HAWTHORNE, NV - Federal inspectors discovered that Lefa Seran SNF failed to provide proper pneumonia vaccinations to all 21 residents despite many giving consent for the life-saving immunizations.
Facility-Wide Vaccination Failures Documented
The April 2025 inspection revealed that none of the 21 residents had completed a pneumococcal vaccine series according to current CDC guidelines. The findings showed systematic failures in the facility's immunization program that potentially exposed vulnerable elderly residents to serious pneumococcal infections.
The inspection found residents who had consented to receive pneumonia vaccines but never received them. Resident #19 consented to both influenza and pneumococcal vaccines in January 2025 but received neither vaccination. The Director of Nursing stated the facility was "waiting until the resident was well enough to receive the vaccine" but provided no clinical documentation justifying the delay.
Resident #11 had an undated consent form for pneumococcal vaccination but immunization records showed no vaccines were ever administered. Similarly, Residents #18 and #4 had consent forms but no corresponding vaccinations in their records.
Outdated Policies and Staff Training Gaps
The facility's immunization policy, last revised in April 2012, contained outdated information that did not reflect current CDC vaccination schedules. The policy incorrectly stated that pneumococcal immunizations should be offered "once before the age of 65 and once after the age of 65."
Current CDC guidelines recommend a more comprehensive vaccination schedule. Adults over 65 should receive either the PCV20 or PCV21 vaccine, or alternatively the PCV15 followed by PPSV23 one year later. The facility had only been administering older vaccines like PCV-13 and PPSV23, which do not constitute a complete vaccination series under current standards.
The Infection Preventionist acknowledged being unaware of the most current CDC pneumococcal vaccination schedule and confirmed the facility had never administered the newer vaccines PCV20, PCV21, or PCV15 that are now recommended for complete protection.
Medical Significance of Vaccination Gaps
Pneumococcal disease poses serious risks to nursing home residents, who are among the most vulnerable populations. The bacteria can cause pneumonia, bloodstream infections, and meningitis. Incomplete vaccination leaves residents susceptible to infections that could result in serious illness, hospitalization, or death.
The CDC vaccination schedule exists because different pneumococcal vaccines protect against different strains of the bacteria. The PCV20 and PCV21 vaccines provide broader protection than the older PCV-13 vaccine. When residents receive incomplete vaccination series, they lack immunity against certain bacterial strains that could cause life-threatening infections.
Many residents at Lefa Seran SNF had medical conditions that increase their pneumococcal infection risk. Multiple residents had chronic obstructive pulmonary disease, heart failure, diabetes, and other conditions that compromise immune function. These residents require complete vaccination series for optimal protection.
Quality Assurance Failures Identified
The facility's Quality Assurance and Performance Improvement program failed to identify vaccination deficiencies despite having data showing problems. The 2024/2025 Infection Prevention Plan noted that five residents developed pneumonia in 2024, documenting this surveillance activity as "goal not met." However, this unmet goal was not carried forward to the current infection prevention plan for further action.
The Risk Manager confirmed that the Infection Prevention Plan should have been reviewed by the Quality Assurance committee and that unmet surveillance goals should be reevaluated and addressed in subsequent plans. This oversight meant systemic vaccination problems continued without correction.
The Infection Preventionist stated they presented information during committee meetings but did not review resident vaccination status or present the Infection Prevention Plan to the QAPI committee for review. This represented a breakdown in the oversight process designed to identify and correct facility-wide problems.
Infection Control Surveillance Deficiencies
Beyond vaccination failures, inspectors found the facility lacked proper infection surveillance systems. The Infection Preventionist could not provide ongoing surveillance tools to monitor infection trends, locations of infections within the facility, or staff providing care to infected residents.
The facility policy required surveillance to assess healthcare-associated infections, recognize infection rate trends, and monitor antimicrobial resistance patterns. However, the Infection Preventionist only compiled monthly spreadsheets of culture results and antibiotic orders for long-term care residents, missing critical surveillance components.
This surveillance gap means the facility could miss infection outbreaks or fail to recognize patterns that might indicate problems with infection control practices. Early detection of infection trends is crucial for implementing timely interventions to protect residents.
Additional Assessment Concerns
The facility assessment also failed to accurately identify substance use disorders among residents. Despite having six current cigarette smokers, the assessment documented zero residents with substance use disorders. The Director of Nursing stated they did not consider nicotine addiction to be a substance use disorder, despite CDC guidance that substance use disorders can apply to tobacco products.
This assessment inaccuracy could result in staff not receiving proper training on caring for residents with nicotine dependence, potentially affecting the quality of care provided to smoking residents who require specialized support.
Regulatory Context and Standards
Federal regulations require nursing homes to maintain comprehensive immunization programs and conduct facility assessments that accurately reflect resident populations and care needs. The facility's failures represent violations of multiple federal requirements designed to protect resident health and safety.
Proper vaccination programs require current policies based on CDC guidelines, staff training on immunization schedules, systems to track vaccination status, and quality assurance processes to identify and correct deficiencies. Lefa Seran SNF demonstrated failures in all these areas.
The inspection findings highlight the importance of keeping immunization policies current as medical recommendations evolve. The facility's 13-year-old policy demonstrates how outdated procedures can compromise resident care even when staff believe they are following appropriate protocols.
Immediate Jeopardy Avoided
While the violations were significant, inspectors classified them as causing "minimal harm or potential for actual harm" rather than immediate jeopardy. This suggests that while residents faced increased infection risks, no immediate life-threatening situations were identified during the inspection period.
However, the systematic nature of the vaccination failures affecting all residents demonstrates the potential for serious consequences if not promptly corrected. Pneumococcal infections can develop rapidly in elderly populations and may become severe before symptoms are recognized.
The facility must develop comprehensive corrective action plans to address policy updates, staff retraining, vaccination completion for consenting residents, and quality assurance improvements to prevent future occurrences of similar systematic failures.
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.
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