Health inspection·December 4, 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 two sampled residents (Resident 1) was not subject to abuse when Resident 2, who has history of schizophrenia (a mental illness that is characterized by disturbances in thought), and sudden mood changes threw water on Resident 1. This deficient practice resulted in Resident 1 feeling like she was drowning when the water that Resident 2 threw on her, covered her face, went into her mouth and down her throat.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 a diagnosis of hypertensive heart disease (a condition where the heart has been damaged by years of high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/10/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 was dependent on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired, and Resident 2 required partial/moderate assistance (helper does less than half the effort) to complete her ADLs. During an interview on 10/21/2025 at 9:04 a.m., Resident 1 stated while she was receiving ADL care from CNA 1, Resident 2 came over and poured water on her face, and the water went down her throat. During the interview Resident 1 was observed crying and stated she felt like she was drowning when the water was going down her throat. Resident 1 stated Resident 2 did not like her voice and had told her in the past, to shut the f*ck up and facility staff were present in the room when this happened. During an interview on 10/21/2025 at 9:45 a.m., Resident 3 stated she saw Resident 2 pour water on Resident 1's face. Resident 3 stated it looked like attempted murder, and it was intentional, like Resident 2 was drowning someone who could not move. Resident 3 stated the facility should have called the police, but they did not. During an interview on 10/21/2025 at 9:56 a.m., and a subsequent interview at 12:24 p.m., CNA 1 stated while providing ADL care to Resident 1, she (CNA 1) left the room to follow up on Resident 1's treatment. CNA 1 stated when she returned to the room she heard Resident 1 screaming. CNA 1 stated Resident 1 informed her that Resident 2 threw water on her. CNA 1 stated Resident 1 was crying, and her upper body was soaking wet. CNA 1 stated there were times when Resident 1 feared Resident 2 because when Resident 1 watched her television, Resident 2 would get mad at Resident 1 for having the volume up. CNA 1 stated on the same day, before the incident with the water pitcher, she saw Resident 2 move Resident 1's bedside table to her (Resident 2) side of the room, which made Resident 1 upset and caused her to cry. CNA 1 stated she had to remind Resident 2 that it was not her (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 4 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 12/04/2025 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)