Medicare shows an abuse citation on record. Review the linked inspection sources and ask the facility about corrective action before deciding.
based on 16 Google reviews

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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Medicare shows an abuse citation on record. Read the linked source details, ask the administrator what corrective action was taken, and independently verify the facility’s current status before deciding.
Families should approach this facility with significant caution due to serious allegations regarding medication errors, lack of responsiveness from administration, and unprofessional conduct. While some reviewers praise the cleanliness and specific nursing staff, there are recurring reports of poor communication, difficulty reaching social workers, and issues with patient advocacy.
Quality Themes
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Concerns
Rating Trends
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Distribution · 18 analyzed
Personalized based on this facility's data
Key Review Excerpts
“The nurses and caregivers are attentive, patient, and genuinely caring, creating a safe and supportive environment for residents and families.”
“I left two messages on social workers ext. finally got to talk to Nancy the Social worker. I said I've left two messages on her ext nd she said she doesn't even have voice mail set up yet”
“They put a false statement in my sister's chart saying she struck at nurses, so she was rejected by another nursing home;”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 16 measures
9
measures
4
measures
3
measures
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose bladder or bowel control got worse
Residents needing more daily help over time
Residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Pacific Villa shows concerning patterns of repeated deficiencies, particularly in abuse protection and medication management, with families filing numerous complaints that triggered inspections. The facility has struggled with protecting residents from abuse, proper medication handling, infection control, and maintaining safe living conditions. While all violations show correction dates, the persistence of similar issues across multiple surveys suggests ongoing systemic problems that families should carefully evaluate before considering this facility.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Have properly installed hallway dispensers for alcohol-based hand rub.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Nursing and Physician Services Deficiencies
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.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Install an approved automatic sprinkler system.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Resident Rights Deficiencies
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Nursing and Physician Services Deficiencies
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Federal Penalties
Fine
Apr 28, 2025
$36,112
Fine
Feb 20, 2024
$2,279
Fine
Jan 22, 2024
$3,418
Pacific Villa, INC
for profit
Rollins-Nelson Healthcare Management
10 facilities nationwide
Chain avg rating: 2.1/5 · Rank 10 of 10 (Lowest rating)
Owners
Pacific Villa INC
Owner · Organization
The Palms Real Estate, LLC
Owner · Organization
Nelson, William
Owner
Rollins, Vicki
Owner
Nelson, William
Owner (parent company)
Rollins, Vicki
Owner (parent company)
Key personnel
Contact this facility directly and verify the details that matter most to your family.
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Google Reviews
16 reviews from families & visitors
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Original nursing home datasets
EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
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