Pacific Villa, Inc

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for one of three sampled residents (Resident 1). This deficient practice had the potential to expose residents to unsanitary conditions and increase the risk of transmission of disease-causing organisms. Findings: During review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), hyperlipidemia ( a condition where both cholesterol and triglycerides are elevated in the blood) , and lack of coordination (refers to jerky, uncoordinated movements and balance problems caused by an issue with the part of the brain that controls muscle coordination). During a review of Resident 1's Minimum Data Set (MDS -resident assessment tool), dated 09/19/2025, the MDS indicated Resident 1's cognitive (ability to think, understand, learn, and remember) skill for daily decision-making was intact. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half of the effort. Helpers lift or hold

the trunk or limbs and provide less than the effort) in oral hygiene, toilet hygiene, shower/bath self, upper body dressing, lower body dressing, putting on /taking off footwear and personal hygiene. During a concurrent observation on 11/19/2025 at 9:30 a.m., with Resident 1. Resident 1's room was observed to be

in an unsanitary condition. Resident trash was overflowing from the bedside trash can, brown substances were scattered on the floor near the bed, the wall beside the bed had visible juice-like stains, and the restroom had multiple black stains on the floor and around the toilet. During an interview on 11/19/2025 at 11:21 a.m., with Certified Nurse Assistant (CNA) 1 , CNA 1 stated she had not yet called housekeeping, as

she was waiting to assist Resident 1 out of the room. CNA 1 stated she should have picked up the trash and cleaned the area, even while attending to other residents.During an interview on 11/19/25 at 1:42 p.m. with Housekeeper (HK), HK stated she was working her way down the hallway and had not yet reached Resident 1's room HK stated resident rooms were cleaned once per shift and as needed. During an

interview on 11/19/25 at 1:54 pm with the Housekeeping Supervisor (HS), HS stated that rooms are cleaned daily, and housekeepers were expected to make rounds of their assigned areas before leaving. HS acknowledged the restroom stains and stated that facility management was working on replacing the old flooring. During an interview on 11/19/25 at 2: 13 p.m. with the Director of Nursing (DON) the DON stated

she was unaware of the room's condition and acknowledged that all rooms were undergoing remodeling.

The DON stated she will address the issue with housekeeping and provide in-service training. During a

review of the facility's policy and procedure (P&P) titled Safe and home like Environment (undated) the P&P indicated In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pacific Villa, Inc

3501 Cedar Avenue Long Beach, CA 90807

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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observation, interview, and record review, the facility failed to ensure that window blinds were intact and provided adequate visual privacy for 5 of 18 sampled residents. This deficient practice resulted in residents' exposure to the parking lot and sunlight and a potential violation of residents' rights to visual privacy in five resident rooms.Findings: During a concurrent observation and interview on 11/19/2025 at 09:30 a.m. with Resident 1, Resident 1 room window blinds were missing slats, allowing sunlight and visibility from the parking lot. Resident 1 stated, I turn to the opposite side and cover my head when the sun rises. During a concurrent observation and interview on 11/19/2025 at 10:06 a.m., with Resident 4 in Resident 4's room, observed missing pieces of the window blinds. Resident 4 was exposed to the parking lot and sunlight was penetrating in the room on Resident 4 face. Resident 4 stated that the blinds had been broken for a long time and no one had come to fix them. During an interview on 11/19/25 at 2: 13 p.m. with

the Director of Nursing (DON), the DON stated she was aware of the missing blinds. The DON stated she would conduct rounds to ensure such issues were addressed promptly. During an interview on 11/19/2025 at 2:35 pm with Maintenance Director (MD), the MD stated the broken window blinds had been brought to his attention, but he had failed to follow up. The MD stated it was his responsibility to conduct daily rounds.

The MD stated he would implement a task log to ensure follow-up. The MD confirmed that the missing blinds exposed residents to the parking lot and sunlight and reported that replacement parts had been ordered and repairs were underway. During a review of the facility's policy and procedure (P&P) titled Resident Right, (undated), the P&P indicated, The residents have a right to a safe, clean, comfortable and homelike environment. During a review of the facility's P&P titled Safe and home like Environment (undated), the P&P indicated In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment.

Event ID:

Facility ID:

If continuation sheet