LEFA SERAN SNF
1ST AND A ST
HAWTHORNE, NV, 89415
7759452461
CCN: 295001
1
Overall2
Health4
Staffing1
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| MT GRANT GENERAL HOSPITAL | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| COEN, PATRICIA | CORPORATE DIRECTOR | NOT APPLICABLE |
| DOW, MICHELLE | CORPORATE DIRECTOR | NOT APPLICABLE |
| QUALLS, HUGH | CORPORATE DIRECTOR | NOT APPLICABLE |
| SCHUMANN, RICHARD | CORPORATE DIRECTOR | NOT APPLICABLE |
| WOMACK, KAREN | CORPORATE DIRECTOR | NOT APPLICABLE |
| MT GRANT GENERAL HOSPITAL | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| QUALLS, HUGH | W-2 MANAGING EMPLOYEE | NOT APPLICABLE |
Health Deficiencies (49)
2025-04-10 · Health
D
F949 · Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
D
F946 · Administration Deficiencies
Provide training in compliance and ethics.
D
F945 · Infection Control Deficiencies
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
D
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
D
F942 · Resident Rights Deficiencies
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
D
F941 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
D
F887 · Infection Control Deficiencies
Educate 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.
F
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
D
F838 · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
D
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
D
F726 · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
2024-05-23 · Health
F
F887 · Infection Control Deficiencies
Educate 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.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F700 · Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
E
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
D
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
2023-08-10 · Health
E
F942 · Resident Rights Deficiencies
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
C
F847 · Administration Deficiencies
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
D
F838 · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
D
F835 · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F727 · Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F
F700 · Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F640 · Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
D
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
D
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
2023-04-05 · Health
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
5.62
RN Hrs/Resident/Day0.54
1.13
LPN Hrs/Resident/Day0.81
0.97
CNA Hrs/Resident/Day2.33
3.52
PT Hrs/Resident/Day0.12
0.00
Data as of 2026-03-01