Lefa Seran SNF: COVID Vaccine Consent Failures - NV
At Lefa Seran SNF, a skilled nursing facility on 1st and A Street in Hawthorne, a resident's COVID-19 vaccination consent form had both boxes checked: the one indicating the resident wanted the vaccine, and the one indicating the resident was declining it. The form was signed by the resident and a facility employee on October 29, 2024. It sat in the clinical record, contradicting itself, until a federal inspection in April 2025.
A second resident at the same facility had no form at all, consent or declination, and had never received a single dose of the COVID vaccine.
Inspectors from the Centers for Medicare and Medicaid Services documented both failures during an April 10, 2025 survey. The deficiency was cited at a level of minimal harm or potential for actual harm, with a finding that the failures had the potential to result in residents not receiving a vaccine they wanted, and then experiencing severe illness, hospitalization, or death from COVID infection.
The resident whose form checked both boxes, identified in inspection records as Resident 18, was admitted to the facility with diagnoses that included adult failure to thrive and a personal history of a benign brain tumor. The last time Resident 18 had received a COVID vaccine, according to the facility's own immunization record, was April 21, 2022, more than two and a half years before the contradictory consent form was signed.
When inspectors sat down with the facility's Infection Preventionist on the morning of April 9, 2025, the answer was immediate and unambiguous. The Infection Preventionist confirmed that yes, the form showed the resident had both consented to and declined the vaccine simultaneously. The Infection Preventionist said the consent should have been clarified and corrected to reflect the resident's actual choice.
It had not been.
The second resident, Resident 21, was admitted with type II diabetes without complications and adult failure to thrive. The clinical record contained nothing, no consent form, no declination form, no documentation that anyone had ever approached this resident about the COVID vaccine or offered them a choice. The immunization record confirmed Resident 21 had never received any dose.
The Director of Nursing acknowledged the gap directly when inspectors asked. During an interview at 10:42 AM on April 9, 2025, the Director of Nursing confirmed that a consent or declination form had simply never been completed for Resident 21.
Together, the two cases describe the same underlying failure from opposite directions. One resident had a form that was useless because it said everything. The other had no form because nobody had gotten around to it. In both cases, the result was the same: there was no reliable record of what these residents actually wanted, and no way to confirm whether their wishes had been honored.
The facility's own COVID-19 Voluntary Vaccination Policy, revised as recently as February 20, 2024, committed the facility to providing education and resources about COVID vaccination, and to making regular communication efforts to inform residents about the vaccine's availability, benefits, and recommended guidelines. The policy existed. The practice did not consistently follow it.
Hawthorne is a small city in Mineral County, Nevada, roughly two hours southeast of Reno. Lefa Seran SNF is a modest facility, and the inspection covered only five residents sampled specifically for vaccination records. Two of those five had documentation problems serious enough to cite. That is a 40 percent failure rate within a targeted sample.
The inspection report does not say whether Resident 18 actually wanted the vaccine or was declining it. That is precisely the problem. The form that was supposed to capture that decision captured nothing, because it captured both. Resident 18's last immunization was in April 2022, before the contradictory form was signed in October 2024. Whether the resident wanted an updated dose and never got one because the paperwork was never fixed, the inspection report cannot say. The record does not show it.
For Resident 21, who had never received any COVID vaccine at all and had no documentation of ever being offered one, the gap is starker. A resident with type II diabetes and adult failure to thrive faces elevated risk from respiratory illness. The inspection report notes that failing to receive a desired COVID vaccine carries the potential for severe or prolonged illness, hospitalization, or death. The report does not say Resident 21 wanted the vaccine. It says there is no record either way, because nobody completed the form.
That is not a paperwork technicality. A consent or declination form is the mechanism by which a resident's choice gets recorded and acted on. Without it, there is no way to know whether Resident 21 was offered the vaccine and declined, was never offered it, or was offered it and wanted it and was simply never followed up with. The form's absence makes all of those outcomes equally invisible.
The Infection Preventionist's acknowledgment on April 9 that Resident 18's form needed to be clarified and corrected was accurate as far as it went. The Director of Nursing's acknowledgment that Resident 21's form had never been completed was equally straightforward. Neither acknowledgment explained how either situation had persisted without correction, or who was responsible for ensuring the forms were completed and reviewed.
The facility's policy called for regular communication efforts. The inspectors found two residents for whom that communication either produced a document too flawed to be useful, or produced nothing at all.
The deficiency was classified at the lower end of the harm scale, minimal harm or potential for actual harm, with few residents affected. That classification reflects the fact that inspectors found no documented evidence that either resident suffered a direct health consequence from the paperwork failures. It does not reflect what was not documented, which is what Resident 18 actually chose, and whether Resident 21 ever had a real conversation with anyone about a vaccine they may have wanted and never received.
Resident 18's contradictory form was signed in October 2024. The inspection was conducted in April 2025. For roughly five months, the form sat in the record with both boxes checked, unresolved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lefa Seran Snf from 2025-04-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 30, 2026 · Our methodology
LEFA SERAN SNF in HAWTHORNE, NV was cited for violations during a health inspection on April 10, 2025.
The form was signed by the resident and a facility employee on October 29, 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.