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Nursing HomeMedicaid Investigative

Lefa Seran Snf

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1st and a St, Hawthorne, NV 8941524 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing

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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Above-median deficiencies (18 vs median 8.0)
  • High staff turnover (62%)
  • High RN turnover (83%)

Bottom 25% in NV · Meets national RN staffing standard · Above recommended total nurse staffing · No penalties on record

Source: Medicare data

What this means for your family

This facility has areas of concern that warrant careful consideration. The facility has 18 deficiencies, which is above the state average. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
1.09hrs
OK
Registered nurses for medical care
Total Nursing
5.86hrs
OK
All nurses + aides combined
Staff Turnover
85%
Lower is better (< 30% = good)
RN Turnover
86%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 14 measures

Medicare Rating
2/ 5
Better Than Avg

6

measures

Worse Than Avg

8

measures

Long-Stay Residents
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility34.3%
Worse than Avg
Here
34.3%
US
14.4%
NV
13.7%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility34.9%
Worse than Avg
Here
34.9%
US
15.5%
NV
17.6%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility33.4%
Worse than Avg
Here
33.4%
US
15.3%
NV
16.5%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility78.3%
Worse than Avg
Here
78.3%
US
95.5%
NV
89.6%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
NV
5.1%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

⚖️

Residents who lost too much weight

↓ Lower is better
This Facility15.8%
Worse than Avg
Here
15.8%
US
5.3%
NV
5.8%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

18deficiencies
Well above state avg (9.4)

This facility has 58 deficiencies across four surveys with two complaint-triggered issues, indicating families have filed reports about resident safety and financial protection. The most recurring problems involve care planning and assessments, safety hazards and accident prevention, and infection control. While all deficiencies appear to have correction dates, the pattern of repeated issues across multiple surveys in these core areas suggests ongoing challenges with fundamental care processes.

Apr 10, 2025Routine
19
0867Potential for harm · WidespreadCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0883Potential for harm · WidespreadCorrected

Infection Control Deficiencies

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

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0726Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

0838Potential for harm · IsolatedCorrected

Administration Deficiencies

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

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.

0941Potential for harm · IsolatedCorrected

Administration Deficiencies

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

0942Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

0943Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

0945Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

0946Potential for harm · IsolatedCorrected

Administration Deficiencies

Provide training in compliance and ethics.

0949Potential for harm · IsolatedCorrected

Administration Deficiencies

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

0918Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

May 23, 2024Routine
13
0887Potential for harm · WidespreadCorrected

Infection Control Deficiencies

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.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0700Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0867Potential for harm · IsolatedCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0345Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0511Potential for harm · IsolatedCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0354Minimal · WidespreadCorrected

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Aug 10, 2023Routine
24
0700Potential for harm · WidespreadCorrected

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

0758Potential for harm · WidespreadCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

0942Potential for harm · PatternCorrected

Resident Rights Deficiencies

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

0036Potential for harm · PatternCorrected

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

0712Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0561Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

0640Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0727Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0835Potential for harm · IsolatedCorrected

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

0838Potential for harm · IsolatedCorrected

Administration Deficiencies

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.

0867Potential for harm · IsolatedCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0025Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Create arrangements with other facilities to receive patients.

0912Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

0918Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0847Minimal · WidespreadCorrected

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Lefa Seran Snf

Organization Type

government

Ownership & Management

Owners

Mt Grant General Hospital

Owner · Organization

100%

Key personnel

Dow, MichelleOfficer / DirectorReed, PaulaOfficer / DirectorRuch, SharonOfficer / DirectorRutherford, NancyOfficer / DirectorSchumann, RichardOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

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