Health inspection·January 21, 2024

F 0550 Drape and dress residents appropriately at all times to avoid exposure and embarrassment. Level of Harm - Minimal harm or potential for actual harm Based observation, interview and record review the facility failed to ensure three of 13 sampled residents rights were protected by: Residents Affected - Some 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. Findings: 1.During a review of Resident 49 admission Record (Face Sheet) the Face Sheet indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a serious condition in which the heart does not pump blood as sufficiently as it should), glaucoma (a group of eye disease), difficulty walking, and dysphagia (difficulty in swallowing). During a review of Resident 49's History and Physical (H&P) dated 12/13/2023, the H&P indicated Resident 49 had fluctuating (changing frequently and uncertainty) capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/15/2024, the MDS indicated, Resident 49 required setup or clean up assistance with eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 49 required supervision from staff with toileting, showering, lower body dressing, putting on and taking off footwear, changing positions from left to right, sitting to lying, sitting to standing, transferring from the bed to chair, transferring to the shower and walking. During an interview with Resident 49 on 1/20/24 at 10:27 a.m., Resident 49 stated a week ago (cannot remember exact date) a male nurse placed him in a cold shower. Resident 49 stated he told the nurse the water was too cold and was made to take a cold shower until the water eventually warmed up. Resident 49 stated sometimes you think you have no choice, and you feel helpless. During an interview on 1/21/2024 at 8:26 a.m. with Certified Nurse Assistant (CNA) 5, CNA 5 stated it can take up to five to seven minutes before the water starts to warm up in the shower. During an interview on 1/21/2024 at 8:37 a.m. with the Director of Nursing (DON), the DON stated it was a matter of resident rights Resident 49 should not be made to take a cold shower. During an observation on 1/21/2024 at 8:38 a.m. in shower 1, CNA 5 turned on the water in shower 1 and observed going to get towels while letting the water in shower 1 run. CNA 5 stated she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 2 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0550 preparing a resident for a shower. Level of Harm - Minimal harm or potential for actual harm During an observation on 1/21/2024 at 8:45 am, observed the temperature of the water in shower 1 was cold, a resident (unknown) in shower 1 stated it takes a while for the water to heat up. The resident got in the shower and stated the water was still cold. Residents Affected - Some During an interview on 1/21/2024 at 4:08 pm with Registered Nurse (RN) 1, RN 1 stated CNA 5 should allow the shower to warm up and ask the resident to test the temperature on their wrist, then proceed with the shower when resident says it was an acceptable temperature. RN 1 stated if residents are taking cold showers the residents will be cold, or frustrated and may feel they are not being listened to by the staff. During a concurrent interview and record review on 1/21/2024 at 4:38 pm with Maintenance (MN), the facility's Water Temperature Log, dated January 2024 was reviewed. The Water Temperature Log indicated, on 1/2/2024 the shower temperature was 112 degrees Fahrenheit (°F-scale of temperature), on 1/9/2024 the shower temperature was 110°F, on 1/11/2024 the shower temperature was 110 °F. MN stated the temperature in the showers was low. MN stated he found out a week ago the shower temperature was low, and a plumber was called to fix the problem with water temperature. During a review of the facility's policy and procedure (P&P) titled, Resident Dignity and Personal Privacy, dated 12/2016, the P&P indicated, Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's, goals, preferences, and choices. When providing care and services, staff must respect each resident's individuality, as well as honor and value their input. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 3 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few 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. Findings: During a review of Resident 43's admission Record (Face Sheet) the Face Sheet indicated Resident 43 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with other specified complications ( a chronic condition that affects the way the body processes blood sugar, mixed hyperlipidemia ( an inherited condition in which levels of certain fats in the blood are higher than they should be ), schizophrenia ( a disorder that affects a person's ability to think, feel and behave clearly). During a review of Resident 43's History and Physical (H&P) dated 6/20/23, the H&P indicated Resident 43 does not have the capacity to understand and make decisions. During a review of Resident 43's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 11/8/2023, the MDS indicated Resident 43 required supervision/touching assistance (helper provides verbal cues and/ or touching/steadying and or contact guard assistance as resident completes activity, with eating, upper and lower body dressing, and chair bed to chair transfer). During a concurrent observation and interview on 1/17/2024 at 6:21 p.m., observed Resident 43 lying in bed watching television. Resident 43 stated that his bed control had not been working for a week and he does not know where his call light button was. Resident 43 stated he just yell if he need assistance which was not right. During an interview on 1/17/2024 at 7:54 p.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated she was not aware Resident 43's call light was not working, or his call bell was missing. CNA 4 stated whenever Resident 43 needs something he yells for it. CNA 4 stated if a call light was not working, she needs to notify the charge nurse. CNA 4 stated the charge nurse will notify the maintenance staff to fix the call light. CNA 4 stated it was her responsibility to make sure Resident 43's call light was working and within reach. During a concurrent observation and interview on 1/17/2024 at 8:12 p.m., with Registered Nurse (RN) 2, RN 2 stated Resident 43's call light was not working and there was no call button with-in reach of Resident 43. RN 2 stated when she made rounds, she did not check to see if Resident 43 had a call light. RN 2 stated when call lights are not working, we get the resident a call bell, notify maintenance staff and document in the maintenance logbook. RN 2 stated if Resident 43 does not have a working call light or call bell in reach, we cannot address his needs. During an interview on 1/17/2024 at 8:40 p.m., with Director of Nursing (DON), the DON stated it was the licensed nurse's responsibility to make rounds every two hours to make sure call lights are working and within resident's reach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 4 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/18/2024 at 11:25 a.m. with DON, the DON stated the licensed nurses and CNA should do rounding on their residents every two hours. DON stated while rounding call lights [NAME] be assessed to make sure they were working and within resident reach. During a review of the facility's policy and procedure (P&P) titled Call light Outage Plan dated July 2/22, indicated It is the policy of the facility to ensure that there is a call light outage plan when facility's call light system is down. In case a call light outage: If a Resident call light system is down, initiate frequent checks until temporary devices are in place such as bells. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 5 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few 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. Findings: During a review of Resident 48's admission Record (Face Sheet), the Face Sheet indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, bipolar, anxiety, and insomnia (difficulty falling asleep). During a review of Resident 48's History and Physical (H&P) dated 1/18/2023, the H&P indicated Resident 48 had fluctuating (changing frequently and uncertainty) capacity to understand and make decisions. During a review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/13/2023, the MDS indicated Resident 48 required set up or clean up assistance for eating, oral hygiene, personal hygiene and required supervision from staff with toileting, showering, upper and lower body dressing, putting on and taking off footwear, positioning from left to right, sitting to lying, sitting to standing, walking and transferring to the shower and toilet. During a review of Resident 48's PASARR, dated 5/24/2023, the PASARR indicated, Resident 48 had a positive Level I Screening (a preliminary assessment to determine whether an individual might have serious mental illness or intellectual disabilities) and the Level II (individuals who test positive at Level I are then evaluated in depth for determination of need, appropriate setting, a set of recommendations for services for the individual's plan of care) Mental Health Evaluation was not scheduled due to Resident 48 was isolated for health or safety precautions. The PASARR indicated the case was now closed and to reopen the case the facility needed to submit a new Level I Screening. During an interview on 1/21/2024 at 11:14 am with the Social Service Director (SSD) the SSD stated she was responsible for making sure the PASARR was completed. The SSD stated Resident 48 did not have a Level II evaluation due to Coronavirus disease (COVID-19 a potentially severe respiratory illness caused by a corona virus and characterized by fever, coughing, and shortness of breath) exposure. The SSD stated a Level II screening needed to be done to evaluate Resident 48's psychosocial well-being. The SSD stated Resident 48 should have a new Level 1 PASARR screening submitted. During an interview on 1/21/2024 at 11:18 am, with the Minimum Data Set nurse, the MDS nurse stated the Level I Screening should have been resubmitted to make sure Resident 48 was reassessed again if need a Level II Mental Health Evaluation. During a review of the facility's policy and procedure titled, PASSR, dated 12/2017, indicated, The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 6 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0645 Level of Harm - Minimal harm or potential for actual harm facility also conducts Level I screen for current residents who experience a significant change in their condition based on MDS guidelines. A Level I PASRR is completed each time a resident is hospitalized and readmitted if there has been a significant change in condition. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 7 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few 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. Findings: During a review of Resident 32's admission Record (Face Sheet), the Face Sheet indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including ischemic with cardiomyopathy ( heart muscle that cannot pump well because of damage from lack of blood supply to the heart), pressure ulcer of unspecified part of back unstageable ( a type of pressure ulcer that occurs due to prolong pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue) and the sacral region( a large triangular bone at the base of the spine). During a review of Resident 32's history and physical (H&P) report undated, the H&P indicated Resident 32 had the capacity to understand and make decision. During a review of Resident 32's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 12/24/2023, the MDS indicated Resident 32 requires partial/ moderate assistance (helper lifts hold or supports trunk and or limbs but provides less than half) with chair to bed to chair transfer, lying to sitting on side of bed, and toilet transfer. During a review of Resident 32's Order Summary Report, the Order Summary Report indicated an order for low air loss mattress for wound care management was ordered 12/20/2024. During an initial facility tour observation on 1/19/2024 at 6:48: p.m., Resident 32 was in bed, observed the low air loss mattress was deflated, the light indicating the bed was functioning was off. During an interview on 1/20/24 at 7:54 p.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated was not aware Resident 32's low air loss mattress was not working and stated if it was not working, CNA should inform the charge nurse. During a concurrent observation and interview on 1/19/2024 at 8:20 p.m., with the Registered Nurse (RN) 2, RN 2 stated Resident 32 was on a low air loss mattress and used for residents who have pressure ulcers. RN 2 stated she did not notice Resident 32 low air loss mattress was not on when she made rounds. RN 2 stated it was the licensed nurse responsibility to make sure the low air loss mattress was in working condition to prevent Resident 32's pressure ulcer from getting worse. During an interview on 1/19/2024 at 8:40 p.m., with the Director of Nursing (DON), the DON stated Resident 32 's low air loss mattress should be working 24 hours a day seven days a week and it was the CNA responsibility to inform the charge nurse if a bed was not working. DON stated it was the responsibility of the Licensed Vocational Nurse (LVN) and CNA to make rounds every two hours to make sure the bed was functioning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 8 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 1/ 21/2024 at 4:11 p.m., LVN 2, LVN 2 stated it was the responsibility of all the licensed nurses to monitor Resident 32 air mattress for a decrease in air flow or if the bed light was off. During a record review of the facility's policy and procedure (P&P), dated 4/2022, titled Pressure Reducing Mattress indicated A specialty mattress will be obtained for pressure relief of the residents that have pressure injury or at risk for pressure injury. A trained adult care giver such as Certified Nursing Assistants is available to assist the patient with activities of daily living, fluid balance, dry skin care, repositioning, recognition, and management of altered mental status, dietary needs, prescribed treatments and management and support of the air fluidized bed system and its problems such as leakage. Event ID: Facility ID: 055329 If continuation sheet Page 9 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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: Residents Affected - Few 1. Ensure the licensed nurses followed the Registered Dietician (RD) dietary recommendations of Multivitamins (a pill containing a combination of vitamins), Prostat (a ready-to-drink concentrated liquid high in protein) 30 cubic centimeter ([cc]-unit of volume) daily, and iron (a mineral that the body needs to produce red blood cells) supplements on 11/16/2023, recommendations of including a 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, recommendations of change order for Ensure one carton daily to two times a day, follow up with laboratory tests ordered on 12/17/2023 (not done until 1/12/24) and continue with weekly weights on 12/23/2023. 2. Ensure the facility held Interdisciplinary Team ([IDT] group of healthcare professionals working together to plan the care needed for each resident) meeting to address Resident 40's continued unplanned weight loss and make recommendations to prevent further weight loss. These failures resulted in Resident 40's weight loss of 14 lbs. (7.4 % in one month and 10.3 % in two months) from 11/11/2023 to 12/22/2023. Findings: During a concurrent observation and interview on 1/19/2024 at 7:30 p.m. with Resident 40 at his bedside, Resident 40 was observed being frail (physically weak) and thin with sunken eyeball, and dry skin in appearance. Resident 40 stated he had lost weight since being in the facility because he does not always like the food he was served, and he was not offered a food alternative (different choices). Resident 40 stated he has friends who will bring him food he likes once or twice a week. During a review of Resident 40's admission Record (Face Sheet) dated 11/10/2023, the Face Sheet indicated Resident 40 was admitted to the facility with diagnoses including cellulitis (a common skin infection caused by bacteria) of the left leg, hypertension (high blood pressure), and adult failure to thrive (a syndrome of weight loss, decreased appetite, and poor nutrition). During a review of Resident 40's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 11/14/2023, the MDS indicated Resident 40 was alert and oriented and able to make independent decisions about his activities of daily living. The MDS indicated Resident 40's height was 70 inches and weight of 136 lbs. During a review of Resident 40's Care Plan (CP) titled Alteration in nutritional status revised 11/15/2023, the CP indicated Resident 40 was at risk for the weight loss. The CP indicated the goal for Resident 40 was to minimize further weight loss. The CP indicated the interventions included to offer food substitutes (in addition to a meal and provides sustenance such as drinks designed to replace meals and aid in weight loss) for any meals refused, monitor weights, perform laboratory tests as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 10 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm ordered or indicated and report significant weight loss of five (5) pounds or more in one month to the primary physician. During a review if Resident 40's Physician's Order dated 10/19/2023, the Physician's Order indicated Heart Health Diet (cardiac diet- diet that focuses on reducing the risk for heart disease). Residents Affected - Few During a review of Resident 40's Physician's Order dated 12/23/2023, the Physician's Order indicated Resident 40 had an order for Ensure (dietary supplement) one can twice a day as a dietary supplement. During a review of Resident 40's Weight and Vitals Summary report dated 11/11/2023-1/11/2024, the Weight and Vitals Summary report indicated the following resident's weight: 1. On 11/11/2023-136 pounds. 2. On 12/14/2023-126 pounds (7.4% weight loss since admission on [DATE]). 3. On 12/22/2023-123 pounds (9.6% weight loss since admission on [DATE]). 4. On 12/29/2023-123 pounds (9.6% weight loss since admission on [DATE]). 5. On 1/4/2024-126 pounds. 6. On 1/10/2024-122 pounds (10.3% weight loss since admission on [DATE]). During a review of Resident 40's Registered Dietician (RD) Initial Nutritional assessment dated [DATE], the RD' Initial Nutritional Assessment indicated Resident 40's diet was the Regular diet with no added salt (NAS). The RD' Initial Nutritional Assessment indicated Resident 40's current weight was 136 lbs., height of 70 inches with ideal body weight ([IBW]-weight for height) of 166 lbs. (plus/minus 10 percent). The RD's Initial Nutritional Assessment indicated Resident 40 was at risk for unintended weight loss, dehydration (a harmful reduction in the amount of water in the body) and malnutrition (lack of proper nutrition, caused by not having enough to eat or not eating enough). The RD's Initial Nutritional Assessment indicated recommendations including Multivitamins (a pill containing a combination of vitamins), Prostat (a ready-to-drink concentrated liquid high in protein [main nutritional food groups]) 30 cubic centimeter ([cc]-unit of volume) daily, and iron (a mineral that the body needs to produce red blood cells) supplements (which were not ordered until 1/21/2024). During a review of Resident 40's RD Medical Nutritional Therapy Assessment Recommendation dated 12/15/2023, the Medical Nutritional Assessment Recommendation indicated recommendations including weekly weights for four (4) weeks, snacks three times a day between meals, Ensure one carton at 2 p.m., and laboratory tests including a 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, which were not completed until 1/12/2024. During a review of Resident 40's RD's Medical Nutritional Therapy Assessment Recommendations dated 12/23/2023, indicated recommendations including change order for Ensure one carton daily to two times a day, follow up with laboratory tests ordered on 12/17/2023 (not done until 1/12/24) and continue (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 11 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with weekly weights as ordered. The RD's Medical Nutritional Therapy Recommendation indicated Resident 40 had a weight loss of three (3) pounds in one (1) week and 13 pounds in two months as of 12/23/2023. During a review of Resident 40's RD's Medical Nutritional Therapy Assessment Recommendations dated 1/11/2024, indicated continue with weekly weights for four weeks, to follow up with labs ordered on 12/17/2023 (not drawn) and change Ensure to Boost (high calorie nutritional supplement) one carton three times a day with medication administration. The Medical Nutritional Therapy Assessment Recommendation indicated Resident 40 had a weight loss of four (4) lbs. in one (1) week and 14 pounds in two months. During a review of Resident 40's meal percentage record dated 12/10/2023-12/30/2023, the meal percentage record indicated Resident 40's meal intake varied between 20%-100% during breakfast, lunch, and dinner. During a review of Resident 40's meal percentage record dated 1/1/2024-1/20/2024, the meal percentage record indicated Resident 40's meal intake varied between 20%-100% during breakfast, lunch, and dinner. During a review of Resident 40's Physician's Order dated 12/17/2023 indicated an order to obtain CBC, CMP and TSH test. During a review of Resident 40's laboratory report dated 1/12/2024 (ordered on 12/17/2023), the laboratory report indicated Resident 40 had a hemoglobin of 7.8 grams/deciliter ([g/dl]-unit of measurement]. The hemoglobin reference range was 13.5-16.9 g/dl. The laboratory report indicated Resident 40's albumin (protein found in the blood plasma [component of blood]) level was 3.1 g/dl. The albumin reference range is 4.2-5.5 g/dl. During an interview on 1/21/2024 at 10:28 a.m., the Director of Nurses (DON) stated a Change of Condition (COC) should have been done for Resident 40's weight loss of 10 lbs. from 11/11/2023 on 12/14/202. The DON stated there should be an IDT meeting to address Resident 40's significant weight loss but there was no IDT meeting until 1/4/2024. The DON stated Resident 40 should have had an IDT to discuss care and RD's recommendations for resident 40's severe weight loss. The DON stated it was important for the licensed nurses to follow up on the RD's recommendations for Resident 40 to prevent the delay in care. During an interview on 1/21/2024 at 1:06 p.m., the RD stated she was aware of Resident 40 weight loss. The RD stated she made recommendations on 12/15/2023 including weekly weights, snacks three times a day, Ensure one carton at 2 p.m. and CBC, and CMP for Resident 40 but were not done by the licensed nurses so new recommendations were made on 12/23/2023. The RD stated she did not see Resident 40 until 1/10/2024, 17 days later (12/23/2023-1/10/2023), and the recommendations she (RD) made on 12/23/2023 were not done by the licensed nurses for Resident 40. The RD stated she failed to check to see if the laboratory recommendations made on 12/15/2023 and ordered on 12/17/2023 were done. The RD stated it was important to check to see if the recommendations were followed through by the licensed nurses to avoid further weight loss for Resident 40. The RD stated, the laboratory values were out of range on 1/12/2024 and Resident 40 would have benefited from the previous recommendations made on 11/16/2023 for Multivitamins and Iron. The RD stated Resident 40 was not weighed between 1/10/2024 and 1/21/2024 despite the order of weekly weights. The RD stated Resident 40 did not have an IDT meeting for weight loss until 1/4/2024. The RD stated the importance of addressing Resident 40's weight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 12 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few loss through IDT meeting was to monitor the Resident 40's weights, ensure recommendations were followed through, evaluate appropriateness of the diet and current measures for weight loss prevention, and recommend other measures to prevent further weight loss. During an interview on 1/21/2024 at 2 p.m. a Certified Nurse Assistant (CNA 4) stated Resident 40 often ask for food substitutions because he does not like the food he was served from the kitchen. CNA 4 stated Resident 40 was pretty skinny and ate about 60-70% of his meals. During a concurrent interview and record review on 1/21/2024 at 2:48 p.m. the Registered Nurse (RN 1), reviewed Resident 40's medical record. RN 1 stated RD's recommendations for laboratory tests dated 12/15/2023 were ordered by physician on 12/17/2023 and were not carried out until 1/12/2024. RN 1 stated there was a delay in care and Resident 40 could experience an adverse event like dehydration. RN 1 stated it was the responsibility of the licensed nurses to ensure the laboratory tests ordered on 12/17/2023 were carried out as ordered. RN 1 stated the laboratory tests results dated 1/12/2024 indicated Resident 40 hemoglobin had out of range. RN 1 stated, Resident 40 could have benefited from the RD's recommendation given on 11/16/2023 for Iron supplements. RN 1 stated the RD's recommendations on 11/16/2023 for Iron or Multivitamins were not ordered until 1/21/2024. RN 1 stated, Resident 40 did not have a COC and IDT meeting for weight loss in November and December 2023. RN 1 stated the first wight loss IDT meeting was held on 1/4/2024. RN 1 stated if an IDT and COC was done sooner for Resident 40, it could have prevented the resident's further weight loss because all recommendations will be addressed and followed through. During an interview on 1/21/2024 at 4:03 p.m. Resident 40 stated he started to receive Boost at the beginning of January 2024. During an interview on 1/23/2024 at 2:17 p.m. the RD stated Resident 40 caloric intake should be between 1550-1860 calories based on his admission weight of 136 pounds. The RD stated Resident 40 consumed 50-100% of his meals per day. The RD stated her recommendations from 11/16/2023 were just followed up on by licensed nurses on 1/21/2024 and that should not have happened. The RD stated recommendations should be followed up within 24-48 hours after the recommendations were written. The RD stated she sent her written recommendations via electronic mail to the DON, Dietary Supervisor, and Medical Records staff. During a review of the facility's policy and procedure (P&P) titled Unplanned Weight Loss dated 4/2018, the P&P indicated the purpose was to provide appropriate intervention for any unplanned weight loss. The DON shall be responsible for implementation of the unplanned weight loss policy. It was the policy of the facility to identify conditions and potential causes of weight loss that places the residents at risk. The P&P indicated a weight loss of 5% in one month was significant and greater than 5% was severe, the weight loss of 7.5% in three months was significant and greater that 7.5% was severe, and weight loss of 10% in six months was significant and greater than 10% was severe. During a review of the facility job description (JD) titled Registered Dietician dated 5/2017, the JD indicated the RD will monitor and evaluate the effectiveness of nutritional interventions. The JD indicated the RD will ensure appropriate and timely documentation of nutrition assessment tools, recommended interventions and follow up. During a review of the facility P&P titled Food Preferences, the P&P indicated the RD, dietary manager or nursing staff will visit residents periodically to determine if revisions are needed regarding food preferences. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 13 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm During a review of the facility P&P titled Weight Assessment and Interventions dated 11/2017, the P&P indicated it is the policy of the facility to monitor a patient's weight. The P&P indicated any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. The P&P indicated care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, dietician, and the consultant pharmacist with time frames for monitoring and re Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 14 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based 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). Residents Affected - Few This deficient practice had the potential to delay necessary care and treatment for Resident 40. Findings: During a review of Resident 40's admission Record (Face Sheet) dated 11/10/2023, the Face Sheet indicated Resident 40 was admitted to the facility with diagnoses including cellulitis (a common skin infection caused by bacteria) of the left leg, hypertension (high blood pressure), and adult failure to thrive (a syndrome of weight loss, decreased appetite, and poor nutrition). During a review of Resident 40's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 11/14/2023, the MDS indicated Resident 40 was alert and oriented and able to make independent decisions about his activities of daily living. The MDS indicated Resident 40's height was 70 inches and weight of 136 lbs. During a review of Resident 40's RD Medical Nutritional Therapy Assessment Recommendation dated 12/15/2023, the Medical Nutritional Assessment Recommendation indicated recommendations laboratory tests including CBC,CMP and TSH ordered by physician on 12/17/2023. During a review of Resident 40's Physician's Order dated 12/17/2023 indicated an order to obtain CBC, CMP and TSH test. During a review of Resident 40's laboratory report dated 1/12/2024 (ordered on 12/17/2023), the laboratory report indicated Resident 40 had a hemoglobin of 7.8 grams/deciliter ([g/dl-unit of measurement] normal range 13.5-16.9) and hematocrit of 24.4 percent (normal range 39.5-50.0). The laboratory report indicated Resident 40's albumin level (helps keep fluid from leaking out of your blood vessels into other tissues) was 3.1 g/dl (normal range 4.2-5.5). During a concurrent interview and record review on 1/21/2024 at 2:48 p.m. the Registered Nurse (RN 1), reviewed Resident 40's medical record. RN 1 stated RD's recommendations for laboratory tests dated 12/15/2023 were ordered by physician on 12/17/2023 and were not carried out until 1/12/2024. RN 1 stated there was a delay in care and Resident 40 could experience an adverse event like dehydration. RN 1 stated it was the responsibility of the licensed nurses to ensure the laboratory tests ordered on 12/17/2023 were carried out as ordered. RN 1 stated the laboratory tests results dated 1/12/2024 indicated Resident 40 hemoglobin had out of range. RN 1 stated, Resident 40 could have benefited from the RD's recommendation given on 11/16/2023 for Iron supplements. RN 1 stated the RD's recommendations on 11/16/2023 for Iron or Multivitamins were not ordered until 1/21/2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 15 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. During observation, interview and record review the facility failed to ensure food was stored under food safety requirement by: Residents Affected - Many 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. Findings: During an observation 1/19/2024 at 5:38 p.m. on the initial kitchen tour in the facility kitchen, observed the freezer was unplugged since 5 p.m. on 1/19/2024. Observed ice cream was melted. During an interview on 1/19/2024 at 5:55 p.m. with the Maintenance Director (MD), the MD stated the freezer was unplugged 30 minutes ago because ice was building up on the condenser. During a concurrent observation and interview on 1/19/2024 at 5:57 p.m. with the Dietary Supervisor (DS), the DS stated the temperature inside the freezer was five °F- temperature and it should be at zero °F. The DS stated the freezer was unplugged for over 30 minutes because of ice build up on the condenser (part of a refrigeration system ). During a concurrent observation and interview on 1/19/2024 at 6:10 p.m. with the DS the freezer was plugged in. The DS stated 154 cartons of ice cream was melted because the freezer was not working. During a concurrent observation and interview on 1/19/2024 at 6:30 p.m. with the DS, it was observed that all the food in the freezer was thrown away in the trash and the freezer was empty. The DS stated she threw away all the food in the freezer so the residents will not get sick. During an interview on 1/20/2024 at 10:37 a.m. with the Administrator (ADM), the ADM stated she was aware that the freezer in the kitchen was broken and was informed on 1/19/2024 at 9 p.m. The ADM stated if the freezer was not working the food would be rotten. The ADM stated if rotten food was served to the residents, it could have bacteria and the residents could get diarrhea (loose stool) or infection. During a record review of an invoice for the repair of the facility freezer dated 1/20/2024, the invoice indicated the freezer had badly damaged doors as the door gaskets were not properly sealed and the freezer was considered Red Tag (a safety concern with the appliance or part to which it is attached) and not to be used. During a review of the facility policy and procedure (P&P) titled Monitoring Large Kitchen Appliances revised 4/2015, the P&P indicated the freezer temperature should be zero degrees or below. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 16 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0812 During a review of the facility P&P titled Food Storage Principles dated 4/2020, the P&P indicated the facility should preserve food quality before and after it is served. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 17 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based 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: Residents Affected - Many 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. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever that can lead to other serious medical complications and hospitalization. Findings: During an observation on 1/19/2024 at 5:40 p.m. during the initial kitchen tour it was observed that the dishwasher and chlorine sanitizer was not working properly and read at 0 PPM after two (2) wash cycles. Observed the dishwasher temperature for the wash cycle was at 110 degrees and the rinse temperature was at 110 degrees. During a concurrent observation and interview on 1/19/2024 at 6 p.m. with the Dietary Aide (DA), the DA stated the dishwasher temperature for the wash cycle was at 110 degrees and the rinse temperature was at 110 degrees and it was correct for the low temperature dishwasher. The DA stated the chlorine sanitizer agent strip was at 5 ppm and it should be between 50-100 ppm. The DA stated the dishwasher was broken that day on 1/19/2024. The DA stated the resident's ate dinner with plates and silverware (forks, knives and spoons) washed in the dishwasher that day. During a concurrent observation and interview on 1/19/2024 at 6:04 p.m. with the DA, the DA stated the second wash and rinse dishwasher cycle chlorine sanitizer ppm was at 25 ppm and it should be between 50-100 ppm. The DS stated the residents ate dinner on plates that were washed in the dishwasher on 1/19/2024. During a concurrent observation and interview on 1/19/2024 at 6:06 p.m. with the Dietary Supervisor (DS), the DS stated the dishwasher is a low temperature machine. Stated the ppm checked was at 0 ppm and not effective as a sanitizer. During a concurrent observation and interview on 1/20/2024 at 10:05 a.m. with the Dietary Supervisor (DS), it was observed that the chlorine sanitizer strips were expired and dated 7/1/2023. The DS stated the strips being used by the kitchen staff was expired and stated they would not be effective to use in the kitchen. During a concurrent observation and interview on 1/21/2024 at 11:45 p.m. with the DS, the DS stated the dishwasher temperature load was at 102 degrees. It was observed for 3 cycles of the dishwasher and the highest temperature was at 102 degrees. The DS stated if the dishes are not cleaned at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 18 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many correct temperature of at least 120 degrees, the residents could get sick because the dishes were not sanitized properly. During a review of the facility policy and procedure (P&P) titled Machine Dishwashing Racking Procedure dated 4/2020, the P&P indicated dishes that are sanitary are free from bacteria which cannot be seen by the naked eye. During a review of the facility P&P titled Testing Sanitizer and Temperature in Low Temp Dish Machines dated 4/2020, the P&P indicated to test the sanitizer with chlorine test strips obtained by the chemical vendor or food distributor. The P&P indicated a proper level is 50 ppm chlorine in the rinse water and an appropriate temperature for wash and rinse is 120°-160. The P&P indicated to inform the Dietary Manager if the minimum requirements for either sanitation solutions or temperatures are not adequate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 19 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: During an observation on 1/20/23 at 1:17 p.m., observed room [ROOM NUMBER] occupied five residents and room [ROOM NUMBER] was occupied with six residents. The residents were able to move in and out of their rooms and there was space for the beds, side table and wheelchairs. During a record review of the room waver signed by the Administrator dated 1/24 , submitted by the administrator indicated Resident room [ROOM NUMBER] and 3 did not meet the four residents per room required by federal regulation . The letter indicated room [ROOM NUMBER] and 3 had enough space to provide each resident care without affecting their health and safety or impeding any of the residents in the room to attain his or her wellbeing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 20 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings : During an observation on 1/21/2024 at 1:17 p.m., with Maintenance (MN), observed multiple resident's rooms with two, three and six beds in a room. Observed residents go in and out of beds with adequate spacing, side tables, beds, wheelchairs readily available without impending any movement. During an interview on 1/21/2024 at 1:19 p.m. with MN, the MN stated we have a room waiver and would like to apply for another one this year. During a review of the room size waiver dated 1/23 submitted by the Administrator , for 17 residents rooms was reviewed, the letter indicated there was ample room to accommodate residents and enough space for nursing care and the health and safety of the residents occupying these rooms. The letter indicated the following : Room Number Beds per Room Total Square Footage room [ROOM NUMBER] 6 470 sq. ft. room [ROOM NUMBER] 6 426 sq. ft. room [ROOM NUMBER] 2 143 sq. ft. room [ROOM NUMBER] 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 21 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0912 155 sq. ft. Level of Harm - Potential for minimal harm room [ROOM NUMBER] 2 Residents Affected - Some 146 sq. ft. room [ROOM NUMBER] 2 145 sq. ft. room [ROOM NUMBER] 2 144 sq. ft. room [ROOM NUMBER] 2 144 sq. ft. room [ROOM NUMBER] 2 146 sq. ft. room [ROOM NUMBER] 3 213 sq. ft. room [ROOM NUMBER] 3 187 sq. ft. room [ROOM NUMBER] 2 129 sq. ft. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 22 of 23 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 055329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Serena Healthcare Center 723 E 9th Street Long Beach, CA 90813 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)

F 0912 room [ROOM NUMBER] Level of Harm - Potential for minimal harm 2 133 sq. ft. Residents Affected - Some room [ROOM NUMBER] 3 210 sq. ft. room [ROOM NUMBER] 3 214 sq. ft. room [ROOM NUMBER] 3 216 sq. ft. room [ROOM NUMBER] 3 217 sq. ft. The minimum sq. ft. for a two bedroom is 160 sq. ft. The minimum sq. ft. for a three bedroom is 240 sq. ft. The minimum sq. ft. for a six bedroom is 480 sq. ft. During the survey from, 1/19/24 to 1/21/24, there were no observed adverse effects as to the adequacy of space, nursing care comfort and privacy to the residents. There was ample space to accommodate wheelchairs, beds, and other medical equipment including space for mobility and locomotion of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055329 If continuation sheet Page 23 of 23