Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
6’23
41’24
17’25
15’26
79 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Feb 27, 2026 | D · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Feb 27, 2026 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Routine |
| Feb 27, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| Feb 27, 2026 | D · potential | Respond appropriately to all alleged violations. | Routine |
| Feb 27, 2026 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Feb 27, 2026 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Feb 27, 2026 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Feb 27, 2026 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Feb 27, 2026 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Feb 27, 2026 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Feb 27, 2026 | E · potential | Provide routine and 24-hour emergency dental care for each resident. | Routine |
| Feb 27, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 27, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Feb 27, 2026 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 27, 2026 | D · potential | Implement a program that monitors antibiotic use. | Routine |
| Dec 16, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Dec 16, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 4, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 4, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Dec 4, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Nov 19, 2025 | D · potential | 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. | Complaint |
| Nov 19, 2025 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Complaint |
| May 16, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| May 16, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| May 16, 2025 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| Apr 28, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 28, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Apr 28, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 28, 2025 | D · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Complaint |
| Apr 28, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Mar 14, 2025 | F · potential | Dispose of garbage and refuse properly. | Complaint |
| Feb 19, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 20, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Dec 20, 2024 | E · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Dec 20, 2024 | D · potential | 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. | Routine |
| Dec 20, 2024 | B · minimal | Ensure each resident receives an accurate assessment. | Routine |
| Dec 20, 2024 | E · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Dec 20, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 20, 2024 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Dec 20, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Dec 20, 2024 | E · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Dec 20, 2024 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Dec 20, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Dec 20, 2024 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Dec 20, 2024 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Dec 20, 2024 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Dec 20, 2024 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 20, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Dec 20, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 17, 2024 | D · potential | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Complaint |
| Feb 2, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Feb 1, 2024 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Feb 1, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jan 5, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Jan 5, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jan 5, 2024 | E · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Jan 5, 2024 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jan 5, 2024 | E · potential | Respond appropriately to all alleged violations. | Complaint |
| Jan 5, 2024 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Jan 5, 2024 | E · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jan 5, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jan 5, 2024 | D · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Jan 5, 2024 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jan 5, 2024 | D · potential | Provide care or services that was trauma informed and/or culturally competent. | Routine |
| Jan 5, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jan 5, 2024 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Jan 5, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jan 5, 2024 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jan 5, 2024 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jan 5, 2024 | E · potential | Provide routine and 24-hour emergency dental care for each resident. | Routine |
| Jan 5, 2024 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jan 5, 2024 | D · potential | Develop and implement policies and procedures for flu and pneumonia vaccinations. | Routine |
| Jan 5, 2024 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Dec 11, 2023 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Dec 11, 2023 | D · potential | Honor the resident's right to choose his or her attending physician. | Complaint |
| Dec 11, 2023 | D · potential | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Complaint |
| Dec 11, 2023 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Dec 11, 2023 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Complaint |
| Dec 11, 2023 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Pacific Villa, INC
3501 Cedar Avenue, Long Beach, CA 90807 · (562) 595-1731
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 056313
- Certified beds
- 95
- Legal owner
- Pacific Villa INC
- Part of
- Rollins-Nelson Healthcare Management
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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