointment]." During an interview on 7/2/25 at 9:57 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 had a loss of vision to his left eye due to the facility not giving his Lumigan eye drops as ordered by OPTH. During a review of Resident 1's Minimum Data Set (MDS - comprehensive assessment tool), dated 7/10/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS - an assessment of how well a person thinks, remembers, and learns) score was 15 on a scale of 0 - 15 (13-15 means cognitively intact). During a concurrent observation and interview on 7/15/25 at 2:01 p.m. with Resident 1 in Resident 1's room, Resident 1 was lying in bed, the room was darkened with all the lights off. Resident 1 had reddened lines in the white portion of his left eye. Resident 1 was using a communication board (a board with letters, symbols, and/or photos that allow a person who cannot speak to communicate) and using his head in a yes or no fashion. Resident 1 stated, "I am going blind." Resident 1 stated he had pain in both eyes at a level of 9 on the pain scale (a pain scale of 9 means severe pain, with 10 being the highest). During an interview on 7/15/25 at 2:15 p.m. with Registered Nurse (RN) 1, RN 1 stated she was assigned to Resident 1 over the past several months. RN 1 stated Resident 1's room is kept dark because the light bothers his eyes. RN 1 stated there was a recent issue with Resident 1 not getting his medicated eye drops for approximately a month and a half. During an interview on 7/15/25 at 2:40 p.m. with SSD, SSD stated during an interdisciplinary meeting (IDT - a gathering of healthcare professionals from various disciplines to discuss and coordinate a patient's care plan) (date not specified) with FM 1 regarding Resident 1, SSD stated Resident 1's Lumigan eye drops were stopped after he had to go to the emergency department (ED) for chest pain (date not specified) and when he returned, there was a miscommunication about the Lumigan eye drop orders, and they (Lumigan eye drops) were not resumed despite having no order to discontinue. During an interview on 7/15/25 at 3:17 p.m. with Nursing Facility Supervisor (NFS), NFS stated Resident 1 was sent to the ED (Emergency Department/Hospital) on 4/10/25 for complaints of chest pain and was admitted to the acute hospital. NFS stated Resident 1 returned to the facility on 4/12/15 but the orders for his Lumigan eye drops were dropped for some unknown reason. NFS stated Resident 1 did not start his Lumigan eye drops again until after his OPTH appointment on 6/17/25 (two months and five days later). NFS stated, "My opinion is, they [acute hospital] dropped the ball [Resident 1's Lumigan eye drop order] and we [facility staff] should picked it back up [Lumigan eye drop]." During a review of Resident 1's "Medication Administration Record Report (MARR)," dated 2025, the MARR indicated Resident 1 did not receive Lumigan eye drops from 4/12/25 until 6/17/25 (two months and five days). During a review of Resident 1's "OPTH Specialist Note (OPTHSN)," dated 7/29/25, the OPTHSN indicated, "On December 19, 2024, [Resident 1] intraocular pressure (IOP) was 17 mmHg [millimeters of mercury, a unit of pressure, specifically indicating the pressure exerted by a column of mercury one millimeter, normal IOP is 10 - 21 mmHg] in the right eye and 46 (mmHg) in the left eye. Moderate ptosis [drooping/sagging of the upper eyelid] was present as well as cataract [a medical condition in which changes to the lens of the eye causes blurred vision and whitening] changes. . . Lumigan drop(s) was ordered to the left eye for his elevated intraocular pressure. His next visit was in three to four weeks. . . On February 11, 2025 [7 weeks 5 days], he [Resident 1] was seen for a follow up examination. He was not on the eyedrops [Lumigan] that was prescribed. His intraocular pressure was 13 [normal] and 34 [high] in the right and left eye respectively. Corneal edema was present in the left eye. He [Resident 1] was reordered the Lumigan to the left eye . . . His next follow up was approximately next month. . . He was seen on June 17, 2025 [18 weeks / 4 months and two weeks later]. The patient relayed a history of pain with headaches, photosensitivity and blurry vision. Ascertained [found out] at 20/400 [this vision score means you can only see clearly at 20 feet what a person with normal vision can see at 400 feet] in the right eye and no light perception [the ability to detect the presence or absence of light, distinguishing it from darkness] in left eye. The examination is noteworthy for dense milky white cataract, left eye much worse than right. He also was not using his prescribed eyedrops. Patient [Resident 1] was also noted to have neovascularization in the left eye due to presumed ischemia. . . Orders for the Lumigan . . . to both eyes were prescribed." During a review of the facility's policy and procedure (P&P) titled, "MEDICATION ADMINISTRATION (MA)," dated 4/10/24, the P&P indicated, "All patient care areas where medications are administered are affected by this policy . . . Medications at [facility] will be administered only upon the order of physicians . . . Nursing staff assumes the responsibility of retrieving and administering medications based on complete and validated orders. In all areas, this includes responsibility for accurate documentation of medication administration. . ." This policy was not followed when the nursing staff did not administer the Lumigan eye drops as prescribed by the physician from 4/12/25 to 6/16/25 (over two months). During a review of Resident 1's "Resident Progress Notes (RPN), dated 2/11/25, the RPN indicated Resident 1's OPTH scheduled Resident 1 to be seen again on 3/11/25 at 2:30 p.m. During a review of the facility's "RAC," dated 2025, the RAC indicated Resident 1 was not scheduled by the facility for the 3/11/25 appointment per OPTH. During an interview on 7/2/25 at 9:57 a.m. with FM 1, FM 1 stated Resident 1 did not go to his OPTH appointment on 3/11/25. FM 1 stated she was unaware of Resident 1's appointment on 3/11/25 until Resident 1 was seen by OPTH in June 2025. During an interview on 7/15/25 at 2:40 p.m. with SSD, SSD stated Resident 1 missed his OPTH appointment on 3/11/25 because the nurse (not specified who) did not place it [appointment] into the RAC. During an interview on 7/17/25 at 1:22 p.m. with NFS, NFS stated the process the facility takes for resident appointments is to verify the order, log the appointment in the facility RAC, notify family of appointment, and ensure appropriate staff are scheduled to go with the resident. NFS stated it appeared as though the nurse (not specified) who received the order on 2/11/25 for Resident 1's follow up with OPTH on 3/11/25 did not verify the order nor place it into the facility RAC. During an interview on 8/8/25 at 1:49 p.m. with Quality Assurance Nurse (QAN), QAN stated the facility did not have a policy and procedure on arranging resident appointments. The facility failed to follow prescribed orders, administer medication in accordance with physician orders, develop and implement its own policies and procedures and ensure proper treatment to maintain vision. These failures to administer essential medication and assist with follow OPTH appointments resulted in Resident 1 experiencing untreated and sustained elevated intraocular pressure in the left eye for months, with documented findings of decompensated glaucoma on exam including corneal edema and neovascularization, contributing to cataract progression, ischemia, and optic nerve damage, and permanent loss of vision in the left eye. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a Class "A" citation.