Lefa Seran Snf

F-F657

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 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. Level of Harm - Minimal harm or potential for actual harm 41848

Residents Affected - Few Based on interview, clinical record review, and document review, the facility failed to ensure nursing staff responsible for administering vaccinations had been trained according to accurate vaccination guidelines and were not instructed to follow a facility policy containing outdated and inaccurate information affecting 21 of 21 residents residing in the facility.

Findings include:

On 04/09/2025 at 6:08 PM, the Director of Nursing (DON) verbalized the facility would follow the Centers for Disease Control and Prevention (CDC) guidelines for vaccine schedules. The DON confirmed none of the 21 residents in the facility had completed a pneumococcal vaccine series per the CDC pneumococcal vaccine schedule.

On 04/10/2025 at 9:38 AM, the Infection Preventionist (IP) verbalized the immunization program for residents was the responsibility of the IP. The IP confirmed the IP was responsible for providing the orientation and training to facility staff on the immunization program. The IP verbalized the facility was following CDC guidelines. The IP verbalized the IP's understanding of pneumococcal vaccines was for a resident to receive one vaccine before age 65 and one vaccine after age 65. The IP confirmed the IP was unaware of the most current CDC schedule for pneumococcal immunizations and confirmed the facility was not following the CDC guidelines for pneumococcal vaccinations when presented with the CDC's guidelines on pneumococcal vaccine timing for adults.

On 04/10/2025 at 4:11 PM, the Risk Manager confirmed the facility policy for Immunizations was not up to date or accurate and the facility was not vaccinating residents for pneumonia per current CDC guidelines.

The facility policy titled Immunizations, revised 04/06/2012, documented all residents would be offered influenza or pneumococcal immunizations unless medically contraindicated. The facility would follow current CDC guidelines for immunization schedules. Influenza immunizations would be offered as soon as the vaccination was available in the fall and continued until March 31st yearly. Pneumococcal immunizations would be offered once before the age of 65 and once after the age of 65.

Cross reference with

F-F692

Level of Harm - Minimal harm or 43311 potential for actual harm Resident #21 Residents Affected - Few Resident #21 was admitted to the facility on [DATE REDACTED], with diagnoses including type two diabetes mellitus without complications, failure to thrive, and acquired absence of unspecified leg below knee.

Resident #21's Care Plan documented the following activities care plan focus on 02/18/2025: The resident partially depended on staff for activities due to physical limitations of using a wheelchair and requiring staff to assist with transfers. The goal documented Resident #21 wanted to go on a nature adventure within the

review period and was dated 02/18/2025. The goal was revised on 03/29/2025, to include a target date of 05/16/2025.

Resident #21's Care Plan lacked interventions related to the documented activities focus and goals.

On 04/09/2025 at 2:21 PM, the DON explained the Activities Director (AD) would fill out the activities portion of the care plan for all residents. The DON verbalized an expectation the AD would accurately and completely document the resident's preferred activities focus, goals, and interventions on the care plan. The DON confirmed Resident #21's Care Plan lacked interventions related to the residents' preferred facility activities and services.

On 04/09/2025 at 4:07 PM, the AD explained the activities portion of Resident #21's Care Plan was created by the AD during the resident interview. The AD explained the AD was not aware the interventions were missing from the care plan and would be necessary to provide activities in a manner the resident preferred.

The AD confirmed the activities interventions were the AD's responsibility to document and implement and were not documented on Resident #21's Care Plan.

The facility policy titled Care Plans, revised 03/22/2017, documented each resident would have a comprehensive person-centered care plan developed by the interdisciplinary team. The care plans would be updated as the needs of the resident changed and would include any updated information based on details of the comprehensive assessment. The care plan included the instructions needed to provide effective person-centered care of the resident that met professional standards of quality care. The comprehensive person-centered care plan was consistent with resident's rights and included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment and included the description of any services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41848

Residents Affected - Few Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a resident did not have a wooden trap (a trap using a spring-loaded mechanism with a metal bar designed to snap shut with sufficient force to trap and kill a rodent when the trap was triggered) set and baited with peanut butter in a resident's bathroom for 1 of 12 sampled residents (Resident #15). This deficient practice had the potential to result in a resident accidentally triggering the trap when entering the bathroom and sustaining injury to the resident's foot; and 2) unsecured medications prescribed to facility staff were not left unattended at the Nurse's Station. This deficient practice had the potential to cause harm by ingestion of unsecured medications by residents residing in the Long Term Care Unit.

Findings include:

Resident #15

Resident #15 was admitted to the facility on [DATE REDACTED], with diagnoses including chronic atrial fibrillation, unspecified and adult failure to thrive.

On 04/07/2025 at 11:50 AM, there was a wooden rodent trap set and baited in the resident's bathroom. The resident verbalized the resident had woken up one night and saw a mouse near the entrance to the bathroom. The resident verbalized the resident told staff and staff's solution was to put the rodent trap in the resident's bathroom.

On 04/08/2025 at 2:36 PM, the Director of Nursing (DON) verbalized the facility had found no evidence of mice in resident rooms and the trap in the resident's bathroom could have been a safety hazard if the resident accidentally triggered the trap with the resident's foot.

43311

Unsecured Medications

On 04/09/2025 at 5:02 PM, a duffle bag was observed at the Nurse's station to be open, unsecured, and unattended with four medication bottles in view.

On 04/09/2025 at 5:42 PM, a Registered Nurse (RN) explained the open duffle bag belonged to staff and was left unattended at the Nurse's Station with four medication bottles in view. The RN confirmed there were four medication bottles that were prescribed to a staff member in the duffle bag and were left unsecured and available to residents for an unknown amount of time. The RN explained the RN had moved the duffle bag into the DON's office once the unsecured bag was discovered.

The RN confirmed the labeled contents of the four unsecured medication bottles were as follows:

-Hydrochlorothiazide 25 milligrams (mg),

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 -Lisinopril 10 mg,

Level of Harm - Minimal harm or -Losartan potassium 100 mg, and potential for actual harm -Losartan potassium 50 mg. Residents Affected - Few

The RN confirmed the medications could have caused a resident's blood pressure to bottom out, which meant a resident's blood pressure could be rendered low enough to cause a medical emergency.

On 04/09/2025 at 5:46 PM, the DON confirmed the staff duffle bag was left unsecured and contained a staff member's personal medications. The DON explained the expectation of staff was to secure any personal belongings and not allow resident access to unprescribed medications for safety concerns.

The facility document, titled Resident Rights, revised 08/2018, documented the resident had the right to a safe environment. This included ensuring the physical layout of the facility maximized resident independence and did not pose a safety risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41848 potential for actual harm Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Residents Affected - Few facility policy for weight loss was followed when a resident experienced a significant weight loss for 1 of 12 sampled residents (Resident #11). This deficient practice had the potential to result in a resident experiencing adverse outcomes from a significant weight loss not identified by the facility and a delay in care from the Registered Dietitian (RD) not being notified of the resident's weight loss.

Findings include:

Resident #11

Resident #11 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including type II diabetes mellitus without complications, pressure-induced deep tissue damage of right heel, and chronic obstructive pulmonary disease, unspecified.

On 04/07/2025 at 1:22 PM, the resident was lying in bed and the resident's face appeared gaunt with a sunken appearance around the resident's eyes and cheeks. The resident verbalized the resident had been eating less due to a decreased appetite and the resident did not like the food served by the facility. The resident verbalized the resident felt the resident had lost weight because of not eating.

The Weights and Vitals Summary for Resident #11 documented the following:

- On 04/06/2025, the resident's weight was 154.6 lbs. A 15.01% weight loss over three months from the resident's weight of 181.9 lbs on 01/06/2025.

The Weights and Vitals Summary for Resident #11 did not include documentation of a weight taken on 04/07/2025 to verify the significant weight loss.

The clinical record for Resident #11 did not include documentation of notification of the significant weight loss to the RD.

On 04/09/2025 at 11:19 AM, the Registered Nurse (RN) for Resident #11 verbalized a resident with a significant weight loss would be reweighed the following day to verify the findings. The RN verbalized the RN would not contact the RD to notify of the significant weight loss.

On 04/09/2025 at 2:46 PM, the Director of Nursing (DON) confirmed Resident #11 did have significant weight loss based on the weight recorded from 04/06/2025. The DON verbalized the process for reviewing significant weight loss was for staff to discuss resident weights during an interdisciplinary team (IDT) meeting

on Monday mornings and the RD would attend the IDT meeting once a month. The DON verbalized a resident with a significant weight loss would be reweighed the following day to verify the weight loss and the RD would be notified. The DON confirmed Resident #11 had not been reweighed and the RD had not been notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 On 04/10/2025 at 9:06 AM, the RD verbalized the RD was sent an email from the facility on Monday mornings notifying the RD if a resident has a nutrition concern or significant weight loss. The RD verbalized Level of Harm - Minimal harm or the RD reviewed the communication the RD was sent by the facility on Monday, 04/07/2025, and Resident potential for actual harm #11 was not discussed in the email. The RD confirmed the RD had not been informed of Resident #11's most recent significant weight loss. The RD confirmed a 15% weight loss over three months was considered Residents Affected - Few a significant weight loss. The RD verbalized the RD would expect the facility to reweigh the resident to verify

the weight change and would then review the resident's recent meal intake and percentage of meals eaten.

The RD discussed possible interventions the RD would initiate included adding a nutritional supplement, increasing protein due to the increased risk of skin breakdown, reinforcing the importance of turning the resident every two hours, and requesting bloodwork.

The facility policy titled Weight Loss, revised 09/06/2012, documented residents would be evaluated for weight loss. Residents with a weight change of five pounds would be reweighed the next day. Significant changes in weights would initiate a nutrition meeting and weekly weights until weights were stable.

Cross reference with

F-F867

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41848

Residents Affected - Few Based on interview, clinical record review, and document review, the facility failed to ensure resident consents for the COVID-19 (Covid) vaccination were offered or completed correctly for 2 of 5 residents sampled for vaccinations (Resident #18 and #21). This deficient practice had the potential to result in residents wishing to receive a Covid vaccination not receiving the vaccine and experiencing severe or prolonged illness, hospitalization , or death as the result of infection with the Covid virus.

Findings include:

Resident #18

Resident #18 was admitted to the facility on [DATE REDACTED], with diagnoses including adult failure to thrive and personal history of benign neoplasm of the brain.

A Covid vaccine consent and declination form for Resident #18 had both the checkboxes for consent and declination completed and was signed by the resident and a facility employee on 10/29/2024.

The Immunization Record for Resident #18 documented the resident's most recent dose of the Covid vaccine was administered on 04/21/2022.

On 04/09/2024 at 9:24 AM, the Infection Preventionist (IP) confirmed Resident #18's consent form for the Covid vaccine indicated the resident both wanted the vaccine and was declining the vaccine. The IP verbalized the consent should have been clarified and corrected to indicate the resident's choice.

Resident #21

Resident #21 was admitted to the facility on [DATE REDACTED], with diagnoses including type II diabetes mellitus without complications and adult failure to thrive.

The clinical record for Resident #21 lacked a consent or declination form for the Covid vaccine.

The Immunization Record for Resident #21 documented the resident had not received any doses of the Covid vaccine.

On 04/09/2025 at 10:42 AM, the Director of Nursing (DON) verbalized a consent or declination form for the Covid vaccine had not been completed for Resident #21.

The facility policy titled COVID-19 Voluntary Vaccination Policy, revised 02/20/2024, documented the facility would provide education and resources to promote the benefits and safety of COVID-19 vaccination. Regular communication efforts would be made to inform individuals about the availability, benefits, and recommended guidelines for COVID-19 vaccination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Level of Harm - Minimal harm or potential for actual harm 50210

Residents Affected - Few Based on interview, personnel record review, and document review, the facility failed to ensure initial communications training was completed timely per facility policy for 1 of 18 sampled employees (Employee #4). This deficient practice had the potential to prevent residents with communication needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being.

Findings include

Employee #4

Employee #4 was hired as the Registered Dietician on 10/21/2024.

Employee #4's personnel record documented communication training completed on 11/30/2024, 40 days

after hire.

On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed communication training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor.

On 04/10/2025 at 3:01 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of communication training completed prior to 11/30/2024.

The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete communication training prior to beginning work on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0942 Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Level of Harm - Minimal harm or potential for actual harm 50210

Residents Affected - Few Based on interview, personnel record review, and document review, the facility failed to ensure initial resident rights training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to prevent residents from being able and encouraged to practice their rights as residents.

Findings include

Employee #4

Employee #4 was hired as the Registered Dietician on 10/21/2024.

Employee #4's personnel record documented resident rights training completed on 01/11/2025, 82 days after hire.

Employee #10

Employee #10 was hired as a Registered Nurse on 10/21/2024.

Employee #10's personnel record documented resident rights training completed on 11/23/2024, 33 days

after hire.

On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed resident rights training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor.

On 04/10/2025 at 3:04 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of resident rights training completed prior to 01/11/2025, and Employee #10's personnel record lacked documented evidence of resident rights training completed prior to 11/23/2024.

The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete resident rights training prior to beginning work on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 50210

Residents Affected - Few Based on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #8). This deficient practice had the potential to place all residents at risk for abuse and neglect.

Findings include

Employee #4

Employee #4 was hired as the Registered Dietician on 10/21/2024.

Employee #4's personnel record documented elder abuse prevention training completed on 12/07/2024, 47 days late.

Employee #8

Employee #8 was hired as a Certified Nursing Assistant on 04/27/2023.

Employee #8's personnel record documented elder abuse prevention training completed on 01/02/2024, and annual elder abuse prevention training completed on 01/24/2025, 22 days late.

On 04/09/2025 at 2:27 PM, the Human Resources (HR) Manager verbalized all staff were required to take elder abuse prevention training before stepping foot on the floor and annually. The HR Manager verbalized Employee #4's personnel record lacked elder abuse prevention training completed prior to 12/07/2024, and Employee #8's personnel record lacked elder abuse prevention training completed prior to 01/24/2025.

The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete elder abuse prevention training prior to beginning work on the floor and annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0945 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Level of Harm - Minimal harm or potential for actual harm 50210

Residents Affected - Few Based on interview, personnel record review, and document review, the facility failed to ensure initial infection control training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to put residents at risk of contracting avoidable infections and diseases.

Findings include

Employee #4

Employee #4 was hired as the Registered Dietician on 10/21/2024.

Employee #4's personnel record documented infection control training completed on 11/30/2024, 40 days

after hire.

Employee #10

Employee #10 was hired as a Registered Nurse on 10/21/2024.

Employee #10's personnel record documented infection control training completed on 11/21/2024, 31 days

after hire.

On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed infection control training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor.

On 04/10/2025 at 3:15 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of infection control training completed prior to 11/30/2024, and Employee #10's personnel record lacked documented evidence of infection control training completed prior to 11/21/2024.

The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete infection control training prior to beginning work on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0946 Provide training in compliance and ethics.

Level of Harm - Minimal harm or 50210 potential for actual harm Based on interview, personnel record review, and document review, the facility failed to ensure initial Residents Affected - Few compliance and ethics training was completed timely per facility policy for 2 of 18 sampled employees (Employee #4 and #10). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations.

Findings include

Employee #4

Employee #4 was hired as the Registered Dietician on 10/21/2024.

Employee #4's personnel record documented compliance and ethics training completed on 11/30/2024, 40 days after hire.

Employee #10

Employee #10 was hired as a Registered Nurse on 10/21/2024.

Employee #10's personnel record documented compliance and ethics training completed on 11/23/2024, 33 days after hire.

On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed compliance and ethics training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor.

On 04/10/2025 at 3:26 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of compliance and ethics training completed prior to 11/30/2024, and Employee #10's personnel

record lacked documented evidence of compliance and ethics training completed prior to 11/23/2024.

The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete compliance and ethics training prior to beginning work on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Level of Harm - Minimal harm or 50210 potential for actual harm Based on interview, personnel record review, and document review, the facility failed to ensure initial Residents Affected - Few behavioral health care training was completed timely per facility policy for 1 of 18 sampled employees (Employee #4). This deficient practice had the potential to prevent residents with behavioral health care needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being.

Findings include

Employee #4

Employee #4 was hired as the Registered Dietician on 10/21/2024.

Employee #4's personnel record documented behavioral health care training completed on 12/23/2024, 63 days after hire.

On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed behavioral health care training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor.

On 04/10/2025 at 2:56 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of behavioral health care training completed prior to 12/23/2024.

The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete behavioral health training prior to beginning work on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 295001

F-F883

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 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. Level of Harm - Minimal harm or potential for actual harm 41848

Residents Affected - Few Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Facility Assessment (FA) was accurate and included nicotine dependence and addiction with the facility's common diagnoses and conditions. This deficient practice had the potential to result in facility staff not receiving adequate training on the care of residents with nicotine dependence and addiction diagnoses and

the needs of those residents not being met.

Findings include:

During the entrance conference with the facility on 04/07/2025, a list of cigarette smokers (smokers) residing

in the facility and the FA was provided by the facility.

The list of smokers in the facility included six residents. Three residents were able to smoke unsupervised and three residents required supervision during the designated smoking times of every two hours between 7:00 AM and 11:00 PM. The smoking location was designated as the smoke shack off the outside patio accessed through the facility dining room.

The facility document titled Facility Assessment, reviewed 01/15/2025, did not include nicotine abuse or addiction under the list of common diagnoses and listed the number of active or current substance abuse disorders among residents as zero.

On 04/10/2025 at 2:09 PM, the Director of Nursing (DON) verbalized the DON assisted with reviewing and completing the FA. The DON confirmed nicotine addiction was not identified on the FA as a diagnosis in the facility and the FA documented the number of residents with active or current substance use disorders was zero. The DON verbalized the DON did not consider nicotine addiction to be a substance use disorder. The DON confirmed six residents in the facility were current cigarette smokers.

The Centers for Disease Control and Prevention article titled Treatment of Substance Use Disorders, dated 04/25/2024, documented a substance use disorder was a treatable, chronic disease and could range in severity from moderate to severe. A substance use disorder could be applied to many types of drugs including tobacco (nicotine).

The facility document titled Facility Assessment Tool, undated, documented the FA would include the care required by the resident population considering the types of diseases and other pertinent facts present within

the population.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 41848

Residents Affected - Many Based on interview, clinical record review, and document review, the facility failed to ensure the facility's Quality Assurance and Performance Improvement Program identified areas of concern with the facility's Infection Prevention and Control Plan including concerns with pneumococcal immunizations and the immunization policy affecting 21 of 21 residents residing in the facility. This deficient practice had the potential to result in high-risk areas of concern and deficient infection control practices not being corrected and leading to infectious disease outbreaks and residents suffering severe illness or death from lack of vaccinations.

Findings include:

The facility document titled Infection Prevention and Control Annual Plan 2024/2025, documented a surveillance activity from the prior year was Prevention and Reduction of Pneumonia in long term care residents. The 2024 outcome of the surveillance activity was five residents had pneumonia in 2024. The effectiveness of the surveillance activity was documented as goal not met. The surveillance activity was not carried over to the 2024/2025 Infection Prevention Plan.

The facility policy titled Immunizations, revised 04/06/2012, documented all residents would be offered influenza or pneumococcal immunizations unless medically contraindicated. The facility would follow current CDC guidelines for immunization schedules. Influenza immunizations would be offered as soon as the vaccination was available in the fall and continued until March 31st yearly. Pneumococcal immunizations would be offered once before the age of 65 and once after the age of 65.

On 04/10/2025 at 9:43 AM, the Infection Preventionist (IP) verbalized the IP did present information during

the QAPI committee meetings, but did not review the vaccination status of the residents and the Infection Prevention and Control Annual Plan was not presented to the QAPI committee for review.

On 04/10/2025 at 4:11 PM, the Risk Manager verbalized the Infection Prevention Plan should have been reviewed by the QAPI committee and an unmet goal for a surveillance activity should have been reevaluated and carried over to the current plan. The Risk Manager confirmed the facility policy for Immunizations was not up to date or accurate and the facility was not vaccinating residents for pneumonia per current CDC guidelines.

Cross reference with 883

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 41848 potential for actual harm Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Residents Affected - Few Infection Prevention and Control Plan included a method of ongoing surveillance of active infections in the facility. This deficient practice had the potential to result in a delay in recognition of infection outbreaks and reversible trends going unrecognized leading to missed opportunities for staff education and infection spreading among residents and staff in the facility.

Findings include:

On 04/10/2025 at 9:24 AM, the Infection Preventionist (IP) verbalized the IP would compile a spreadsheet at

the end of every month for residents in long term care with culture results and antibiotic orders. The IP was unable to provide an ongoing surveillance tool with locations of infections within the facility and verbalized

the IP did not have a tool to monitor trends including location of infections, staff providing care to infected residents, residents colonized with multi drug resistant organisms, or infections not requiring antibiotics. The IP verbalized the facility was small so the IP would know if there was a concern with multiple infections but was unable to provide documentation of infection surveillance.

The facility policy titled Surveillance Plan, revised 10/06/2024, documented the plan would assess the magnitude of healthcare associated infections within the facility, recognition of trends in infections rates, antimicrobial resistance, and healthcare associated pathogens.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41848 potential for actual harm Based on interview, clinical record review, and document review, the facility failed to ensure the facility's Residents Affected - Many immunization policy was accurate and included correct, up to date information for vaccinations, resident's were provided vaccinations when the resident's consented to receive pneumococcal vaccines, and staff were training on accurate and correct information related to pneumococcal vaccinations affecting 21 of 21 residents residing in the facility (Residents #12, #17, #14, #8, #6, #20, #13, #2, #4, #5, #16, #19, #15, #11, #7, #10, #21, #3, #18, #1, and #9). This deficient practice had the potential to result in staff providing inaccurate education and information to residents based on the facility policy and training provided and residents experiencing severe or life-threatening illness from infection with pneumococcal bacteria due to lack of completing a pneumococcal vaccination series.

Resident #12

Resident #12 was admitted to the facility on [DATE REDACTED], with diagnoses including obesity, unspecified and personal history of COVID-19.

A Pneumonia Vaccination Administration consent for Resident #12, dated 04/05/2017, documented the resident's responsible party had consented to the resident receiving the vaccine as recommended by the Centers for Disease Control and Prevention (CDC).

The Immunization Record for Resident #12 documented the resident had received the following pneumococcal vaccines:

- Pneumococcal conjugate vaccine to protect against 13 strains of streptococcus pneumoniae bacteria (PCV-13) administered 02/09/2017.

- Pneumococcal polysaccharide vaccine to protect against 23 serotypes of streptococcus pneumoniae bacteria (PPSV23) administered 09/21/2018.

Resident #17

Resident #17 was admitted to the facility on [DATE REDACTED], with diagnoses including Parkinson's disease and chronic systolic (congestive) heart failure.

The clinical record for Resident #17 lacked a consent or education regarding the influenza vaccination.

The facility was unable to provide an immunization record for Resident #17.

Resident #14

Resident #14 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including chronic obstructive pulmonary disease, unspecified, acute bronchitis, unspecified, and nicotine dependence, cigarettes, with unspecified nicotine-induced disorders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 A Pneumonia Vaccination Administration consent for Resident #14 documented the resident had consented to receiving the vaccine on 12/16/2024. Level of Harm - Minimal harm or potential for actual harm An Influenza Vaccine Administration consent for Resident #14 documented the resident had consented to receiving the vaccine on 12/16/2024. Residents Affected - Many

The Immunization Record for Resident #14 documented the resident had last received an influenza vaccine

on 10/03/2023, and had received the following pneumococcal vaccines:

- PCV-13 on 06/05/2019.

- PPSV23 on 03/17/2020.

Resident #8

Resident #8 was admitted to the facility on [DATE REDACTED], with diagnoses including cerebral infarction, unspecified and nicotine dependence, cigarettes, with unspecified nicotine-induced disorders.

A Pneumonia Vaccination Administration consent for Resident #8 documented the resident had consented to receiving the vaccine on 07/22/2021.

The clinical record for Resident #8 lacked an Influenza Vaccination Administration consent for the 2024/2025 influenza season.

The Immunization Record for Resident #8 documented the resident had last received an influenza vaccine

on 09/28/2021, and had not received a pneumococcal vaccine.

Resident #6

Resident #6 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including shortness of breath and chronic obstructive pulmonary disease, unspecified.

A Pneumonia Vaccine Administration consent for Resident #6, dated 10/31/2022, was signed by the resident and witnessed by a Licensed Practical Nurse (LPN) under both the section consenting to administration of

the vaccine and the section declining administration of the vaccine.

The Immunization Record for Resident #6 documented the resident had received the following pneumococcal vaccines:

- PPSV23 on 11/05/2015.

- PPSV23 on 01/15/2021.

Resident #20

Resident #20 was admitted to the facility on [DATE REDACTED], with diagnoses including hypothyroidism, unspecified and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 The clinical record for Resident #20 lacked a Pneumonia Vaccine Administration consent or declination.

Level of Harm - Minimal harm or The Immunization Record for Resident #20 documented the resident had received the following potential for actual harm pneumococcal vaccines:

Residents Affected - Many - PPSV23 on 12/11/2009.

- PCV-13 on 05/11/2017.

- PPSV23 on 09/27/2019.

Resident #13

Resident #13 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including pneumonia, unspecified organism and chronic obstructive pulmonary disease.

A Pneumonia Vaccine Administration consent for Resident #13 documented the resident's representative had consented to the resident receiving the vaccination on 07/31/2023.

The Immunization Record for Resident #13 documented the resident had received the following pneumococcal vaccines:

- PCV-13 on 11/01/2018.

- PPSV23 on 02/04/2020.

Resident #2

Resident #2 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including type II diabetes mellitus without complications, nicotine dependence, cigarettes, with unspecified nicotine-induced disorders, and morbid (severe) obesity due to excess calories.

A Pneumonia Vaccine Administration consent for Resident #2 documented the resident had consented to receiving the vaccine on 02/06/2020.

The Immunization Record for Resident #2 documented the resident had received the PPSV23 vaccine on 12/24/2019.

Resident #4

Resident #4 was admitted to the facility on [DATE REDACTED], with diagnoses including spastic quadriplegic cerebral palsy, acute cough, and wheezing.

The clinical record for Resident #4 lacked a Pneumonia Vaccine Administration consent or declination.

The facility was unable to provide an immunization record for Resident #4.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Resident #5

Level of Harm - Minimal harm or Resident #5 was admitted to the facility on [DATE REDACTED], with diagnoses including type II diabetes mellitus without potential for actual harm complications and adult failure to thrive.

Residents Affected - Many A Pneumonia Vaccination Administration consent for Resident #5 documented the resident had consented to receiving the vaccine on 06/30/2020.

The Immunization Record for Resident #5 documented the resident had received the PPSV23 vaccine on 07/03/2013.

Resident #16

Resident #16 was admitted to the facility on [DATE REDACTED], with diagnoses including heart failure, unspecified and chronic kidney disease, unspecified.

A Pneumonia Vaccination Administration consent for Resident #16 documented the resident had consented to receiving the vaccine on 04/27/2023.

The Immunization Record for Resident #16 documented the resident had received the PCV-13 vaccine on 10/05/2016.

Resident #19

Resident #19 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including chronic obstructive pulmonary disease, unspecified and congenital pneumonia, unspecified.

An Influenza Vaccine Administration consent for Resident #19 documented the resident had consented to receiving the vaccine on 01/02/2025.

A Pneumonia Vaccination Administration consent for Resident #19 documented the resident had consented to receiving the vaccine on 01/02/2025.

The Immunization Record for Resident #19 documented the resident had not received a pneumococcal or influenza vaccine.

Resident #15

Resident #15 was admitted to the facility on [DATE REDACTED], with diagnoses including chronic atrial fibrillation, unspecified, lobar pneumonia, unspecified organism, and contact with and (suspected) exposure to other viral communicable diseases.

The clinical record for Resident #15 lacked a consent or declination for an influenza vaccine for the 2024/2025 influenza season. The most recent consent/declination forms for both influenza and pneumococcal vaccines available in the resident's record were dated 09/28/2021.

The Immunization Record for Resident #15 documented the resident had last received an Influenza vaccine

on 10/23/2023, and the resident had not received any pneumococcal vaccines.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Resident #11

Level of Harm - Minimal harm or Resident #11 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including potential for actual harm heart failure, unspecified and chronic obstructive pulmonary disease, unspecified.

Residents Affected - Many A Pneumonia Vaccination Administration consent for Resident #11 documented the resident had consented to receiving the vaccine. The consent was undated.

The Immunization Record for Resident #11 documented the resident had not received any pneumococcal vaccines.

Resident #7

Resident #7 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including type II diabetes mellitus without complications and essential (primary) hypertension.

A Pneumonia Vaccination Administration consent for Resident #7 documented the resident's representative had consented to the resident receiving the vaccine on 07/27/2023.

The Immunization Record for Resident #7 documented the resident had received the PCV-13 vaccine on 01/16/2020.

Resident #10

Resident #10 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], and 06/28/2024, with diagnoses including chronic obstructive pulmonary disease, unspecified and pneumonia, unspecified organism.

A Pneumonia Vaccination Administration consent for Resident #10 documented the resident had consented to receiving the vaccine on 03/22/2023.

The Immunization Record for Resident #10 documented the resident had received the following pneumococcal vaccinations:

- PPSV23 on 09/26/2014.

- PCV-13 on 02/15/2016.

- Pneumococcal, UF (unspecified vaccine) on 02/15/2016.

- PCV-13 on 02/08/2017.

Resident #21

Resident #21 was admitted to the facility on [DATE REDACTED], with diagnoses including type II diabetes mellitus without complications and adult failure to thrive.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 A Pneumonia Vaccination Administration consent for Resident #21 documented the resident had consented to receiving the vaccine on 02/10/2025. Level of Harm - Minimal harm or potential for actual harm The Immunization Record for Resident #21 documented the resident had received the following pneumococcal vaccinations: Residents Affected - Many - PPSV23 on 02/16/2010.

- PCV-13 on 08/12/2015.

- PPSV23 on 04/05/2018.

Resident #3

Resident #3 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], and 07/03/2023, with diagnoses including chronic obstructive pulmonary disease, unspecified and type II diabetes mellitus without complications.

A Pneumonia Vaccination Administration consent for Resident #3 documented the resident's representative had consented for the resident to receive the vaccine on 07/05/2023.

The Immunization Record for Resident #3 documented the resident had received the following pneumococcal vaccinations:

- PPSV23 on 12/04/2008.

- PCV-13 on 01/31/2016.

Resident #18

Resident #18 was admitted to the facility on [DATE REDACTED], with diagnoses including adult failure to thrive and personal history of benign neoplasm of the brain.

A Pneumonia Vaccination Administration consent for Resident #18 documented the resident had consented to receive the vaccine on 05/28/2024.

The Immunization Record for Resident #18 documented the resident had not received a pneumococcal vaccine.

Resident #1

Resident #1 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including epilepsy, unspecified, not intractable, without status epilepticus and hydrocephalus, unspecified.

A Pneumonia Vaccination Administration consent for Resident #1 documented the resident had received a pneumococcal vaccine on 04/10/2013. The consent was not signed by the resident and was signed by an LPN on 04/19/2022.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 The Immunization Record for Resident #1 documented the resident had received the PPSV23 vaccine on 04/10/2013. Level of Harm - Minimal harm or potential for actual harm Resident #9

Residents Affected - Many Resident #9 was admitted to the facility on [DATE REDACTED], with diagnoses including other myeloid leukemia not having achieved remission, acute cough, and type II diabetes mellitus with diabetic neuropathy, unspecified.

A Pneumonia Vaccination Administration consent for Resident #9 documented the resident had consented to receive the vaccine on 08/15/2023.

The Immunization Record for Resident #9 documented the resident had received the following pneumococcal vaccinations:

- PPSV23 on 03/04/2013.

- PCV-13 on 02/01/2016.

- PPSV23 on 03/04/2017.

On 04/09/2025 at 10:25 AM, the Director of Nursing (DON) verbalized Resident #19 had not received the influenza or pneumococcal vaccination the resident had consented to because the facility was waiting until

the resident was well enough to receive the vaccine. The DON verbalized the resident did not have fevers but the resident just wasn't themselves. The DON confirmed the resident had not been given further education on delaying the vaccinations and the resident's clinical record lacked documentation of a clinically indicated reason for the delay in vaccination.

On 04/09/2025 at 10:27 AM, the Infection Preventionist (IP) verbalized the facility followed CDC guidelines for vaccination and would follow the CDC recommendations for vaccine schedules.

The IP confirmed Resident #11 had consented to receive the pneumonia vaccine, but a pneumonia vaccine had not been administered to the resident.

On 04/09/2025 at 6:08 PM, the DON verbalized the facility followed CDC guidelines for vaccine schedules.

The DON confirmed none of the 21 residents in the facility had completed a pneumococcal vaccine series per the CDC pneumococcal vaccine schedule.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 On 04/10/2025 at 9:38 AM, the IP verbalized the immunization program for residents was the responsibility of the IP. The IP confirmed the IP was responsible for providing the orientation and training to facility staff on Level of Harm - Minimal harm or the immunization program. The IP verbalized the facility was following CDC guidelines. The IP verbalized the potential for actual harm IP's understanding of pneumococcal vaccines was for a resident to receive one vaccine before age 65 and one vaccine after age 65. The IP confirmed the IP was unaware of the most current CDC schedule for Residents Affected - Many pneumococcal immunizations. The IP confirmed residents in the facility had only received either the PPSV23 or PCV-13 vaccine. When shown the current CDC complete pneumococcal vaccine schedule for adults the IP confirmed PPSV23 and PCV-13 did not complete a pneumococcal vaccine series. The IP confirmed the facility had not administered the pneumococcal conjugate vaccine to protect against 20 strains of the bacteria streptococcus pneumoniae (PCV20), the pneumococcal conjugate vaccine to protect against 21 strains of the bacteria streptococcus pneumoniae (PCV21), or the 15-valent pneumococcal conjugate vaccine (PCV15).

The facility document titled Infection Prevention and Control Annual Plan 2024/2025, documented a surveillance activity from the prior year was Prevention and Reduction of Pneumonia in long term care residents. The 2024 outcome of the surveillance activity was five residents had pneumonia in 2024. The effectiveness of the surveillance activity was documented as goal not met. The surveillance activity was not carried over to the 2024/2025 Infection Prevention Plan.

On 04/10/2025 at 4:11 PM, the Risk Manager verbalized the Infection Prevention Plan should have been reviewed with the Quality Assurance and Performance Improvement committee and an unmet goal for a surveillance activity should have been reevaluated and carried over to the current plan. The Risk Manager confirmed the facility policy for Immunizations was not up to date or accurate and the facility was not vaccinating residents for pneumonia per current CDC guidelines.

The CDC guideline titled Pneumococcal Vaccine Timing for Adults, dated 10/2024, documented adults [AGE] years or older had the following options to complete a pneumococcal vaccine schedule:

- Those with no prior vaccine had the option to receive either the PCV20 or PCV21 or the option to receive

the PCV15 and then the PPSV23 a year later.

- Those who received the PPSV23 at any age had the option to receive either the PCV20 or PCV21 at least one year later or the option to receive the PCV15 at least one year later.

- Those who received the PCV13 at any age would receive the PCV20 or PCV21 at least one year later.

- Those that received the PCV13 at any age and the PPSV23 after [AGE] years of age would receive the PCV20 or PCV21 after at least five years.

The schedule for adults 19 to [AGE] years old with chronic health conditions included offering those with no prior vaccines either the option of receiving the PCV20 or PCV21 or the option of receiving the PCV15 and then the PPSV23 after one year.

The facility policy titled Immunizations, revised 04/06/2012, documented all residents would be offered influenza or pneumococcal immunizations unless medically contraindicated. The facility would follow current CDC guidelines for immunization schedules. Influenza immunizations would be offered as soon as the vaccination was available in the fall and continued until March 31st yearly. Pneumococcal immunizations would be offered once before the age of 65 and once after the age of 65.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 29 295001 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295001 B. Wing 04/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lefa Seran Snf 1st and A St Hawthorne, NV 89415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Cross reference with