Lefa Seran SNF

In the surveyor’s words

From the most serious findings on record at Lefa Seran SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF867Apr 10, 2025

  Based on interview, clinical record review, and document review, the facility failed to ensure the facility's Quality Assurance and Performance Improvement Program identified areas of concern with the facility's Infection Prevention and Control Plan including concerns with pneumococcal immunizations and the immunization policy affecting 21 of 21 residents residing in the facility. This deficient practice had the potential to result in high-risk areas of concern and deficient infection control practices not being corrected and leading to infectious disease outbreaks and residents suffering severe illness or death from lack of vaccinations. […]

• No harm, potential for more than minimal, widespreadF883Apr 10, 2025

  Based on interview, clinical record review, and document review, the facility failed to ensure the facility's immunization policy was accurate and included correct, up to date information for vaccinations, resident's were provided vaccinations when the resident's consented to receive pneumococcal vaccines, and staff were training on accurate and correct information related to pneumococcal vaccinations affecting 21 of 21 residents residing in the facility (Residents #12, #17, #14, #8, #6, #20, #13, #2, #4, #5, #16, #19, #15, #11, #7, #10, #21, #3, #18, #1, and #9). […]

• No harm, potential for more than minimal, widespreadF887May 23, 2024

  Based on clinical record review, interview, and document review the facility failed to ensure residents were screened for eligibility to receive a COVID-19 (COVID) vaccine, education regarding the vaccine was provided to the resident or resident representative, and if the vaccine was offered and either administered or declined 19 of 20 residents sampled for immunizations (Resident #17, #2, #13, #19, #15, #9, #6, #8, #14, #3, #5, #18, #16, #12, #7, #11, #4, #1, and #10). Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pain unspecified, edema unspecified, and acute embolism and thrombosis of other specified deep vein of left lower extremity. […]

• No harm, potential for more than minimal, widespreadF700Aug 10, 2023

  Based on observation, interview, clinical record review, and document review, the facility failed to ensure the alternatives were attempted, risks and benefits were explained, consents were obtained prior to installation of bedrails or grab bar (Halo ring) and mobility assessments were completed for 15 of 21 residents residing in the facility (Resident #1, #2, #3, #4, #5, #7, #9, #10, #12, #14, #15, #16, #17, #171, and #172). Resident #1 Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and falls. On 07/31/23, Resident #1's bed had a Halo ring on the left side. […]

• No harm, potential for more than minimal, widespreadF758Aug 10, 2023

  Based on interview, clinical record review, and document review, the facility failed to ensure residents did not receive unnecessary psychotropic medications when the facility lacked specific indications for use, monitoring of the behaviors associated with the psychotropic medications, and monitoring for adverse side effects for 11 of 11 residents receiving psychotropic medications (Resident #1, #3, #5, #6, #7, #9, #12, #14, #4, #13, and #16), residents did not receive an increase in a hypnotic medication related to environmental factors and resident request and a gradual dose reduction was attempted despite resident request to continue all psychotropic medications for 2 of 11 residents receiving psychotropic medications (Resident #14 and #16), and as needed (PRN) physician ordered… […]