Pacific Care Nursing Center
Pacific Care Nursing Center in Long Beach, CA — inspection on August 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
dirty diaper until someone finally came to change her. Resident 4 stated the facility was aware of the complaints against the 11 p.m. to 7 a.m. shift but it was still an ongoing issue.
During an interview on 8/21/2025 at 3 p.m., the director of staff development (DSD) stated she attended the Resident Council meetings and was aware of the issue with delayed response time to call lights during the 11 p.m. to 7 a.m. shift.
The DSD stated she had been working at the facility for four months and when she started the complaints about call light response times were really bad and now, they are just bad not really bad.
The DSD stated the expectation for answering call lights when residents needed something was right away or at least within 10 minutes.
The DSD stated the potential outcome of not answering a resident's call light right away was falls, the resident could be sitting in urine or poop for extended periods of time, and the residents may feel terrible.
During an interview on 8/21/2025 at 4:10 p.m., the director of nursing (DON) stated she was aware of complaints regarding the 11 p.m. to 7 a.m. call light wait times.
The DON stated the potential outcome of extended wait times for call lights was the resident's needs were not being met, patient satisfaction goes down, and increased risk for falls so it was very important to answer call lights right away.
The DON stated her staff were in-serviced regarding the long wait times during the 11 p.m. to 7 a.m. shift and the issue still continued.
The DON stated her staff were not competent in answering the call lights in a timely manner or the importance of answering the call lights within a timely manner.During a review of the facility's policy and procedure (P&P) titled Call Lights and dated 1/2017, the P&P indicated it was the facility's policy to respond to the resident's requests and needs and call lights should be answered promptly.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.