Lefa Seran SNF: Care Plan Gaps for Amputee Resident - NV
Nobody wrote down how to get her there.
The resident, identified in inspection records as Resident 21, was admitted to Lefa Seran SNF with type two diabetes and failure to thrive in addition to the partial leg amputation. Her activities care plan, created in February 2025 by the facility's Activities Director, captured what she wanted. The goal was recorded on February 18. It was revised on March 29 to include a target date of May 16, 2025.
What was never recorded, across any version of that care plan, were the interventions, the specific steps staff would take to actually provide activities in a way that worked for her.
When inspectors reviewed the care plan on April 9, 2025, the gap was plain. The Director of Nursing confirmed it. The Activities Director confirmed it. Both said the interventions were the Activities Director's responsibility to document. The Activities Director told inspectors she had not realized the interventions were missing and had not understood they would be necessary to deliver activities in the manner the resident preferred.
That explanation, offered at 4:07 in the afternoon, was the first time anyone at the facility appears to have caught the problem.
The Director of Nursing, speaking with inspectors about an hour and a half earlier, said she expected the Activities Director to document the resident's preferred activities focus, goals, and interventions accurately and completely. She confirmed that had not happened for Resident 21.
The care plan had a focus. It had a goal. It had a revised target date. It did not have a single instruction for how staff should help a wheelchair-dependent amputee pursue the activities she had told the facility she wanted.
Inspectors rated the deficiency as causing minimal harm or the potential for actual harm, affecting a small number of residents. It was the only deficiency documented in this inspection report.
That rating reflects the regulatory floor, not necessarily what it means in practice to be a person with a partial amputation, dependent on others for movement, who told the staff around her what she wanted out of her days, and whose answer was recorded and then left sitting without any follow-through plan attached to it.
The facility's own care plan policy, last revised in March 2017, described care plans as documents that would include the instructions needed to provide effective person-centered care. The policy called for measurable objectives and timeframes and a description of services furnished to help residents reach their highest practicable physical, mental, and psychosocial well-being.
Resident 21's care plan had the objective. May 16 was the timeframe. The instructions for getting her outside, into nature, in a wheelchair, with the transfers she needed help completing, were never written.
Whether anyone took her on that adventure before or after inspectors arrived, the inspection report does not say.
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.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
Nobody wrote down how to get her there.
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.