Pacific Palms Healthcare: Missed Eye Drops Order - CA
The resident, identified in the inspection report only as Resident 1, had been admitted to Pacific Palms Healthcare with a diagnosis of paraplegia. His cognition was intact. He required substantial help from staff to complete daily activities like bathing and dressing, but he knew what medications he was supposed to be getting, and he knew he wasn't getting one of them.
His physician had ordered Refresh Liquigel Ophthalmic Gel 1 percent, one application in both eyes at bedtime for dry eyes. The order was written on December 18. For twelve days, the drops were never administered.
When inspectors spoke with him at 10:56 in the morning on December 30, he was direct: he had not been receiving the eye drops at night that his doctor ordered.
Less than an hour later, inspectors walked to the East 2 Station medication cart with the licensed vocational nurse assigned to it. The nurse looked and confirmed there were no Refresh eye drops in the cart for Resident 1. She said she would need to follow up with her supervisor.
That follow-up led to the house supply closet, a locked storage area where the facility keeps over-the-counter medications. A registered nurse checked the closet. No Refresh drops there either. She then looked for pharmacy delivery receipts that would show the medication had at least been sent to the building at some point. She couldn't find any. "There should have been a follow up regarding Resident 1's Refresh eye drops to see why it was not delivered to the facility," she told inspectors. She added that if Resident 1 did not receive the prescribed eye drops, his eye dryness would remain untreated.
Inspectors then contacted the pharmacy directly. The pharmacist confirmed that Resident 1's order for the Refresh eye drops had been processed that day, December 30, the same day inspectors arrived. Not December 18, when the physician wrote the order. December 30, twelve days later, only after the inspection had already surfaced the problem.
The pharmacist explained how the gap happened. For over-the-counter medications, the pharmacy does not automatically fill and deliver them unless the facility specifically requests it. The pharmacist said there was no documentation that anyone at Pacific Palms had ever called about the Refresh eye drops.
The facility's own pharmacy services policy, last updated in April 2019, states that nursing staff are responsible for communicating prescriber orders to the pharmacy and for contacting the pharmacy if a medication is not available for administration.
Nobody had.
The inspection cited one deficiency, rated at minimal harm or potential for actual harm, affecting one of four sampled residents. The regulatory language is careful and qualified. But the experience it describes is not complicated: a man who cannot move his legs, who depends on staff for most of what he needs each day, told his caregivers through the normal channels that he needed eye drops at bedtime. A physician wrote the order. Twelve days passed. The drops were never ordered, never delivered, never placed in a cart, never administered. He was still waiting when inspectors walked in.
Dry eyes are not a life-threatening condition. The discomfort they cause, the gritty, burning sensation that worsens through the night without lubrication, is the kind of thing a person who could simply get up and drive to a drugstore would handle in an afternoon. Resident 1 could not do that. He was dependent on the system around him to do it for him. The system did not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pacific Palms Healthcare from 2025-12-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 20, 2026 · Our methodology
PACIFIC PALMS HEALTHCARE in LONG BEACH, CA was cited for violations during a health inspection on December 30, 2025.
The resident, identified in the inspection report only as Resident 1, had been admitted to Pacific Palms Healthcare with a diagnosis of paraplegia.
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.