Health inspection·March 28, 2025

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 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. Residents Affected - Few This deficient practices placed Resident 1 not being monitored for the COC and had the potential for delay in care. Findings: During a review of Resident 1's admission record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), muscle wasting and atrophy, and Type 2 (II) Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/3/2025 the MDS indicated Resident 1's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 1 required moderate assistance for performing Activities of Daily Living (ADL: bathing, dressing, toileting hygiene, personal hygiene, chair/bed-to-chair transfer, and required supervision for oral hygiene and eating. During a review of the Situation, Background, Assessment, Recommendation (SBAR: structured communication tool used to ensure clear and concise information exchange) Communication Form and progress note dated 3/22/2025 at 9:16a.m., the SBAR indicated Resident 1 was being monitored following an incident where another resident was found on top of Resident 1 with a skin tear on the left arm. The SBAR indicated Resident 1 had a left antecubital skin tear and does not indicate Resident 1's pain status. During a review of Resident 1's progress note dated 3/25/2025, the progress note indicated the Nurse Practitioner 1 (NP) assessed Resident 1. Resident 1's left arm skin tear was reclassified to left forearm skin tear. The skin assessment was done with two other licensed nurses with findings of: left forearm skin tear, left upper arm multiple abrasions, and multiple discolorations on right upper extremity. During an interview on 3/27/2025 at 11:49a.m. with Treatment Nurse (TXN), TXN stated he did a skin assessment on 3/25/2025 and indicated there was a skin tear on the left arm and discoloration on the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055329 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 03/28/2025 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)