California Post Acute: Glaucoma Care Plan Failures - CA
California Post Acute's own Minimum Data Set nurse confirmed the facility failed to address the resident's glaucoma in both their standardized assessment and individualized care plan. The nurse acknowledged this created serious safety risks.
"The risk to the resident is injury, resident cannot reach call light, weight loss due to not seeing food," the MDS nurse told inspectors during an August 1 interview.
Resident 1 arrived at the facility with three significant medical conditions requiring coordinated care. The paraplegia left them unable to control or move muscles in their legs and lower body. Their bipolar disorder causes shifts in mood, energy and concentration. The glaucoma threatens their vision.
Yet when inspectors reviewed the resident's Minimum Data Set assessment, they discovered a contradiction. The standardized screening tool indicated Resident 1 "has adequate vision and does not wear corrective lenses" — despite the documented glaucoma diagnosis.
The MDS nurse reviewed the resident's complete medical record with inspectors at 11:22 a.m. on August 1. She confirmed the glaucoma diagnosis existed in the admission records. She confirmed neither the MDS assessment nor the care plan addressed this condition.
Glaucoma damages the optic nerve and can cause blindness if untreated. For a resident who already cannot move their lower body, vision problems compound mobility limitations and safety concerns.
The facility's own policy manual emphasizes thorough assessment and careful planning. The Care Plans policy, dated 2024, states interventions "are derived from a thorough analysis of the information gathered as part of the comprehensive assessment."
The policy requires "careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making."
None of this happened for Resident 1's glaucoma.
The MDS nurse's acknowledgment of injury risk reveals the practical consequences. A resident who cannot see properly and cannot move their legs faces heightened danger. They may struggle to locate their call light during emergencies. They may have difficulty identifying food on their plate, leading to poor nutrition.
These risks compound for someone with bipolar disorder, where mood and concentration fluctuations can affect decision-making and self-advocacy.
The inspection occurred in response to a complaint, suggesting someone outside the facility recognized problems with Resident 1's care that staff had missed or ignored.
Federal regulations require nursing homes to develop comprehensive, individualized care plans addressing each resident's medical conditions and functional limitations. The assessment process should identify all diagnoses and translate them into specific interventions.
At California Post Acute, this fundamental responsibility broke down. Staff documented the glaucoma diagnosis during admission but never integrated it into daily care planning.
The MDS assessment's claim that Resident 1 has "adequate vision" directly contradicts the glaucoma diagnosis in the same medical record. This suggests either inadequate communication between departments or insufficient attention to existing medical information.
For Resident 1, the oversight means living with untreated vision risks while managing paraplegia and bipolar disorder. The combination creates a cascade of potential problems that proper care planning should have anticipated and addressed.
The facility admitted knowing about all three conditions but chose to ignore one of them in their care approach. This selective attention to medical diagnoses violates federal standards requiring comprehensive, person-centered planning.
Resident 1's situation illustrates how administrative failures translate into daily vulnerability for nursing home residents who depend on staff for safety and basic needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for California Post Acute from 2024-08-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CALIFORNIA POST ACUTE in LOS ANGELES, CA was cited for violations during a health inspection on August 1, 2024.
The nurse acknowledged this created serious safety risks.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.