Pacific Care Nursing: Hygiene & Pain Care Failures - CA
The family member told federal inspectors they had to cut the resident's nails during every visit to prevent injury. "The fingernails on Resident 15's right hand would pinch his skin and cause a cut to the middle of his palm," the family member said during a July 24 phone interview. They had notified nurses about the long fingernails several times, but the resident continued to have overgrown nails during their next visit.
When inspectors observed the resident that same day, they found long, jagged untrimmed fingernails on both hands. The fingernails on his contracted right hand were digging into his palm, causing visible redness to the area.
Licensed Vocational Nurse 3 opened the resident's contracted hand during the inspection and confirmed the damage. The nurse stated the long fingernails were causing redness to the palm "which could lead to injury and cause an infection." She said certified nursing assistants should cut residents' fingernails every week.
The resident, who suffered from cerebral infarction and was totally dependent on staff for all personal care, had a care plan specifically addressing skin integrity issues related to his hand contracture. Yet staff failed to provide the basic nail care that could have prevented the injury.
Another resident endured unrelieved pain for days while nurses failed to follow their own protocols for pain management. Resident 27, who had fibromyalgia and bilateral knee osteoarthritis, repeatedly told inspectors her pain remained at 7-8 out of 10 even after receiving morning medications.
"I received the patch for pain in the morning along with pain medications, but I continued to have pain," she said during a July 22 observation, pointing to her left upper arm where a lidocaine patch was applied. "The pain in my left upper arm was a 7-8/10 on the pain scale."
The next day, she shook her head and grimaced while rubbing her arm. "I received my morning pain medication, but I continued to have pain," she told inspectors, rating her pain at the same severe level.
Her care plan required staff to reassess pain 30 minutes after medication and notify the physician if additional medication was needed. Licensed Vocational Nurse 4 admitted she failed to document pain reassessments and should have offered additional medications or called the physician when the resident's pain wasn't relieved.
"If she had reassessed Resident 27's pain, she could have offered additional pain medications or called the physician if her pain was not relieved," LVN 4 told inspectors. She acknowledged the resident "could become distressed from having continuous unrelieved pain."
The facility also endangered a dialysis patient by failing to keep emergency bleeding supplies at his bedside. Resident 192, who received hemodialysis three times weekly, had no dialysis emergency kit in his room during multiple inspections over three days.
"Every resident that received dialysis needed to have a dialysis e-kit inside their room in case the resident experienced bleeding from their access site," Licensed Vocational Nurse 1 explained. "Residents were most at risk for bleeding after their dialysis."
The resident had received dialysis on July 23 and could have experienced excessive bleeding when he returned to the facility. Without the emergency kit containing clamps, tape, and gauze, nurses would not have had supplies to stop bleeding from his dialysis access site.
Registered Nurse 1 noted the resident received anticoagulant medication, making him higher risk for bleeding. "If Resident 192 were to have bleeding from his dialysis access site and did not have a dialysis e-kit readily available, he could have excessive blood loss," she said.
The Director of Nursing acknowledged the oversight could cause serious complications. "Excessive bleeding could cause a number of complications such as hypotension and hypovolemic shock," she told inspectors.
Medication errors throughout the facility put residents at additional risk. One nurse prepared double the ordered dose of iron supplement for a resident with a feeding tube, then administered it without checking tube placement or properly positioning the patient's head. The resident's head was elevated only 15 degrees instead of the required 30 degrees, creating aspiration risk.
Another nurse drew insulin from a vial without disinfecting it with alcohol, potentially exposing the diabetic resident to bacterial infection.
Staff also failed to document controlled substance administration properly. Licensed Vocational Nurse 3 gave a resident both pregabalin and tramadol on July 25 but didn't record either medication in the controlled substance log until questioned by inspectors.
"When administering controlled substances, it should be signed and documented as soon as possible to prevent medication errors," the nurse admitted.
The facility's infection control failures extended beyond medication handling. A resident's peripheral IV catheter had no date or initials, making it impossible to know when it was inserted or who placed it. Facility policy required changing IVs every 72 hours to prevent phlebitis.
Ventilator tubing for another resident was six weeks overdue for changing, despite monthly replacement requirements to prevent lung infections.
A nebulizer mask and tubing for treating breathing problems were found on the floor next to a resident's bed, undated and not stored in the required plastic bag. The respiratory therapist called the condition "unacceptable" and said it put the resident "at very high risk for respiratory infection."
During wound care treatment, a nurse repeatedly changed gloves without performing hand hygiene between changes, potentially spreading bacteria to open wounds. The treatment nurse acknowledged improper hand hygiene "had the potential to spread infection to Resident 37's wounds."
Food safety violations affected all 89 residents. The ice machine's interior showed black and brown residue when wiped with a clean paper towel, indicating possible mold or bacteria growth in ice served to residents throughout the facility.
A dented can of applesauce remained on storage shelves with ready-to-use cans instead of being separated for disposal. The dietary supervisor explained dented cans "put that food item at risk for the growth of botulism, which could be transmitted to the residents."
Expired medications and medical supplies created additional hazards. Sixty-nine packets of anti-diarrheal supplement expired in February 2023 remained in the medication storage room alongside four bottles of ultrasound gel expired since November 2023.
Eye drops and antifungal powder on medication carts lacked proper resident identification labels, creating risk for cross-contamination between patients.
The facility's quality assurance program failed to catch these systemic problems. The infection preventionist had not attended any monthly quality committee meetings since being promoted to the position, preventing the committee from receiving updates about infection control practices and outcomes.
These violations occurred during a routine federal inspection in July 2024 at Pacific Care Nursing Center, which houses residents requiring skilled nursing care and rehabilitation services. The facility received citations for failing to provide adequate personal hygiene care, pain management, respiratory care, dialysis safety, medication management, infection control, and food safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pacific Care Nursing Center from 2024-07-25 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 21, 2026 · Our methodology
Pacific Care Nursing Center in Long Beach, CA was cited for violations during a health inspection on July 25, 2024.
The family member told federal inspectors they had to cut the resident's nails during every visit to prevent injury.
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.