The Vardell Report.Villa Serena Healthcare Center

Across 9 inspections from January 2024 to April 2026, state surveyors documented 44 findings at Villa Serena Healthcare Center; 44 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

9

2024–2026, complaint and standard

Findings

44

Deficiencies cited by state inspectors

Corrected

44

Of 44 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Apr 292026

   Complaint investigation

   2 findings

   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected May 22, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected May 22, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Apr 72026

   Complaint investigation

   2 findings

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 30, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Feb 92026

   Standard health inspection

   8 findings

   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Feb 27, 2026
   • F814Dispose of garbage and refuse properly.Level ENo actual harm, potential for moreCorrected Feb 27, 2026
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Feb 27, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 27, 2026
   • F730Observe each nurse aide's job performance and give regular training.Level DNo actual harm, potential for moreCorrected Feb 27, 2026
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Feb 27, 2026
   • F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.Level BPotential for minimal harmCorrected Feb 27, 2026
   • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Feb 27, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Nov 252025

   Complaint investigation

   1 finding

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 5, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Mar 282025

   Complaint investigation

   1 finding

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 16, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Jan 182025

   Standard health inspection

   17 findings

   • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level JImmediate jeopardyCorrected Feb 12, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Feb 12, 2025
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Feb 12, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Feb 12, 2025
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Feb 12, 2025
   • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level ENo actual harm, potential for moreCorrected Feb 12, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Feb 12, 2025
   • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Feb 12, 2025
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level ENo actual harm, potential for moreCorrected Feb 12, 2025
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected Feb 12, 2025
   • F880Provide and implement an infection prevention and control program.Level CPotential for minimal harmCorrected Feb 12, 2025

   Enforcement Action

   Civil money penalty, $26,685 imposed January 18, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of January 18, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. May 312024

   Complaint investigation

   2 findings

   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 20, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jun 20, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. May 62024

   Complaint investigation

   1 finding

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected May 24, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Jan 212024

   Standard health inspection

   10 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Feb 20, 2024
   • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Feb 20, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Feb 20, 2024
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 20, 2024
   • F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Feb 20, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 20, 2024
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Feb 20, 2024
   • F770Provide timely, quality laboratory services/tests to meet the needs of residents.Level DNo actual harm, potential for moreCorrected Feb 20, 2024
   • F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.Level BPotential for minimal harmCorrected Feb 20, 2024
   • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Feb 20, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Dignity and Resident Rights, Cited in Three Inspections

   Inspectors cited F550 in January 2024, February 2026 and April 2026. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424252525262626F550 across all 9 inspections, oldest to newest
2. 2

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in January 2024, March 2025 and November 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424252525262626F684 across all 9 inspections, oldest to newest
3. 3

   Care Plan Timing and Review, Cited in Two Inspections

   Inspectors cited F657 in May 2024 and April 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424252525262626F657 across all 9 inspections, oldest to newest
4. 4

   Pharmacy Services, Cited in Two Inspections

   Inspectors cited F755 in January 2025 and February 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424252525262626F755 across all 9 inspections, oldest to newest
5. 5

   Kitchen and Food Safety, Cited in Two Inspections

   Inspectors cited F812 in January 2024 and January 2025. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424252525262626F812 across all 9 inspections, oldest to newest
6. 6

   Infection Control, Cited in Two Inspections

   Inspectors cited F880 in May 2024 and January 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424252525262626F880 across all 9 inspections, oldest to newest
7. 7

   Citation F911, Cited in Two Inspections

   Inspectors cited F911 in January 2024 and February 2026. The agency describes it this way: Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. None rose above level B (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424252525262626F911 across all 9 inspections, oldest to newest
8. 8

   Citation F912, Cited in Two Inspections

   Inspectors cited F912 in January 2024 and February 2026. The agency describes it this way: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. None rose above level B (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242424252525262626F912 across all 9 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do staff learn each resident’s preferences, and how is a complaint about dignity handled?

   Dignity and Resident Rights: cited in three inspections, most seriously at level E.

2. 02

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in three inspections, most seriously at level D.

3. 03

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in two inspections, most seriously at level D.

4. 04

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in two inspections, most seriously at level E.

5. 05

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in two inspections, most seriously at level F.

6. 06

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in two inspections, most seriously at level F.

7. 07

   What changed after F911 was cited, and how do you check it now?

   Citation F911: cited in two inspections, most seriously at level B.

8. 08

   What changed after F912 was cited, and how do you check it now?

   Citation F912: cited in two inspections, most seriously at level B.

9. 09

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

10. 10

    What led to the 2025 fine, and has it been paid?

    A $26,685 civil money penalty was imposed January 18, 2025. CMS publishes the fine, not whether it has been paid.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jan 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection May 6, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection May 31, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jan 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Mar 28, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Nov 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Feb 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Apr 7, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Apr 29, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 055329

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.