Lefa Seran Snf

sodium levels or symptoms of low sodium levels for the resident.

Nursing (DON) was responsible for updating the care plan.

The RN verbalized the resident's low

and changes in eating and drinking habits.

The RN verbalized the cause of the low sodium levels had not yet been determined.

The RN confirmed the resident did not have a care plan addressing the concerns of low sodium levels and the symptoms and interventions to alleviate symptoms should have been care planned.

On 04/09/2025 at 2:45 PM, the DON confirmed the DON would frequently document the care plans but any nurse caring for a resident could document in the care plan.

The DON confirmed Resident #14 did not have a care plan related to the resident's low sodium levels and verbalized a care plan would have been helpful to the nurses managing the resident's symptoms.

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.

Comprehensive person-centered care plans must include measurable objectives and timeframes to meet a resident's mental and psychosocial needs.

Comprehensive care plans must meet the requirements of the baseline care plans to incorporate physician orders.

295001 04/10/2025

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

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.

295001 04/10/2025

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

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.

295001 04/10/2025

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

over three months was considered a significant weight loss.

The RD verbalized the RD would expect

would initiate included adding a nutritional supplement, increasing protein due to the increased risk of

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-F657

295001 04/10/2025

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

way that maximizes each resident's well being.

interview, clinical record review, and document review, the facility failed to ensure nursing staff

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 [AGE] and one vaccine after age [AGE].

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

• Cross reference with F-F883

295001 04/10/2025

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

contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on

behaviors were monitored related to an ordered psychotropic medication for 1 of 12 sampled residents (Resident #18).

This deficient practice had the potential to result in an unmanaged medication regimen, missed signs of worsening condition, and compromised resident safety.

Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with a primary diagnosis of disorder of brain, unspecified.

A physician's order dated 04/03/2025, documented Lorazepam oral concentrate 2 milligrams (mg) per milliliter (ml), give 0.5 ml by mouth every four hours as needed for terminal agitation for 14 days.

The behavior and side effect monitoring binder lacked psychotropic monitoring for Resident #18.

On 04/10/2025 at 9:23 AM, the Assistant Director of Nursing (ADON) explained all residents on psychotropic medications required behavior and side effect monitoring.

Monitoring was done in a binder at the nurse's station.

The ADON confirmed the binder lacked side effect and behavior monitoring for Resident #18's Lorazepam.

On 04/10/2025 at 10:31 AM, the Director of Nursing (DON) verbalized behavior and side effect monitoring for Resident #18's Lorazepam had not yet begun.

On 04/10/2025 at 1:28 PM, the Director of Nursing (DON) explained Lorazepam was being used to treat Resident #18's terminal agitation. In December of 2024, Resident #18 began to have terminal agitation exhibited by hallucinations, decreased communication, decreased appetite, sleeping more often, and sensitivity to light.

The facility policy titled Psychotropic Medication Use, revised 04/20/2023, documented psychotropic medications included hypnotics, antipsychotics, benzodiazepines, sedatives, and antidepressants.

Licensed nurses would be aware of potential side effects of psychotropic medications and all medical and nursing staff would evaluate the effectiveness of as needed psychotropic drugs to manage behavior.

295001 04/10/2025

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

Based on observation, interview, clinical record review, and document review, the facility failed to

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.

295001 04/10/2025

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

corrective plans of action.

facility's Quality Assurance and Performance Improvement Program identified areas of concern with

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

• 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 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

295001 04/10/2025

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

infections in the facility.

This deficient practice had the potential to result in a delay in recognition of

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.

295001 04/10/2025

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

been reviewed with the Quality Assurance and Performance Improvement committee and an unmet

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 50 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

• Cross reference with F-F726 and F-F867

295001 04/10/2025

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

and staff after education, and properly document each resident and staff member's vaccination

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on

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], 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], 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.

295001 04/10/2025

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

communications for direct care staff members.

communications training was completed timely per facility policy for 1 of 18 sampled employees

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.

295001 04/10/2025

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

care for its residents.

resident rights training was completed timely per facility policy for 2 of 18 sampled employees

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.

295001 04/10/2025

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

report abuse, neglect, and exploitation.

abuse prevention training was completed timely per facility policy for 2 of 18 sampled employees

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.

295001 04/10/2025

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

written standards, policies, and procedures for the program.

infection control training was completed timely per facility policy for 2 of 18 sampled employees

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.

295001 04/10/2025

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

(Employee #4 and #10).

This deficient practice had the potential to put residents at risk of receiving

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.

295001 04/10/2025

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

assessment.

behavioral health care training was completed timely per facility policy for 1 of 18 sampled employees

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.

295001

Form Approved OMB

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

potential for actual harm Resident #21

Resident #21 was admitted to the facility on [DATE], 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.

295001

Form Approved OMB

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

potential for actual harm

295001

Form Approved OMB

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

295001

Form Approved OMB

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