Villa Serena Healthcare Center
VILLA SERENA HEALTHCARE CENTER in LONG BEACH, CA — inspection on April 29, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reviewed, and revised by a team of health professionals.
interview and record review, the facility failed to revise the care plan for one of three sampled
4/9/2026.This had the potential to result in not meeting Resident 2's needs, poor resident outcomes, or risk of serious injury.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain), dysphagia (difficulty swallowing), and chronic bronchitis (inflammation of airways in the lungs.)During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2026, the MDS indicated Resident 2 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, for oral and personal hygiene, and upper body dressing, required moderate assistance (helper does less than half the effort) for toileting and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing.During a concurrent interview and record review on 4/28/2026 at 1:34 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's change of condition (COC) dated 4/5/2026 and COC dated 4/9/2026 were reviewed. LVN 1 stated the COC on 4/5/2026 indicated Resident 2 was coughing while drinking liquids. LVN 1 stated the COC on 4/9/2026 indicated Resident 2 was pocketing food (storing food in the mouth instead of chewing and swallowing it).During a concurrent interview and record review on 4/28/2026 at 3:26 p.m. with the MDS Coordinator (MDSC), Resident 2's COC dated 4/5/2026, 4/15/2026 and care plans were reviewed.
The MDSC stated Resident 2's care plan tilted Resident 2 is at risk for impaired nutritional and hydration status was not revised to reflect Resident 2's COC episodes of coughing while drinking liquids on 4/5/2026 and pocketing food on 4/9/2026.
The MDSC stated the care plan should have been revised at the time of the COC's on 4/5/2026 and 4/29/2026.
The MDSC stated if care plans are not revised right away, there is a risk for resident decline, not meeting the resident's needs, or risk of serious injury.
During an interview on 4/29/2026 at 2:18 p.m. with the Director of Nursing (DON), the DON stated Resident 2's care plans should have been revised on 4/5/2026 and 4/9/2026 when the COC's were identified to ensure the appropriate interventions were implemented.During a review of the facility's policy and procedure (P&P), titled Care Planning, dated 2/9/2024, the P&P indicated a licensed nurse will initiated the care plan, and the plan will be finalized in accordance with OBRA/MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by the clinical assessment and judgment on an as needed basis.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
055329 04/29/2026
Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813
During a review of the facility's job description (JD), titled
evaluates residents and develops appropriate care plan and communicates patient status and need to the patients, family, caregivers, or other members involved with patient care.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.