Lefa Seran Skilled Nursing Facility

Total Number of Beds: 24	Percent of Occupied Beds: 96%
Total Number of Residents: 23	Located Within a Hospital: Yes
Type of Ownership: For profit - Corporation	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 02/21/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.74

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.99

Number of CNA Hours per Nursing Home Resident per Day: 2.98

Number of Staff Hours per Nursing Home Resident per Day: 4.71

Nursing Home Resident Information**:

** Details Last Reported on: 2/21/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2000-11-29	2001-01-31	Resident Rights Deficiencies	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Isolated	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Resident Rights Deficiencies	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Mistreatment Deficiencies	Keep each resident free from drugs that restrain them, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Nutrition and Dietary Deficiencies	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Pattern	Potential for minimal harm
2000-11-29	2001-01-31	Resident Assessment Deficiencies	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Potential for minimal harm
2000-11-29	2001-01-31	Pharmacy Service Deficiencies	Keep drugs and other similar products locked safely and properly stored.	Pattern	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Environmental Deficiencies	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Pattern	Minimal harm or potential for actual harm
2000-11-29	2001-01-31	Administration Deficiencies	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Resident Rights Deficiencies	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Mistreatment Deficiencies	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Quality Care Deficiencies	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
2002-01-30	2002-02-22	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Quality Care Deficiencies	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Pharmacy Service Deficiencies	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Quality Care Deficiencies	Use a registered nurse at least 8 hours a day, 7 days a week.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Environmental Deficiencies	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
2002-01-30	2002-02-22	Environmental Deficiencies	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Mistreatment Deficiencies	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Mistreatment Deficiencies	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Resident Rights Deficiencies	Make sure that each resident has the right to join in social, religious, and community activities.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Quality Care Deficiencies	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Environmental Deficiencies	Keep a resident apart from the others if the resident has an infection that can spread.	Isolated	Minimal harm or potential for actual harm
2003-02-21	2003-04-01	Administration Deficiencies	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.