Buena Park Nursing Center: Care Plan Failures - CA
The resident, identified in inspection records only as Resident 1, was readmitted to the facility in March 2025 with a medical history that included glaucoma. A health examination conducted two days after her readmission noted she had no capacity to understand or make decisions for herself. She could not ask where her medications were. She could not call the pharmacy. She could not tell anyone her eyes were dry or her pressure was building.
Three eye medications had been ordered for her. Refresh Plus, a lubricating drop, was prescribed every two hours for dry eyes and surface irritation. 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, prescribed to reduce redness, was also ordered twice daily.
What the medication records show is a months-long pattern of missed doses with almost no explanation.
On March 29, 2025, the same day Refresh Plus was first ordered, it wasn't administered. The medication record was coded to indicate the dose was held, and separately coded to indicate her vitals were outside the parameters for administration. But the progress notes contained no explanation of what those parameters were or why the medication was withheld.
June 1 was worse. Refresh Plus was not given twelve times in a single day, from midnight through ten at night. A progress note acknowledged the pharmacy had been contacted for a refill. There is no record that the physician was ever informed. The following day, the medication was still missing. Nine more doses went ungivern before a supply apparently arrived.
The glaucoma medication, Timoptic, was missed on August 11. The record was coded to indicate nurses should see the progress note for an explanation. The progress note contained none. On September 3, the same medication was missed again. The progress note that day said the facility was awaiting delivery.
By October 15, it was Lumify that wasn't available. Nursing staff made three follow-up calls to the pharmacy. The pharmacy told them it didn't have the medication in stock. The records contain no indication that the physician was ever called.
A registered nurse interviewed by inspectors on January 27 acknowledged every one of these findings. She said it was the charge nurse's responsibility to request refills five days before a medication ran out. She also said the physician should have been notified each time a medication wasn't administered as ordered.
Nobody had done that.
The director of nursing and the administrator were both present when inspectors presented their findings on January 30. Both acknowledged what the records showed.
The inspection, conducted as a complaint investigation, cited the facility for failing to provide pharmaceutical services as ordered. Inspectors classified the harm level as minimal, meaning the violations had the potential to cause harm rather than documented injury. Whether the repeated gaps in her glaucoma medication affected Resident 1's eye pressure or vision, the inspection report does not say. That information wasn't recorded. The physician, by the facility's own nurse's account, was never told there was anything to ask about.
Resident 1 had been living with a condition that, left unmanaged, can permanently damage the optic nerve. Her doctor had written orders specifically designed to manage it. For months, those orders weren't followed, and no one with the authority to adjust her care or find another pharmacy was ever informed that the medications meant to protect her sight weren't making it to her eyes.
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.
The resident, identified in inspection records only as Resident 1, was readmitted to the facility in March 2025 with a medical history that included glaucoma.
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.