Lefa Seran SNF: MDS Medication Error Found - NV
The error sat inside a federal assessment form at Lefa Seran SNF until inspectors arrived on April 10, 2025, and compared what the form said against what the resident had actually received.
Resident #1 had been admitted to the facility with a diagnosis of generalized anxiety disorder. A physician's order dated October 15, 2024, prescribed Buspirone Hydrochloride, 10 milligrams by mouth three times a day, specifically for that condition. The medication administration record for February 2025 confirmed the drug was given every single day that month, from the first to the twenty-eighth. There was no antipsychotic order anywhere in the resident's chart.
The facility's quarterly Minimum Data Set assessment told a different story. The MDS is a standardized federal form nursing homes complete regularly to document residents' conditions, diagnoses, and medications. It informs care planning decisions and shapes what interventions a resident receives. In the section tracking high-risk drug classes, the assessment marked that Resident #1 had taken antipsychotic medications during the relevant seven-day window. The box for antianxiety medications was left unchecked.
Both entries were wrong.
The Assistant Director of Nursing, who also served as the facility's MDS Coordinator, confirmed the error directly to inspectors during an interview at 9:20 in the morning on the day of the inspection. She acknowledged that Resident #1 did receive Buspirone and did not receive any antipsychotic during the assessment period. She confirmed the MDS should have documented an antianxiety medication and should not have documented an antipsychotic. She confirmed both mistakes.
The consequences of that kind of error are not abstract. An MDS assessment that falsely indicates a resident is on antipsychotic medication, while erasing the antianxiety drug they are actually taking, can produce a care plan built around the wrong clinical picture entirely. Interventions tied to antipsychotic use, monitoring protocols, dosage reviews, behavioral documentation, would be applied to a resident who needed none of them. Meanwhile, the actual management of her anxiety disorder would lack the documented foundation that guides staff responses, monitoring, and adjustments to her care.
Inspectors classified the deficiency as having the potential for actual harm, noting specifically that it could deprive the resident of a person-centered care plan and the interventions that should follow from it.
The facility's own internal policy on the MDS process, dated August 2003, stated that when a revision was needed, the MDS Coordinator would be notified and a correction would be made. The policy described a mechanism for fixing exactly this kind of mistake. The assessment had not been corrected before inspectors arrived.
Lefa Seran SNF is located on 1st and A Street in Hawthorne, a town of roughly 3,000 people in Mineral County, about three hours southeast of Reno. The inspection covered twelve sampled residents. This was the one where the medication record and the federal assessment did not match.
The MDS Coordinator knew her facility's own correction process. She knew how to fix the form. Resident #1's anxiety disorder was documented, the prescription was active, and the medication was administered every day through the entire month of February. None of that information made it into the federal assessment that was supposed to reflect her care.
The assessment said she was on antipsychotics. She was not. Her anxiety medication went unrecorded. It had been prescribed since October.
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.
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Last verified: October 28, 2026 · Our methodology
LEFA SERAN SNF in HAWTHORNE, NV was cited for violations during a health inspection on April 10, 2025.
Resident #1 had been admitted to the facility with a diagnosis of generalized anxiety disorder.
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.