Cycle 1
Health 2025-04-10 · Fire 2025-04-10
18 health deficiencies
Top issue: Administration (5 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Hawthorne, NV
Lefa Seran SNF
1-star overall rating with 2-star inspections with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1st And A St, Hawthorne, NV
(775) 945-2461
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
24
Certified beds
Average residents
20
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.13
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.52
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
5.62
All reported nurse hours · state 4.34 · national 3.89
Licensed hours
2.10
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
5.02
Weekend nurse staffing · state 3.85 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.85 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.31
CMS adjusted RN staffing hours
Adjusted total hours
6.49
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 46% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 5.93% |
8.2%
2.3 pts worse
|
Numerator 8 · Denominator 135 |
| Staff flu vaccination coverage | 97.87% |
42%
55.9 pts better
|
Numerator 46 · Denominator 47 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
91.5%
3.5 pts better
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 90.0% · 4Q avg 95.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.3% |
89.6%
11.3 pts worse
|
95.5%
17.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 78.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
2.3%
0.2 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.0% · Q3 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.9%
4.9 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 14.5% |
5.6%
8.9 pts worse
|
5.4%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.2% |
22.2%
9 pts worse
|
19.6%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 25.0% · Q3 30.0% · 4Q avg 31.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.3% |
18.5%
13.8 pts worse
|
16.7%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.3% |
19.1%
8.2 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
14.2%
10.8 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.8%
0.8 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.8%
0.8 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.6% |
16.5%
4.1 pts worse
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · 4Q avg 20.6% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.5%
2.8 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 0.0% · 4Q avg 2.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
10 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-10 · Fire 2023-08-10
21 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-29
D · Potential for more than minimal harm
2024-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-05-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-27
C · Minimal harm
2024-05-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-05-29
E · Potential for more than minimal harm
2023-08-10
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-10-15
E · Potential for more than minimal harm
2023-08-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-10
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-08-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-04-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-04-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-04-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-10
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-10
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-10
F838 · Administration Deficiencies
Health
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.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-04-10
F887 · Infection Control Deficiencies
Health
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.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-10
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-10
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-10
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-10
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-10
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-10
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-05-19
F · Potential for more than minimal harm
2024-05-23
F887 · Infection Control Deficiencies
Health
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.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-23
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-05-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-23
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-05-23
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-09
F · Potential for more than minimal harm
2023-08-10
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-10-15
F · Potential for more than minimal harm
2023-08-10
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-10-15
E · Potential for more than minimal harm
2023-08-10
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-10
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-10
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-08-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-10
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-10
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-10
F838 · Administration Deficiencies
Health
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.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-08-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-14
C · Minimal harm
2023-08-10
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-04-05
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-04-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-15
Penalties and ownership
What sits behind the stars
Ownership
Mt Grant General Hospital
5% Or Greater Direct Ownership Interest · Organization
Coen, Patricia
Corporate Director · Individual
Dow, Michelle
Corporate Director · Individual
Mt Grant General Hospital
Operational/Managerial Control · Organization
Qualls, Hugh
Corporate Director · Individual
Qualls, Hugh
W-2 Managing Employee · Individual
Schumann, Richard
Corporate Director · Individual
Womack, Karen
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
South Lyon Medical Center
Yerington, NV
1-star overall rating with 2-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Highland Manor Of Fallon Rehabilitation LLC
Fallon, NV
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $124,459 in total fines with 22 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Gardnerville Health & Rehabilitation Center
Gardnerville, NV
1-star overall rating with 1-star inspections with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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