Inspection·December 30, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide one of four sampled residents (Resident 1) medication as ordered by his physician when Resident 1 did not receive Refresh Liquigel Ophthalmic Gel 1 % (a thick, gel-like eye drop solution, often called artificial tears) in both eyes at bedtime for dry eyes.This deficient practice resulted in Resident 1 not receiving Refresh Liquigel Ophthalmic Gel 1 % as ordered and had the potential for Resident 1 to experience dry eyes.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/4/2025, the MDS indicated Resident 1's cognition (ability to think and reason) was intact required substantial/ maximal assistance (helper does less than half the effort) from staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Order Summary Report (Physician Order's) dated 12/18/2025, Resident 1 was to receive Refresh Liquigel Ophthalmic Gel 1 % one application in both eyes at bedtime for dry eyes, ordered on 12/18/2025. During an interview on 12/30/2025 at 10:56 a.m., Resident 1 stated he has not been receiving the eye drops at night that were ordered by his physician.During a concurrent observation and interview on 12/30/2025 at 11:57 a.m. with Licensed Vocational Nurse (LVN) 1, of the East 2 Station medication cart, LVN 1 stated there were no Refresh eye drops in the medication cart for Resident 1 and would need to follow up with the supervisor.During a concurrent observation and interview on 12/30/2025 at 12:21 p.m. and subsequent interview on 12/30/2025 at 2:36 p.m., with Registered Nurse (RN) 1, of the facility's House Supply closet (a locked storage area where a collection of over-the-counter medications [any non-prescription medicine] are kept in the facility) RN 1 stated there was no Refresh drops in the House Supply closet. RN 1 stated she could not find any pharmacy delivery receipts of the Refresh drops for Resident 1 indicating the Refresh drops were delivered to the facility. RN 1 stated there should have been a follow up regarding Resident 1's Refresh eye drops to see why it was not delivered to facility. RN 1 stated if Resident 1 does not receive the prescribed eye drops then Resident 1's eye dryness will remain untreated.During an interview on 12/30/2025 at 1:07 p.m., the Pharmacist confirmed Resident 1's order for the Refresh eye drops was processed today (12/30/2025). The Pharmacist stated if the medication is an over-the-counter medication, the Pharmacy will not provide it, unless it was specifically requested by the facility. The Pharmacist stated there was no documentation that the facility called regarding the Refresh eye drops.During a review of the facility's policy and procedure (P&P) titled Pharmacy Services, dated 4/2019, the P&P indicated residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. The P&P indicated nursing staff should communicate prescriber orders to the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056164 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056164 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Palms Healthcare 1020 Termino Avenue Long Beach, CA 90804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)