Villa Serena Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for one of three sampled residents (Resident 2) when Resident 2 experienced a change of condition on 4/5/2026 and 4/9/2026. This had the potential to result in not meeting Resident 2's needs, poor resident outcomes, or risk of serious injury.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 2) by failing to communicate Resident 2's change of condition and indication for the Speech Language Pathologist (SLP - profession that identifies, assesses, and treats speech, language, cognitive communication and swallowing disorders) evaluation. This had the potential to result in a delay of care or treatment for Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat one of four sampled residents (Resident 2) with respect and dignity when Resident 2's family member (FM) while on the phone with Resident 2 overheard CNA 1 speak to Resident 2 using an aggressive and frustrated tone. This deficient practice resulted in Resident 2 crying and responding I'm not stupid to CNA 1 and had the potential for Resident 2 to become afraid of and withdrawn when interacting with facility staff.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of verbal abuse for one of four sampled residents (Resident 2) when Resident 2's Family Member (FM) reported to Licensed Vocational Nurse (LVN 1) that Certified Nursing Assistant (CNA) used inappropriate words in an aggressive and frustrated tone when providing care to Resident 2. This deficient practice resulted in the inability of the California Department of Public Health (CDPH) to conduct a timely investigation and had the potential for information to be lost and/or forgotten.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of three of eight sampled residents (Resident 6, 13, and 19) by failing to: a. Assess Resident 6 for the pre (before) and post (after) RASS Assessment (administered tool used to assess a patient's level of agitation or sedation, ranging from +4 (combative) to -5 (unarousable) for administration of narcotic pain medication (powerful drugs used to treat moderate to severe pain) as ordered. This deficient practice had the potential to compromise safe medication administration and increase the risk of adverse outcomes.b. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to keep waste contained (trash covered and secure) when two large trash bins in the facility's parking lot were left open. This failure had the potential to allow pests (tiny living things that can make people sick) to enter the area and result in spread of disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and maintain dignity for one of three sampled Residents (Resident 40) when the resident's meal tray was placed on a cluttered bedside table. This failure resulted in Resident 40's feeling unimportant during meal service.

Inspectors wroteBased on interview and record review, the facility failed to initiate a care plan to address the resident's risk for aspiration (inhalation of foreign materials) for one of three sampled residents (Resident 33). This deficient practice had the potential to increase Resident 33's risk for aspiration and choking.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five employees [Certified Nurse Assistant (CNA) 5] received a performance evaluation annually. This failure had the potential to result in resident injury or decline in level of care because the staff skills are not being evaluated or monitored.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff did not administer medication used to treat sever pain when the resident only had mild pain or no pain to one of four sampled residents (Residents 6). This deficient practice had the potential to result in inconsistent medication administration and Resident 6 receiving unnecessary medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 19 residents' bedroom rooms (2 and 3) accommodate no more than four residents in each room. This deficient practice had the potential to result in inadequate space to provide nursing care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 17 of 19 resident rooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the legally recognized decisionmaker and physician signed the Physician Orders for Life-Sustaining Treatment ([POLST] form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) form for one of three sampled residents (Resident 1). This deficient practice had the potential to cause Resident 1 to receive treatment or services against their wishes.

Inspectors wroteBased on interview and record review, the facility failed to initiate a change of condition (COC) when one of five sampled residents (Resident 1) was found with unknown skin discoloration on his right arm and not doing a pain assessment when Resident 1 was found with a skin tear. This deficient practices placed Resident 1 not being monitored for the COC and had the potential for delay in care.

Inspectors wroteBased on interview and record review, the facility failed to protect the Resident's right to be free from neglect when licensed nurses did not provide needed services to prevent the resident, who had difficulty breathing, from becoming unresponsive and die for one of one sampled resident (Resident 45). The facility failed to: 1. Ensure licensed nurses conducted timely assessments of Resident 45's physical condition when the resident developed breathing difficulty. 2. Ensure Licensed Vocational Nurse (LVN) 1 had Resident 45 vital signs (measurements of the body's basic functions including oxygen saturation [amount of oxygen in blood], blood pressure [force of blood pushing against the blood vessels walls in the heart], respiration [process of breathing in and out], heart rate ( pulse : [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who had a Full Code (resident wants all life saving measures in case of emergencies) status and was in distress received Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart (chest compressions) to increase the chances of a resident's survival for one of 39 residents who had a Full Code status (Resident 45). The facility failed to: 1. Ensure facility staff were knowledgeable what actions to take when responding to a resident in distress. 2. Ensure Licensed Vocational Nurse (LVN )1 announced a Code Blue (an announcement that signifies a medical emergency where a patient is experiencing a life-threatening situation) when he found Resident 45 unresponsive. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the facility's Water Management Plan (plan that identifies hazardous conditions and steps to take to minimize the growth and spread of bacteria[germs]) was implemented when the water management assessment was not completed. This deficient practice had the potential to expose residents and staff to Legionella (bacteria that can cause serious lung infections) and waterborne infections.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (contagious infectious disease), vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for serious outcomes such as being hospitalized due to COVID-19.

Inspectors wroteBased on observation, intervention, and record review the facility failed to provide a minimum of 80 square feet (sq. ft. ) for resident per resident in multiple rooms resident bedrooms ( 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12, 13, 14, 15, 16, 17, 18, and 19 for (17 of 19 residents room). This deficient practice had the potential to impact the ability to provide nursing care to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 4), who was assessed at a moderate risk for developing a skin injury and had intact skin, did not develop the following: a. Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the sacrum area (tailbone) measuring 0.5 centimeters [(cm) unit of measurement] in length, 0.5 cm in width and 0 cm in depth on 1/5/2025. b. An open area 0.5 cm round superficial red open area on the right buttocks area on 5/25/2024, resolved (healed) on 6/7/2024. c. Stage II pressure injury on coccyx (tailbone area) measured 1.5 cm length by 1.3 cm in width, and 0.2 cm in depth on 6/21/2024, resolved on 7/16/2024. The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) resident (Resident 22) received dialysis care and services based on professional standards. The facility failed to: a. Notify the physician, assess Resident 22, educate Resident 22 regarding and risk for missing HD, and monitor Resident 22 for complications after Resident 22 missed HD on 1/2/2025 and 1/3/2025. b. Assess Resident 22 and complete Resident 22's Dialysis Transfer Information (form used by facility and dialysis center to communicate regarding resident status) prior to sending Resident 22 to dialysis on 12/14/2024. These deficient practices had the potential to result in complications from dialysis.

Inspectors wroteBased on interview and record review the facility failed to ensure: a) One of three sampled resident's (Resident 22) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained. b) Three of six sampled resident's (Resident 22, 41, and 18) were evaluated for a gradual dose reduction (involves the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication) of psychotropic medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications appropriately for one (Residents 39) of three residents observed during the medication pass. During medication pass, there were two medication errors out of twenty-six opportunities. These medication administration errors resulted to a medication error rate of 7.69 percent.

Inspectors wroteBased on observation, interview and record review, the facility: a. Failed to ensure medications for one of three residents (Resident 41) were stored in a secure location. b. Failed to ensure the medication refrigerator temperature was within normal range (30 to 4g degrees Fahrenheit). These deficient practices had the potential to result in unauthorized use of medications and the loss of viability (ability to work) of medication for improper storage temperature.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed food production recipes and fortified diet (diet to increase caloric intake) guidelines during lunch preparation and tray line observation on 1/13/2025 when: 1.cook used small scoop size to serve pureed fish for residents on pureed diet. 10 residents on pureed diet received 3/8 cup (3 ounces (oz.)) of pureed fish instead of ½ cup (4ounces (oz).) per menu. Three residents on the renal diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balanced in the body in individuals with kidney disease or who are on dialysis) received peas for lunch instead of green beans per menu. 2. Fortified diets (diet enhanced to increase caloric content) were not prepared and were not served to residents who were on fortified diet. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1. One open bag of frozen pepperoni with and one large plastic bag of diced chicken were stored in the freezer with no open date or label. One bag of frozen chicken thighs stored uncovered in the reach in freezer. 2. One Dietary Aide (DA1) working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine. 3. Dishware were not sanitized with adequate amount of sanitizer per manufactures guidelines. Sanitizers and disinfectants are used on food contact surfaces to prevent food borne illness. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of 10 hours of continued education in the field of Infection Prevention and Control (IPC) for the one of one facility staff (Infection Prevention Nurse -IPN). This failure had the potential to result in negative health outcomes for the staff and residents of the facility.

Inspectors wroteBased on interview, and record review, the facility failed to implement its protocol for antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics by clinicians) by not monitoring the side effects and addressing antibiotic (a substance used to kill bacteria and to treat infection) use for one of two sampled residents (Resident 16). This failure had the potential for the Resident 16 to receive inappropriate antibiotics and develop adverse reactions for long term antibiotic use.

Inspectors wroteBased on observation , interview and record review, the facility failed to ensure two of 19 residents' bedroom , rooms( 2 and 19) accommodate no more than 4 residents in each room. This deficient practice had the potential to result in inadequate space to provide nursing care.

Inspectors wroteBased on observation, interview and record review, the facility's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to ensure one of one resident (Resident 41) was assessed to determine if the resident was capable of self-administering medications. This deficient practice had the potential for Resident 41 to self-administer medications incorrectly resulting in subtherapeutic (below the level necessary to treat effectively) medication effects which can lead to health issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that a resident has an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one of three sampled residents (Resident 42). This deficient had the potential to cause conflict with the residents' wishes regarding health care. During a review of Resident 42's admission record, the admission record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (MDD: a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive state of decline in mental abilities), and hypertension (high blood pressure). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents' (Residents 39 and Resident 44) Preadmission Screening and Resident Review (PASRR) assessment screening was reassessed to determine the facility's ability to provide the special needs of the residents. This deficient practice placed the residents at risk of not receiving necessary care and services they need. a. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (MDD a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (group of mental health conditions characterized by fear, nervousness, and excessive worry), and post-traumatic stress disorder (PTSD: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three residents' (Resident 7) Restoril (medication for insomnia - trouble falling or staying asleep) was available. This deficient practice had the potential to result in Resident 7's lack of sleep which can result in negative health outcomes. Findings During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnosis including insomnia. During a review of Resident 7's Minimum Data Set (MDS), a resident assessment tool, dated 11/14/2024, the MDS indicated Resident 7's cognition was intact. The MDS indicated Resident 7 needed set up assistance when eating, performing oral hygiene, and supervision with upper dressing, toileting hygiene, personal hygiene, and showering. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the physician about an abnormal laboratory (bodily specimen test process and resulting) result in a timely manner for one of one sampled resident (Resident 44). This deficient practice placed Resident 44 at risk for delayed treatment of abnormal laboratory results. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) with current episode manic without psychotic features, alcohol abuse (drinking alcohol in a harmful way or when dependent on alcohol), and adult failure to thrive (decline in health and ability for older individuals). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 34 had a peanut butter sandwich that was requested for a snack. This deficient practice had the potential to affect the resident's rights , wellbeing and can lead to insufficient food intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. One resident (Resident 2) who was on mechanical soft texture diet (soft food) received quesadilla (a Mexican dish consisting of a tortilla that is filled with cheese and then cooked on a griddle or stove) texture in form that meet their needs when the quesadilla was dry with hard and golden brown crispy edges, was not chopped and resident was not able to eat and stated it was overcooked. This deficient practice had the potential to result in decrease intake related to inconsistent texture, meal dissatisfaction, and increase choking and aspiration risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 2) care plan was revised to include interventions to reduce Resident 2's fall risk, such as staff to always provide direct line of sight (unobstructive view) supervision while Resident 2 was awake. The facility also failed to include Resident 2's Responsible Party (RP) in the care planning process during the interdisciplinary Team (IDT-team of healthcare professionals and the resident and/or Resident's RP working together to meet resident's goals) meeting held after Resident 2's sustained fall on 5/15/2024. These deficient practices had the potential to result in future falls for Resident 2 resulting in injury and it violated Resident 2's and Resident 2 RP's rights to be involved in the care planning process.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) who had a history of multiple falls, was supervised, and monitored while sitting in her wheelchair in the dining room. This deficient practice resulted in Resident 2 sustaining an unwitnessed fall on 5/14/2024 when Certified Nurse Assistant (CNA) 1 left Resident 2 unsupervised in the dining room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were enough bath and shower towels for 50 out of 50 sampled residents . This deficient practice places the residents at risk for infection, decrease in hygiene and comfort.

Inspectors wroteDuring observation, interview and record review the facility failed to ensure food was stored under food safety requirement by: 1. Unplugging the freezer for over 30 minutes while storing resident food. 2. Resident food stored in the freezer with a temperature of 15 degrees Fahrenheit (°F- scale of temperature). These deficient practices placed residents at risk for food-borne illness also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) and can lead to other serious medical complications and hospitalization for 48 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper infection control practices for the preparation and distribution of food was done under sanitary conditions in the kitchen for 48 out of 48 residents by: 1. Failing to ensure the Chlorine Sanitizer Agent (recommended to sanitize food contact surfaces including utensils, equipment, and tables) for the dishwasher was between 50-100 PPM (unit used to describe very small concentrations of a substance in a larger solution) for four dishwashing cycles. 2. Failing to ensure the Dish Machine Temperatures was within proper range of 120-160 degrees (a measure of temperature) for 5 dishwashing cycles. [...]

Inspectors wroteBased observation, interview and record review the facility failed to ensure three of 13 sampled residents rights were protected by: 1. Resident 49 received a cold temperature shower. This failure resulted in Resident 49 unknowingly being placed in a cold shower until the water temperature in the shower warmed up. 2. Resident 19 was not provided a dignity bag (restores the dignity of [catheterized-a procedure used to drain the bladder and collect urine, through a flexible tube patient by concealing urinary drainage bags from public view) for Resident 19 indwelling catheter ([foley catheter] plastic or rubber tube that is inserted into the bladder to drain the urine) drainage bag (collects urine). This deficient practice has the potential to affect resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the nursing staff member failed to ensure call light was within reach and in working condition for one of three sampled Residents (Resident 43). This deficient practice had the potential to result in Residents 43 not being unable to call facility staff for help when needed and delay in necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 13 sampled residents (Resident 48) had a Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment done when diagnosed with paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) prior to admission. This deficient practice had the potential for Resident 48 not receiving the necessary services and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased an observation, interview and record review the facility staff failed to ensure a resident's low air loss mattress (mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown. was inflated for one of two sampled residents (Resident 32). This deficient practice had the potential to negatively affect Resident 32 physical comfort and had Resident 32 pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the resident from having an unplanned severe (severe weight loss is the weight loss greater than 5 % in one month and greater than 7.5 % in three months) weight loss of 14 pounds ([lbs.] which constituted 7.4 percent % in one month and 10.3 % in two months) for one of 18 sampled residents (Resident 40). The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory tests of complete blood count ([CBC] a blood test that measures the number and quality of red blood cells (RBCs or erythrocytes) and white blood cells), comprehensive metabolic panel (CMP]a blood test about resident's body's fluid balance and levels of electrolytes) and a thyroid stimulating hormone ([TSH] measures the amount of thyroid stimulating hormone in your blood) test on 12/15/2023 as ordered by the attending physician on 12/17/2023 for one of one sample resident (Resident 40). This deficient practice had the potential to delay necessary care and treatment for Resident 40.

Inspectors wroteBased on observation and record review, the facility failed to ensure two of 19 resident bedrooms (rooms [ROOM NUMBERS] ) accommodated no more than four residents in each room . This deficient practice had the potential to result in inadequate space to provide nursing care.

Inspectors wroteBased on observation and interview and record review the facility failed to provide a minimum of 80 square feet (sq. ft.) for resident per resident in multiple rooms resident bedrooms (rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) for 17 of 19 resident's room. This deficient practice had the potential to impact the ability to provide nursing care to the residents.