Villa Serena Healthcare Center
Long Beach, California · CCN 055329
22 surveys since 2011, 7 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 158
- Surveys
- 22
- Harm or worse
- 7
- Immediate jeopardy
- 2
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 52
- Ownership
- For profit - Limited Liability company
- Chain
- AARON MAYER
- County
- Los Angeles
- Medicare-certified since
- 1969
CMS ratings
- Overall
- 5
- Health inspection
- 4
- Staffing
- 3
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 252 for-profit facilities with fewer than 66 beds in California.
Last survey on record
Apr 29, 2026
194 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.62 | 4.36 |
| Registered-nurse hours per resident day | 0.28 | — |
| Annual nurse turnover | 36.4% | 36.4% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $26,685 across 1 penalty
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J24.1% | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D2449.0% | E1326.5% | F612.2% |
| No harm, potential for minimal | A— | B48.2% | C— |
Most frequently cited here
In CMS’s current monthly file.
- F5503×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F6843×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F9113×
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
- F9123×
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
In the surveyor’s words
From the most serious findings on record at Villa Serena Healthcare Center, in the surveyor’s own words.
- Immediate jeopardy, isolatedF600Jan 18, 2025
Based 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 :… […]
- Immediate jeopardy, isolatedF678Jan 18, 2025
Based 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. […]
- No harm, potential for more than minimal, widespreadF880Jan 18, 2025
Based 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. Findings: During an interview and record review on 1/16/2025 at 9:19 a.m., there was no documented facility water management plan, and the Infection Prevention Nurse (IPN) confirmed the water management assessment was not completed. The IPN stated we need to complete the assessment to ensure microbial growth (germs) was not spreading. […]
- No harm, potential for more than minimal, widespreadF887Jan 18, 2025
Based 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. Findings: During an interview and record review on 1/16/2025 at 12:07 p.m., with the Infection Prevention Nurse (IPN), the facility's employee records of COVID-19 status 2024 to 2025 was reviewed, and the physicians and consultants COVID-19 immunization status were unknown. […]
- No harm, potential for more than minimal, widespreadF912Jan 18, 2025
Based 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. Findings : During and observation on 1/14/2025 at 00:00 a.m., with the Maintenance (MN), observed multiple resident's rooms with two, three and six beds in a room. […]
Read 25 findings in full →The most serious and the most recent: 25 of 158 on record.
Every survey on record
FindingsAt actual harm or above
- Apr 29, 2026Complaint2 findings
- Apr 7, 2026Complaint2 findings
- Feb 9, 2026Standard8 findings
- Nov 25, 2025Complaint1 finding
- Mar 28, 2025Complaint1 finding
- Jan 18, 2025Standard and complaint22 findings · 2 harm
- May 31, 2024Complaint2 findings
- May 6, 2024Complaint1 finding
Show the 14 earlier surveys
- Jan 21, 2024Standard10 findings
- Nov 17, 2021Standard6 findings
- Feb 5, 2021Infection control1 finding
- Oct 27, 2020Infection control1 finding
- Aug 29, 2019Standard11 findings
- Aug 25, 2018Standard10 findings
- Sep 12, 2017Standard13 findings
- Sep 9, 2016Standard and complaint17 findings
- Jul 18, 2015Standard8 findings
- Jan 29, 2015Complaint1 finding
- Apr 22, 2014Standard13 findings
- Mar 11, 2013—1 finding
- Jan 6, 2013—10 findings · 1 harm
- Sep 21, 2011—17 findings · 4 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction