Pacific Villa, Inc

review of facility's P&P titled, Abuse, Neglect, and Injury Reporting Policy, undated, the P&P indicated

was not observed by staff, injury is inconsistent with the resident's clinical condition, or there is

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

fracture was an injury of unknown origin.

The DON stated she did not notify the Administrator when

2/23/2026.

The DON stated the right humeral fracture should have been reported to CDPH

review of facility's P&P titled, Abuse, Neglect, and Injury Reporting Policy, undated, the P&P indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations.

The P&P indicated an injury of unknown origin is considered when the injury was not observed by staff, injury is inconsistent with the resident's clinical condition, or there is insufficient information to determine the cause after assessment.

Cross reference F-F607 and F-F610

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

DON stated she had been sidetracked and that it was her mistake, explaining it did not occur to her

Administrator was aware of the prior shoulder dislocation but not of the newly identified humeral

isolation, and unsafe conditions if abuse or neglect had occurred.During a review of facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, undated, the P&P indicated to take appropriate actions when abuse, or neglect is suspected.

The P&P indicated the facility will consider factors indicating possible abuse, neglect and exploitations of residents the following possible indicators such as physical injury of a resident from unknown source.During a review of facility's P&P titled, Abuse, Neglect, and Injury Reporting Policy, undated, the P&P indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations.

The P&P indicated an injury of unknown origin is considered when the injury was not observed by staff, injury is inconsistent with the resident's clinical condition, or there is insufficient information to determine the cause after assessment.Cross reference F-F607 and F-F609

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

reason.

observation, interview and record review the facility failed to ensure one of one sampled residents

78 at risk for weight loss.

Findings:During an observation on 2/24/2026 at 12:24 p.m. in the dining room, Resident 78 was seated in wheelchair, rocking back and forth and holding spoon in his right hand for 10 minutes before spooning food into his mouth while staff being observed by facility staff.During an observation on 2/24/2026 at 12:48 p.m. in the dining room, Resident 78 was observed with 75% of his meal still on his plate and not eaten after 30 minutes without staff assistance.During an observation on 2/24/2026 at 12:54 p.m. in Resident 78's room, Certified Nursing Assistant (CNA) 4 was observed assisting Resident 78 with his meal after not being assisted in the dining room for 30 minutes.During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including lack of coordination, heart failure(heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (abnormal high levels of fats in the blood), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety (emotion characterized by feelings of tension, worried thoughts).During a review of Resident 78's History and Physical (H&P), dated 10/17/2025, the H&P indicated Resident 78 had the capacity to understand and make decisions.During a review of Resident 78's Minimum Data Set (MDS- a resident assessment tool) dated 1/22/2026, the MDS indicated Resident 78 was dependent (helper does all the effort) on nursing staff with showering.

The MDS indicated Resident 78 needed setup or clean-up assistance with eating.

During an interview on 2/24/26 at 1243 p.m. with Resident 78, Resident 78 was asked if he needed assistance with eating, and Resident 78 stated yes.

During an interview on 2/25/2026 at 2:21 p.m. with CNA 4, CNA 4 stated Resident 78 takes more than a one hour to feed himself. CNA 4 stated when Resident 78 feeds himself, he takes a long time and his food gets cold. CNA 4 stated Resident 78 needs help with eating because he is unstable and rocks back and forth.

During an interview on 2/25/2026 at 2:55 p.m. with CNA 5, CNA 5 stated Resident 78 eats slow and takes too long for him to finish the food due to the movement it takes resident takes an hour to eat. CNA 5 stated when she assists Resident 78 with eating, he finishes in less than hour. CNA 5 stated Resident 78 will benefit from help and assistance with eating.

During an interview on 2/26/2026 at 10:40 a.m. with Registered Nursing Supervisor, (RNS) 1, RNS 1 stated Resident 78 could have a potential for weight loss with an inability to feed himself if not assessed properly.

During an interview on 2/27/2026 at 2:41 p.m. with the Director of Nursing (DON), the DON stated a negative outcome for weight loss could result in actual mental health issues, muscle loss, and nutrient deficiencies, for Resident 78 due to his lack of coordination with feeding.During a review of the facility's policy and procedure (P&P), titled Activities of Daily Living (ADLs), undated, The P&P indicated The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.

This includes the resident's ability to bathe, dress, and groom, transfer and ambulate, toilet, eat and use speech, language or other functional communication systems.

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

(Resident 63) with activities or regular room visits as part of an ongoing program to support the

sense of self-worth and psychosocial wellˆbeing, including feelings of usefulness, social connection, and personal satisfaction.Findings:During review of Resident 63's admission Records, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), major depression ( mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (loss of muscle strength).During a review of Resident 63's Minimum Data Set (MDS- resident assessment tool) dated 02/22/2026, the MDS indicated Resident 63's cognitive (ability to think, understand, learn, and remember) skills for daily decisions making was moderately impaired.

The MDS indicated Resident 63 required setup or clean up assistance (helper set up or clean up; resident completes activity) from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an observation on 02/24/2026 at 11:11 a.m., Resident 63 was observed lying quietly in bed on his side.During a concurrent observation and interview on 02/25/2026 at 10:44 a.m. with Resident 63, Resident 63 was observed lying quietly in bed, staring at the walls of the room. Resident 63 stated, no one regularly brought him books, and it only happened occasionally during his stay. Resident 63 stated he does not like going out for activities due to personal reasons. He stated he preferred his television in his room to be working so he could watch programs. Resident 63 also stated that his wife had recently passed away, and he often feels bored.During a concurrent observation and interview on 02/25/2026 at 11:55 a.m. with the Activity Director (AD), the AD stated she was not aware that Resident 63's room television was not working.

The AD stated the Resident 63 had not reported the issue, but acknowledged that it is the responsibility of all staff to observe and ensure that resident rooms are maintained in a homelike manner.

The AD stated she does not provide inˆroom activities herself and primarily conducts rounds.

The AD stated she will inˆservice staff to ensure resident needs were addressed before leaving their rooms and will increase the frequency of rounds to better identify and meet residents' inˆroom needs.During a concurrent interview and record review on 02/26/2026 at 7:55 a.m. with the Activity Assistant (AA),the activity participation logs were reviewed, including roomˆvisit and independent activity codes.

The activity participation logs indicated the inˆroom activity option coded as V4 (movies/TV) was not offered to Resident 63 according to his preferences throughout the month of February 2026.

The AA stated she thought Resident 63 did not like to watch television.

The AA stated she could not recall the last time she checked whether Resident 63 wanted to watch television or movies.

She stated she should be asking Resident 63 during each activity visit about his preferred activities and provide it to Resident 63 to help maintain a homelike environment for the resident.

During an interview on 02/27/2026 at 1:20 p.m. with the Director of Nursing (DON), the DON stated activities should be encouraged for all residents, and that if a resident refuses one activity, staff should offer an alternative aligned with the resident's preferences.

The DON stated resident preferences should be obtained, and any refusals or actions taken should be documented.During a review of the facility's policy and procedures (P&P) titled, Activities, undated.

The P&P indicated, Facility to provide an ongoing program of activities designed to meet the interest's choice and preference as well as to meet the interests of and support the physical, mental and psychological well-being of each resident, encouraging both independence and interaction in the community , as well as the physical, Mental and psychological well-being of each resident, encouraging both independence and interaction in the community.

Activities will be designed with intent to promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence.

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

the facility's policy and procedure (P&P), titled Ancillary Services, undated, the P&P indicated the

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

with the resident's goals and needs.

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

way that maximizes each resident's well being.

interview and record review, the facility failed to ensure staff competency in cardiopulmonary

breathing or heartbeat has stopped) for one of three reviewed staff members (CNA 2).

The facility failed to:1.Ensure CNA 2 demonstrates the knowledge and skills necessary to perform CPR by obtaining Basic Life Support (BLS-verifies training in essential, life-saving techniques for healthcare professionals and first responders focusing on CPR ) certification that includes an online training and in-person skills demonstrations.The failure to ensure CNA 2 completed the required handsˆon CPR skills competency had the potential to result in CNA 2 performing CPR ineffectively during lifeˆthreatening emergencies (dangerous or serious that it could kill or pose a very high risk of death if not handled or treated immediately) in the facility.Findings:During a concurrent interview and record review on [DATE] at 10:13 a.m. with the Director of Staff Development (DSD), CNA 2's Basic Life Support (BLS (BLS- trains participants to promptly recognize several life-threatening emergencies, give high-quality CPR, deliver appropriate breaths and provide early use of an automated defibrillator [AED used to treat sudden cardiac arrest by delivering a controlled electrical shock to restore a normal heart rhythm]) certificate and the facility's policy titled Cardiopulmonary Resuscitation were reviewed.

The DSD stated CNA 2 completed an online-only BLS course, and she acknowledged that she had accepted the certificate at that time.

The DSD stated the facility's policy requires CPR training to include handsˆon competency for BLS, and because CNA 2 did not complete an inˆperson skills demonstration, she would not be competent to perform CPR during an emergency.During an interview on [DATE] at 2:08 p.m., with the Director of Nursing (DON), the DON stated CNAs obtaining BLS certification through onlineˆonly courses could negatively impact resident care, as staff would be unable to perform proper CPR safely or respond appropriately during emergencies.During a review of facility's policy and procedure (P&P) titled, CPR, undated, the P&P indicated Facility's staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills.

The P&P indicated CPR certification which includes an online knowledge component still requires in-person skills demonstrations to obtain certification.

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

(the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients)

meeting the McGeers Criteria (a set of clinical definitions used for surveillance to define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions).This failure had the potential to result in Resident 48 developing antibiotic resistance (when bacteria develop defenses against the antibiotics designed to kill them) from unnecessary or inappropriate antibiotic use.

Findings:During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 48's diagnoses included hypertensive heart disease (heart damage leading to high blood pressure), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), cataracts (a common age-related eye condition involving the clouding of the eye's normally clear lens) and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 48's History and Physical (H&P) dated 6/18/2025, the H&P indicated Resident 48 was self responsible.During a review of Resident 48's Minimum Data Set (MDS-a resident assessment tool), dated 1/7/2026, the MDS indicated Resident 48 needed substantial to maximal assistance (helper does all the effort) with toileting, showering, and dressing.

The MDS indicated Resident 48 needed partial to moderate assistance (helper does half the record) with eating, oral hygiene, personal hygiene, transferring and walking.During a concurrent interview and record review on 2/26/2026 at 1:05 p.m., with the Infection Preventionist Nurse (IPN), Resident 48's Order Summary, dated 1/10/2026, was reviewed.

The Order Summary indicated Resident 48 had an order for metronidazole external cream (an antifungal antibiotic cream) to treat rosacea (a chronic long-term inflammatory skin) 0.75 percent ([%] unit of measurement) for 30 Days.

The IPN stated today is the first-time she has heard about Resident 48's order for the antibiotic.

The IPN stated the McGeer's criteria were not followed because it was not communicated that Resident 48 was on antibiotics.

The IPN stated Resident 48 could develop a Multi Drug Resistant Organism (MDRO-bacteria or germs resistant to multiple types of antibiotics) if there is no monitoring if the antibiotic is effective.

During an interview on 2/26/2026 at 3:29 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated on 10/31/2025 Resident 48 developed redness on the face and scalp. LVN 3 stated the doctor ordered the metronidazole external cream 0.75 %, on 12/12/2026, 1/10/26, and 2/13/2026. LVN 3 stated she did not notify the IPN Resident 48 was taking metronidazole cream, because she thought she only had to inform the IPN for antibiotics taken by mouth. LVN 3 stated Resident 48 was not monitored for effectiveness of metronidazole cream.

During an interview on 2/27/2026 at 1:57 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated metronidazole cream is an anti-fungal medication and needed to be monitored for Resident 48 for side effects to see if the skin infection was getting better. RNS 1 stated all skin issues should be documented, to know the condition of the skin.During a review of the facility's policy and procedure (P&P), titled, Unnecessary Drugs-Without Adequate Indication for Use, undated, the P&P indicated, each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements dose, duration of use, indications for use, adequate monitoring, presence of adverse consequences which indicate the dose should be reduced or discontinued, any combination of the reasons stated above.

The P&P indicated the use of any drug will be documented in the medical record to facilitate adequate care planning, including appropriate monitoring and resident centered care.

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

seen by a dentist within a couple of weeks.

The SW stated she must have missed arranging the dental

prevent him from consuming solid or harder foods.

During an interview on 2/27/2026 at 2:08 p.m. with

toothaches and experience discomfort while eating, which may lead to weight loss.During a review of facility's policy and procedure(P&P) titled, Ancillary Services, undated, the P&P indicated The facility will assess, arrange, coordinate and monitor ancillary services like dental services based on the resident's needs, physician orders, and interdisciplinary care plan.During a review of facility's P&P titled, Dental Services, undated, the P&P indicated dental needs of each resident are identified through physical assessment and identified needs as specified in resident's plan of care.

The P&P indicated the facility will assist the resident with making dental appointments and obtaining routine and emergency dental care.

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

During an interview on 2/27/2026 at 12:42 p.m. with the ADM, the ADM stated the food in the walk-in freezer should be inside the correct box with an open date.

The ADM stated the food needed to be labeled and dated so the facility will know what the product is and if it's expired.

The ADM stated if there was an old food product it is important to know the date it was opened so the residents would not get sick from Salmonella (a common bacteria that causes food poisoning) or Escherichia coli (E. coli- bacteria spread by eating undercooked ground beef, contaminated produce or unpasteurized dairy).

The ADM stated labeling and dating the food helps to prevent residents from getting sick, especially residents that are in a high-risk environment for foodborne illneses.

During an interview on 2/27/2026 at 12:55 p.m. with the Dietary Supervisor (DS) the DS stated when the kitchen received food products, the kitchen staff need to label the food product and write the date it was received.

The DS stated the dietary staff needed to know how long the food has been in the freezer because expired food could cause food borne illness.

During a review of the facility's policy and procedure (P&P), titled Food Receiving and Storage, undated, the P&P indicated All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

in accordance with accepted professional standards.

observation, interview, and record review, the facility failed to ensure Activity Assistant accurately

in 2/12/2026,2/13/2026,2/14/2026 and 2/2/24/2026.This deficient practice had the potential for confusion in the care and services provided to Resident 63 and placed the resident at risk of not receiving appropriate care due to inaccurate and incomplete medical information.Findings:During review of Resident 63's admission Records, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), major depression ( mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (loss of muscle strength).During a review of Resident 63's Minimum Data Set (MDS- resident assessment tool) dated 02/22/2026, the MDS indicated Resident 63's cognitive (ability to think, understand, learn, and remember) skills for daily decisions making was moderately impaired.

The MDS indicated Resident 63 required setup or clean up assistance (helper set up or clean up; resident completes activity) from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent interview and record review on 02/26/2026 at 7:55 a.m. with the Activity Assistant (AA), Resident 63's Activity Attendance record was reviewed.

The AA stated she did not know why the dates 2/12, 2/13, 2/14, and 02/24/2026 were not signed in the activity records. AA stated other activity staff sometimes assist with activities, and staff may have failed to sign the records.

The AA stated she believed the activities were completed for Resident 63 on those dates.

The AA stated if an activity was not recorded or documented, then it was considered not done.

The AA stated failing to document accurately and timely prevent staff from knowing what activities were provided and when they were completed for Resident 63.

During an interview on 02/27/2026 at 1:20 p.m. with the Director of Nursing (DON), the DON stated any activities completed for each resident must be documented to reflect that they were provided.

The DON stated that all staff should know and understand the importance of documenting what was done, as documentation demonstrates the service was provided.During a review of the facility's policy and procedures (P&P) titled, Documentation, undated the P&P indicated Facility to maintain accurate, complete, and reliable documentation as part of the residents' medical records and designated service log.

Staff are responsible for documenting service they personally provide in a clear, objective, and timely manner.

The entry is completed and signed by the individual who provided the service.

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

F, hot water should be stored above 140 F and circulated at a minimum return temperature of 124

identify where legionella and other waterborne pathogens can grow and spread in the facility's water

Housekeeping Supervisor, observed an uncovered large blue bin for dirty linens were located outside the facility. HS stated the facility outsource laundry services for their dirty linens.

Observed dirty linens not placed in a plastic bag and mixed with other plastic bags filled with dirty laundry.

Observed open plastic bags filled with dirty linens in the uncovered large blue bin. HS stated all dirty linens were placed in a plastic bag and securely closed before putting them in the blue bin. HS stated certified nursing assistants (CNAs) sort the dirty laundry and should place them in a closed plastic bag to prevent spread of infection.During a concurrent observation and interview on 2/26/2026 at 9:34 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 brought the rolling hampers outside the facility and tied the plastic bags filled with dirty linens before placing them in the uncovered blue bin. CNA 1 stated he closed the plastic bag securely to ensure no dirty linens will fall out of the plastic bag causing cross contamination and spread of infection in the facility.

During an interview on 2/26/2026 at 11:08 a.m. with the IPN, the IPN stated dirty linens should be placed in a bag and should be closed securely before placing them in the uncovered laundry bin outside facility to ensure prevention of cross contamination and spread of infection. IPN stated leaving the dirty linens not in the plastic bags or plastic bags not securely closed can attract insects or bugs and can cause spread of infection.During a review of facility's P&P titled, Handling Soiled Linen, undated, the P&P indicated The facility will handle, process and transport linen in a safe and sanitary manner to prevent spread of infection.

The P&P indicated soiled linen should be placed in a linen bag or designated lined receptacle and the bag should be closed securely and placed in the soiled utility room.

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Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807

if an antibiotic was administered without proper indication.During a review of facility's policy and

will be used in accordance with current standards of practice.

The P&P indicated antibiotic orders

appropriateness,