Buena Park Nursing Center: Pharmacy Service Failures - CA
The resident, identified only as Resident 1 to protect confidentiality, was readmitted to the facility in March 2025 with a medical history that included glaucoma. A health examination conducted two days after readmission documented that the resident had no capacity to understand or make decisions. That meant the resident could not advocate for themselves when medications stopped appearing.
Three eye medications had been ordered by the physician. Refresh Plus, a lubricating drop for dry eyes and surface irritation, was ordered every two hours in both eyes, one of the more frequent medication schedules a nursing home staff has to maintain. Timoptic, a prescription drop used to lower fluid pressure inside the eye in cases of uncontrolled primary open-angle glaucoma, was ordered twice daily. Lumify, used to reduce eye redness, was also ordered twice daily.
The missed doses began almost immediately.
On March 29, 2025, the same day Refresh Plus was first ordered, nurses recorded that the medication was held and then marked as outside administration parameters. No progress note explained why, and no parameters were documented.
Then on June 1, 2025, Refresh Plus was not given twelve times across a single day, from midnight through ten at night. A nursing note from that day acknowledged the pharmacy had been contacted for a refill. But there was no documentation that the physician was ever told. The following day, June 2, the medication was again unavailable, and nine more doses were missed before the afternoon.
Months later, problems continued with a different drug. On August 11, Timoptic was not administered at the scheduled five o'clock hour, and the progress note that was supposed to explain why contained no explanation at all. The same thing happened again on September 3, when a note finally stated the medication was awaiting delivery.
By October 15, it was Lumify that had run out. Nursing staff made three follow-up calls to the pharmacy that day. The pharmacy told them it had no stock of the medication. The notes documented the calls. They did not document any call to the physician.
A registered nurse interviewed by inspectors on January 27 acknowledged all of it. She said it was the charge nurse's responsibility to submit a refill request five days before a medication ran out, and that the physician should have been notified whenever a medication was not given as ordered. Neither had happened consistently.
The director of nursing and the facility administrator were both present at a meeting with inspectors on January 30, the last day of the inspection. They acknowledged the findings.
The inspection was triggered by a complaint. Inspectors rated the harm level as minimal, or potential for actual harm, a designation that reflects what was documented rather than what the consequences of missed glaucoma medication may have been over time. Untreated elevated pressure inside the eye is a recognized cause of permanent vision loss.
Buena Park Nursing Center's own medication administration policy, last revised in May 2019, states that medications must be given safely, timely, and in accordance with physician orders. The gap between that written standard and what Resident 1's medication record showed was not subtle. It was twelve missed doses in a single day, a physician left uninformed for months, and a pharmacy that had simply run out of a drug with no documented plan to get it elsewhere.
Resident 1 had no capacity to ask where the eye drops were. Nobody asked on their behalf.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Buena Park Nursing Center from 2026-01-30 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: August 5, 2026 · Our methodology
BUENA PARK NURSING CENTER in BUENA PARK, CA was cited for violations during a health inspection on January 30, 2026.
A health examination conducted two days after readmission documented that the resident had no capacity to understand or make decisions.
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.