Failure to Follow Audiologist and Optometrist Recommendations
Summary
The facility failed to follow through with the recommendations provided by an audiologist and an optometrist for a resident. The resident, who was moderately cognitively impaired, had been diagnosed with several conditions including unspecified psychosis, cognitive communication deficit, and major depressive disorder. The resident's medical record indicated a need for corrective lenses and a follow-up optometry visit, which was not conducted. Additionally, the resident complained of blurred vision and was identified with a cataract, for which surgery was declined, and new glasses were recommended. However, there was no evidence of any optometry visits in 2023 or 2024. Furthermore, the resident had an audiology visit where ear pain was reported, and the audiologist recommended consulting with a physician for wax removal and re-evaluating hearing afterward. Despite these recommendations, the resident did not receive the necessary follow-up care or treatment for ear wax removal. Interviews with the Director of Social Services and the Director of Nursing confirmed that the resident had not received the recommended follow-up care for both vision and hearing issues, which was a failure to adhere to the facility's policy on promoting residents' well-being and dignity.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to coordinate and implement audiology services and related interventions for two residents. One resident with a mild hearing deficit and bilateral hearing aids had orders for daily insertion and removal of the devices, but the aids were lost, later reported as needing repair and then broken, and the resident stated staff did not place them daily and that she had not seen the audiologist despite his recent visit. Another resident with multiple comorbidities had a physician order for audiology evaluation and treatment after an outside appointment, but was never seen by the facility audiologist, and the resident’s sister reported repeated missed audiology appointments and non-administration of ordered Debrox ear drops, ultimately arranging outside audiology care herself. The Administrator acknowledged that, after the social worker responsible for ancillary services left, no staff were covering audiology coordination, contrary to facility policy requiring assistance with routine audiology services and documentation of coordination efforts.
Failure to Provide Access to Vision Services: A resident with ESRD, DM2, hemiplegia, depression, anxiety, and anemia reported blurry vision and said she had not seen an eye doctor since admission despite requesting eye care. Her MDS showed intact cognition and adequate vision, but the care plan did not address vision, and staff confirmed the signed eye-doctor consent was supposed to be sent to Healthdrive yet the resident had not been seen.
Failure to complete audiology follow-up for a resident with hearing concerns. An audiology exam found impacted cerumen in both ears after the resident was referred for decreased hearing, and Debrox was recommended with follow-up in 1-3 months. The resident’s care plan included an audiology referral for a hearing deficit, but the resident was later observed pointing to their ears while trying to communicate, and the SW confirmed no follow-up audiology appointment was scheduled.
A resident on hospice with multiple diagnoses, including hearing loss, had documented moderate hearing difficulty and a care plan addressing hearing deficits, and later signed consent requesting an audiology consultation due to a new hearing deficit and decreased responsiveness. Despite this, the resident was never scheduled or seen by an audiologist for an extended period, could not hear normal conversation, and reported having no hearing aids or ear evaluation since admission. Facility leadership and the LSW confirmed the resident was omitted from the audiology list, missed a scheduled visit, and was affected by provider issues that left her without timely access to audiology services.
A resident with severe vision impairment and multiple comorbidities was recommended for cataract evaluation by an eye care consultant. Although staff attempted to find an ophthalmologist who accepted the resident's insurance and could accommodate bariatric needs, no appointment was scheduled, leaving the resident without necessary follow-up for vision care.
A resident with Alzheimer's disease and glaucoma did not receive a required eye doctor visit despite physician orders and a care plan indicating the need for vision services. Staff confirmed the resident had not been seen by an eye doctor since admission, and her glasses could not be located, contrary to facility policy requiring referrals for eye care.
Failure to Coordinate and Implement Audiology Services for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure audiology services and related interventions were implemented as ordered and as outlined in facility policy for two residents. One resident with diabetes, hypertension, depression, anxiety, and a documented mild hearing deficit had a care plan indicating bilateral hearing aids, with staff responsible for inserting and removing the devices and consulting audiology as needed. Physician orders directed staff to insert the hearing aids each morning and remove them at night, with storage in the medication cart. Nursing notes documented that this resident’s hearing aids were lost in early December and replaced later that month, then subsequently needed repair in late February and were reported as not working properly and then broken in early March. During a care plan meeting in late January, the resident’s representative asked about the hearing aids, and follow-up with nursing was noted. Despite an audiology visit to the facility in early April, the resident was not seen by the audiologist. On observation and interview in early April, the resident and an LPN noted a wire had come out of the right hearing aid; the LPN pushed the wire back in and placed the hearing aids in the resident’s ears, after which the resident stated she thought they were working. The resident reported she had not seen the audiologist in a long time, had wanted to see him during his most recent visit, and believed she had excessive ear wax requiring audiology evaluation. She also stated that nursing staff did not place her hearing aids in daily as ordered. The resident’s most recent annual MDS assessment documented adequate hearing with hearing aids, intact cognition, and no behaviors. The Administrator confirmed that the former social worker had been responsible for making audiology appointments, that the social worker had left, and that there was no one covering audiology coordination at the time, resulting in the resident not being seen during the audiologist’s last visit. A second resident, admitted with multiple diagnoses including a right ilium fracture, COPD, major depressive disorder, bipolar disorder with psychotic features, anxiety disorder, and a history of malignancies with a urostomy, had a physician’s order for audiology to evaluate and treat. The resident’s quarterly MDS showed moderate cognitive impairment, adequate hearing, no need for hearing aids, and independence with personal care. Nursing documentation indicated that after a physician appointment arranged by the resident’s sister, the physician discontinued two medications and ordered audiology assessment. Review of audiology visit records from several months showed the resident was never examined by the facility audiologist, including during the most recent visit. The resident’s sister reported that the resident was supposed to see the facility audiologist on multiple occasions but was not examined, that the facility stated the audiologist went to the resident’s former facility, and that an emergency audiology appointment promised by the facility was not scheduled for several weeks. She also reported being told Debrox ear drops were ordered weekly but never administered, and ultimately arranged an outside audiology appointment herself to have the resident’s ears flushed so the resident could hear again. The ADON confirmed the resident had never seen the facility audiologist since admission, and the Administrator confirmed that no staff were covering audiology or other ancillary services after the former social worker left, despite a facility policy stating the facility would assist residents in obtaining routine audiology services and document coordination efforts in the medical record.
Failure to Provide Access to Vision Services
Penalty
Summary
The facility failed to ensure Resident #102 received vision services. The resident was admitted with diagnoses including end stage renal disease, type 2 diabetes mellitus, hemiplegia and hemiparesis affecting the left nondominant side, major depressive disorder, anxiety disorder, and anemia. Her quarterly MDS assessment indicated intact cognition and adequate vision. A Healthdrive request for service dated 10/03/24 showed the resident requested to be seen by eye care, and a physician order dated 11/04/25 included treatment as needed by a podiatrist, dentist, or optometrist. However, the resident’s plan of care dated 02/25/26 did not address her vision. During interview, the resident stated she had blurry vision and had not seen anyone about it since coming to the facility, despite telling multiple people she wanted to see the eye doctor. Social Service Designee #135 stated that when residents sign the consent for the eye doctor, the form is supposed to be sent to Healthdrive so the resident can be seen, and she verified Resident #102 had signed the consent form but had not been seen. She also reported the resident had not seen the eye doctor since admission and would be signed up to see someone for blurry vision.
Failure to Complete Audiology Follow-Up for Resident with Hearing Concerns
Penalty
Summary
The facility failed to ensure Resident #18 had audiology follow-up completed after an audiology exam identified impacted cerumen in both ears. Resident #18 was admitted on 05/16/25 and had diagnoses including type II diabetes without complications, essential hypertension, peripheral vascular disease, acquired absence of the right leg above knee, plasma cell leukemia not in remission, solitary plasmacytoma not in remission, need for assistance with personal care, adjustment disorder with mixed anxiety and depressed mood, and bilateral hypertensive retinopathy. The 360 care audiology appointment dated 09/29/25 documented that the resident was referred by the facility due to decreased hearing, and the exam found impacted cerumen in both ears with Debrox recommended for cerumen management and follow-up in 1-3 months. The quarterly MDS dated 01/25/26 showed a BIMS score of 15 and noted minimal difficulty with hearing and no hearing aids. The care plan identified a communication deficit related to hearing deficit and included an intervention to refer to audiology for hearing consult as ordered. During observation on 02/17/6, Resident #18 was seen pointing to their ears while attempting to communicate. On 02/18/26, the Social Worker confirmed the resident was not scheduled for a follow-up audiology appointment.
Failure to Provide Timely Audiology Services for Resident With Hearing Deficit
Penalty
Summary
The facility failed to ensure timely access to audiology services for a hospice resident with documented hearing loss and identified hearing concerns. The resident was admitted with multiple diagnoses, including unspecified hearing loss, and an MDS showing moderate difficulty hearing while remaining cognitively intact. Her care plan included interventions for a hearing deficit, such as getting her attention before speaking, facing her in good light, and minimizing background noise. An ancillary services consent form, signed several months after admission, documented a request for an audiological consultation due to a new hearing deficit and decreased responsiveness. The hospice agreement sample indicated that the facility was responsible for providing facility services at the same level of care as before hospice election and in compliance with applicable regulations. Despite the documented need and consent for audiology services, the resident was not seen by an audiologist during her stay up to the time of the survey. Observation showed she could not hear an introduction from the foot of the bed, appeared frustrated, and stated she could not hear unless someone came very close and spoke loudly. She reported she did not have hearing aids, had not seen anyone about her ears since admission, and knew she needed her ears checked before getting help for her hearing. The Administrator, DON, and LSW confirmed the resident had not been seen by an audiologist, explaining she was not placed on the list when first admitted, was omitted from the March audiology schedule after signing consent, and that there were subsequent issues with the provider not having an audiologist in the area while the facility transitioned to a new provider.
Failure to Ensure Timely Ophthalmology Follow-Up for Severely Impaired Vision
Penalty
Summary
A resident with multiple diagnoses, including chronic diastolic heart failure, type 2 diabetes mellitus, morbid obesity, asthma, insomnia, major depressive disorder, dry eyes syndrome, and bilateral age-related cataracts, was admitted to the facility and assessed as having severely impaired vision. The resident was alert, oriented, and cognitively intact. Medical records showed that the resident was seen by an eye care consultant, who recommended a follow-up with an ophthalmologist for cataract evaluation. Despite this recommendation, the resident reported being unable to see due to cataracts and stated that cataract surgery had been recommended but no appointment had been scheduled. Facility staff documented attempts to contact eight ophthalmologist offices, noting difficulties in finding a provider who accepted the resident's insurance and could accommodate bariatric patients, but there was no evidence that an appointment was ultimately scheduled.
Failure to Provide Vision Services as Needed
Penalty
Summary
The facility failed to ensure that a resident received necessary vision services as required. The resident, who had diagnoses including Alzheimer's disease, major depressive disorder, hypertension, and glaucoma, had a physician's order for an eye doctor visit as needed and was prescribed Latanoprost eye drops for glaucoma. The care plan identified impaired visual function and included interventions such as arranging consultations with an eye care practitioner. Despite a referral being sent in June for the resident to be seen by the facility eye doctor, the resident had not been seen by an eye doctor since admission in 2020. Interviews with staff confirmed that the resident had not received an eye doctor visit and that her glasses could not be located. The resident herself was unaware of the whereabouts of her glasses, and a CNA reported never having seen her wear glasses during nine months of employment. The facility's policy required referrals for eye care appointments as needed, but this was not followed, resulting in the resident not receiving appropriate vision services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
