CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Lefa Seran Snf
View the most recent health deficiencies and inspection results for Lefa Seran Snf. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Lefa Seran Snf. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2025-04-10 | 2025-05-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-04-10 | 2025-05-19 | N |
| 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. | Health | 2025-04-10 | 2025-05-19 | N |
| 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. | Health | 2025-04-10 | 2025-05-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-04-10 | 2025-05-19 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2025-04-10 | 2025-05-19 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2025-04-10 | 2025-05-19 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2025-04-10 | 2025-05-19 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2025-04-10 | 2025-05-19 | N |
| Provide training in compliance and ethics. | Health | 2025-04-10 | 2025-05-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-04-10 | 2025-05-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-04-10 | 2025-05-12 | N |
| 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. | Health | 2025-04-10 | 2025-05-02 | N |
| 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. | Health | 2025-04-10 | 2025-05-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-04-10 | 2025-05-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-04-10 | 2025-05-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-04-10 | 2025-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-04-10 | 2025-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-04-10 | 2025-04-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-23 | 2024-07-20 | N |
| 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. | Health | 2024-05-23 | 2024-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-23 | 2024-07-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-05-23 | 2024-07-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-23 | 2024-07-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-23 | 2024-07-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-23 | 2024-07-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-23 | 2024-07-05 | N |
| 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. | Health | 2024-05-23 | 2024-07-05 | N |
| 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. | Health | 2024-05-23 | 2024-07-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-23 | 2024-06-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-23 | 2024-06-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-23 | 2024-05-29 | N |
| 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. | Health | 2023-08-10 | 2023-10-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-10 | 2023-10-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-08-10 | 2023-10-15 | N |
| 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. | Health | 2023-08-10 | 2023-10-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-10 | 2023-10-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-10-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-10 | 2023-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-10-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-08-10 | 2023-10-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-10 | 2023-10-15 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-08-10 | 2023-10-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-10 | 2023-10-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-10 | 2023-09-30 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-08-10 | 2023-09-28 | N |
| 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. | Health | 2023-08-10 | 2023-09-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-10 | 2023-09-18 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-08-10 | 2023-09-15 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-08-10 | 2023-09-15 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-08-10 | 2023-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-09-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-08-10 | 2023-08-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-10 | 2023-08-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-10 | 2023-08-10 | N |
| 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. | Health | 2023-08-10 | 2023-08-10 | N |