Inspection visit
Inspection
Citations
24 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F700 - Bed Rails
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.
F727 - Except when waived under paragraph (f) or (g) of this section, the
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.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F758 - Medication Errors
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.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F838 - Facility assessment
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.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F942 - Training Requirements
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
- 0025GeneralS&S Dpotential for harm
Create arrangements with other facilities to receive patients.
- 0036GeneralS&S Epotential for harm
Establish emergency prep training and testing.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F912 - Measure at least 80 square feet per resident in multiple resident
Have power receptacles that are properly grounded.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
FAQ · About this visit
Common questions about this visit
What happened during the August 10, 2023 survey of LEFA SERAN SNF?
This was a inspection survey of LEFA SERAN SNF on August 10, 2023. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LEFA SERAN SNF on August 10, 2023?
Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.