Health inspection·February 19, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of six sample residents (Resident 1) was not physically assaulted by another resident while under the facility ' s care. This deficient practice resulted in Resident 1 being assaulted by her roommate (Resident 2) when during an unprovoked attack, Resident 2 hit Resident 1 with her fist then her shoe. Resident 1 sustained a contusion (a bruise) to her left upper and lower eyelid. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 2/4/2025 for evaluation and treatment where an ice pack was applied. 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] and readmitted on [DATE] with unspecified dementia (loss of cognitive [thinking process] functioning, remembering, and reasoning to such an extent that it interferes with a person ' s daily life and activities) and schizophrenia (a mental illness which can affect a person ' s thoughts, mood and behavior). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/1/2024, the MDS indicated Resident 1 had severe cognitive impairment. During review of Resident 1 ' s History and Physical (H&P) dated 1/17/2025, the H&P indicated Resident 1 was alert and oriented to person only, with episodes of confusion. During a review of Resident 1 ' s Nursing Progress note dated 2/4/2025 and timed at 2:07 p.m., the Nursing Progress note indicated Resident 1 was lying in bed asleep when Certified Nursing Assistant (CNA) 1 walked by Resident 1 ' s room and saw Resident 1 ' s roommate (Resident 2) assault Resident 1. The Nursing Progress note indicated Resident 1 was noted with a bruise on her left upper and lower eyelid. During a review of Resident 1 ' s Skin assessment dated [DATE] and timed at 2:33 p.m., the Skin Assessment indicated Resident 1 had a contusion on her left upper and lower eyelid. During a review of Resident 1 ' s Physician ' s Order Summary dated 2/4/2025, the Physician ' s Order Summary indicated to transfer Resident 1 to a GACH for further evaluation. During a review of Resident 1 ' s Nursing Note dated 2/4/2025 and timed at 10:59 p.m., the Nursing Note indicated Resident 1 was transported by ambulance to the GACH on 2/4/2025 at 6:05 p.m. (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 3 Event ID: 056313 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 056313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/19/2025 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)