All citations for Lefa Seran SNF

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Lefa Seran SNF

Last standard health inspection on record

April 10, 2025

Showing 1 to 24 of 24 citations

  1. No harm, with potential for more than minimal harm

    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.

    Widespread (many residents). CMS level F.

    Health citation F-0700, Quality of Life and Care Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  2. No harm, with potential for more than minimal harm

    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.

    Widespread (many residents). CMS level F.

    Health citation F-0758, Pharmacy Service Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  3. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0942, Resident Rights Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

  4. No harm, with potential for more than minimal harm

    Establish emergency prep training and testing.

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0036, Emergency Preparedness Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  5. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 30, 2023).

  6. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0552, Resident Rights Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  7. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0561, Resident Rights Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  8. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0640, Resident Assessment and Care Planning Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  9. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  10. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  11. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  12. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0692, Quality of Life and Care Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 10, 2023).

  13. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  14. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0727, Nursing and Physician Services Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 28, 2023).

  15. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0756, Pharmacy Service Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  16. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0757, Pharmacy Service Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 15, 2023).

  17. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0835, Administration Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 28, 2023).

  18. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0838, Administration Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 10, 2023).

  19. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Health citation F-0867, Administration Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 18, 2023).

  20. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 14, 2023).

  21. No harm, with potential for more than minimal harm

    Create arrangements with other facilities to receive patients.

    Isolated (one or a few residents). CMS level D.

    Emergency preparedness citation E-0025, Emergency Preparedness Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

  22. No harm, with potential for more than minimal harm

    Have power receptacles that are properly grounded.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0912, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 15, 2023).

  23. No harm, with potential for more than minimal harm

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

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 15, 2023).

  24. No harm, with potential for minimal harm

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

    Widespread (many residents). CMS level C.

    Health citation F-0847, Administration Deficiencies. Inspection of August 10, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (September 15, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.