Inspection Reports for The Sienna Arbour
945 Sienna Park Drive, Reno, NV 89512, NV, 89512
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Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 6
Nov 5, 2024
Visit Reason
Annual State Licensure survey conducted in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including failure to develop person-centered service plans for all residents, incomplete medication profile reviews, untimely tuberculosis testing for residents and employees, incomplete cultural competency training for an employee, and failure to ensure timely elder abuse prevention training for an employee.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure a person-centered service plan was developed for 5 of 5 residents reviewed. | Severity: 2 |
| Failure to ensure medication profile review was performed at least every six months for 1 of 5 residents. | Severity: 2 |
| Failure to ensure timely tuberculosis testing for 1 of 5 residents. | Severity: 2 |
| Failure to ensure an employee completed a cultural competency course approved by the Division for 1 of 7 employees. | Severity: 2 |
| Failure to ensure employees completed elder abuse prevention training timely for 1 of 7 employees. | Severity: 2 |
| Failure to ensure employees met tuberculosis testing requirements for 2 of 7 employees. | Severity: 2 |
Report Facts
Licensed beds: 8
Residents present: 5
Residents reviewed: 5
Employee files reviewed: 7
Severity 2 deficiencies: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Resident | Resident with medication profile review deficiency |
| Employee #4 | Caregiver | Employee lacking documented initial TB testing |
| Employee #5 | Caregiver | Employee lacking timely elder abuse prevention training |
| Employee #6 | Caregiver | Employee lacking required cultural competency training |
| Employee #7 | Caregiver | Employee lacking current TB test for 2024 |
Inspection Report
Re-Inspection
Census: 7
Capacity: 8
Deficiencies: 0
Sep 17, 2024
Visit Reason
This document is a Statement of Deficiencies generated as a result of a State Licensure mandatory regrading survey conducted at the facility on 09/17/2024.
Findings
The facility was licensed for eight beds and had a census of seven at the time of the survey. Four resident files and three employee files were reviewed. The facility received a grade of A. No regulatory deficiencies were identified and no further action is necessary.
Inspection Report
Re-Inspection
Census: 7
Capacity: 8
Deficiencies: 12
Apr 25, 2024
Visit Reason
This inspection was a State Licensure mandatory regrading survey conducted to assess compliance with Nevada Administrative Code 449 for a Residential Facility for Groups. The visit was triggered by the need to regrade the facility's license and ensure compliance with regulatory requirements.
Findings
The facility was found to have multiple deficiencies including failure to provide adequate oversight by the administrator, untimely elder abuse training for employees, incomplete personnel files lacking physical exams, background checks, CPR and first aid certifications, incomplete medication reviews for residents, improper medication storage, and missing physician placement determinations for residents. Several deficiencies were repeat findings from a prior survey.
Severity Breakdown
Severity: 2: 7
Severity: D: 2
Severity: F: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to staff to ensure compliance with NAC 449.156 to 449.27706 and NRS Chapter 449. | Severity: 2 |
| Employees failed to complete elder abuse prevention training timely for 4 of 5 sampled employees. | Severity: 2 |
| Personnel file lacked documented evidence of physical examination prior to providing care for 1 of 5 sampled employees. | Severity: 2 |
| Personnel files lacked evidence of background checks compliance. | Severity: D |
| Personnel file lacked current first aid training certification for 1 of 5 sampled employees. | Severity: 2 |
| Personnel file lacked CPR and first aid training within 30 days of employment for 1 of 5 sampled employees. | Severity: 2 |
| Failed to ensure medication regimen reviews were completed timely for 5 of 7 sampled residents. | Severity: 2 |
| Medication storage was not consistently secured in locked areas or locked boxes inside refrigerators. | Severity: F |
| Failed to ensure medication was plainly labeled and kept in original container until administration for 2 of 7 residents. | Severity: 2 |
| Failed to ensure physician placement determination was completed upon admission for 2 of 7 residents. | Severity: 2 |
| Resident and personnel files were not always maintained confidentially and securely. | Severity: F |
| Failed to ensure cultural competency training was completed within 30 days of hire for 1 of 4 sampled employees. | Severity: 2 |
Report Facts
Licensed beds: 8
Current census: 7
Employees sampled: 5
Residents sampled: 6
Resurvey fee: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christine Del Rosario | Director owner | Signed the inspection report |
| Employee #1 | Named in findings for untimely elder abuse training, missing physical exam, and termination for non-compliance | |
| Employee #2 | Named in findings for untimely elder abuse training | |
| Employee #3 | Named in findings for untimely elder abuse training and missing CPR/first aid training | |
| Employee #4 | Named in findings for missing CPR/first aid training and cultural competency training | |
| Employee #5 | Named in findings for untimely elder abuse training and missing first aid training |
Inspection Report
Renewal
Census: 7
Capacity: 8
Deficiencies: 14
Oct 12, 2023
Visit Reason
This inspection was a State Licensure mandatory regrading survey and room reconfiguration survey conducted as part of the facility's renewal/licensure process.
Findings
The facility was found deficient in multiple areas including failure to ensure timely elder abuse prevention training, physical examinations, TB screening, background checks, CPR and first aid certification for employees, medication review accuracy, medication storage security, proper labeling of medications, maintenance of resident files, and cultural competency training. These deficiencies were repeat findings from the previous annual re-licensure survey.
Severity Breakdown
D: 7
E: 1
F: 5
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to ensure employees completed elder abuse prevention training timely for 1 of 5 sampled employees (Employee #3). | D |
| Failure to ensure a caregiver had a physical examination prior to providing care and met TB testing requirements for 1 of 5 sampled employees (Employee #3). | D |
| Failure to ensure 1 of 5 sampled employees met background check requirements (Employee #3). | D |
| Failure to ensure 1 of 5 sampled employees was certified to perform CPR and first aid (Employee #3). | D |
| Failure to ensure 1 of 5 sampled employees completed CPR and first aid training within 30 days of employment (Employee #3). | D |
| Failure to ensure residents admitted for six months or greater had a six-month pharmacy review for 4 of 7 sampled residents (Residents #1, #2, #3, and #5). | D |
| Failure to ensure caregivers assisted in medication administration according to regulations. | E |
| Failure to ensure residents' medications were kept secured; unlocked medication cabinet observed for 7 of 7 residents. | F |
| Failure to ensure over-the-counter medications were labeled with resident's and physician's names for 2 of 2 residents (Residents #4 and #5). | F |
| Failure to ensure standard placement determination was accurately completed by a provider upon admission for 2 of 7 residents (Residents #6 and #7). | D |
| Failure to maintain resident files on site and available for review for 7 of 7 sampled residents. | F |
| Failure to ensure an employee completed required cultural competency training for 1 of 5 employees (Employee #3). | D |
| Failure of Administrator to provide oversight and direction to ensure compliance with regulatory requirements. | F |
| Failure to ensure caregivers met qualifications and training requirements. | F |
Report Facts
Licensed beds: 8
Current census: 7
Employees sampled: 5
Residents sampled: 7
Resurvey application fee: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Caregiver | Named in multiple deficiencies including elder abuse training, physical exam, TB screening, background check, CPR/first aid certification, and cultural competency training. |
| Christine Del Rosario | Owner Director | Signed the report and confirmed findings during interviews. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 14
Dec 9, 2022
Visit Reason
This inspection was an annual State Licensure survey conducted in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including caregiver training (use of Hoyer lift, elder abuse prevention, cultural competency), personnel file requirements (TB testing, background checks, CPR/first aid certification), medication administration and storage, resident admission and care policies, and maintenance of resident files including physician placement determinations. Several residents lacked required documentation and medication reviews were not timely.
Severity Breakdown
Level 2: 13
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure staff were trained for the use of a Hoyer lift for 5 of 5 sampled employees. | Level 2 |
| Failed to ensure employees completed the annual elder abuse prevention training for 1 of 5 sampled employees. | Level 2 |
| Failed to ensure caregivers completed pre-employment physical examinations and tuberculosis (TB) testing for multiple employees. | Level 2 |
| Failed to ensure background checks were completed for 1 of 5 sampled employees. | Level 2 |
| Failed to ensure 1 of 5 sampled employees maintained current CPR and first aid certification. | Level 2 |
| Failed to ensure bedfast residents were not retained or admitted without proper waivers and failed to discharge a resident receiving skilled nursing for wound care. | Level 2 |
| Failed to ensure medication reviews were completed every six months for 3 of 6 sampled residents. | Level 2 |
| Failed to ensure ultimate user agreements were completed for 2 of 6 residents. | Level 2 |
| Failed to ensure medications were stored in a locked area for 6 of 6 residents. | Level 2 |
| Failed to ensure an over-the-counter medication had a physician's name and resident's name on the label for 1 of 6 sampled residents. | Level 2 |
| Failed to ensure a standard placement determination accurately completed by a provider upon admission for 5 of 6 residents. | Level 2 |
| Failed to ensure timely tuberculosis testing for 2 of 6 residents. | Level 2 |
| Failed to ensure 1 of 2 employees received four hours of initial training to care for elderly and disabled residents within 60 days of hire. | Level 2 |
| Failed to ensure 4 of 5 employees completed a cultural competency course approved by the Division of Public and Behavioral Health. | Level 2 |
Report Facts
Facility licensed beds: 8
Resident census: 6
Employee files reviewed: 5
Resident files reviewed: 6
Survey date: Dec 9, 2022
Survey grade: D
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Named in deficiency for lack of Hoyer lift training |
| Employee #2 | Owner/Caregiver | Named in deficiencies for lack of Hoyer lift training, late TB testing, and lack of cultural competency training |
| Employee #3 | Owner/MedTech | Named in deficiencies for lack of Hoyer lift training, missing elder abuse training, late TB testing, and lack of cultural competency training |
| Employee #4 | Caregiver | Named in deficiencies for lack of Hoyer lift training, missing pre-employment physical and TB testing, missing background check, and lack of cultural competency training |
| Employee #5 | Caregiver | Named in deficiencies for lack of Hoyer lift training, missing pre-employment physical and TB testing, missing CPR/first aid certification, missing initial caregiver training, and lack of cultural competency training |
| Christine Del Rosario | Director | Signed the inspection report |
Inspection Report
Re-Inspection
Census: 5
Capacity: 8
Deficiencies: 8
Jun 9, 2022
Visit Reason
This inspection was a mandatory re-grading State Licensure survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but was cited for deficiencies including incomplete and inaccurate facility records, failure to ensure medication profile reviews were performed every six months for residents, and issues with medication destruction and storage. Several deficiencies were cited with severity levels ranging from D to F.
Severity Breakdown
F: 5
D: 2
C: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Administrator failed to ensure that the records of the facility are complete and accurate. | F |
| Personnel files lacked evidence of compliance with background check requirements. | F |
| Failure to ensure a medication profile review was performed by a physician, pharmacist, or registered nurse at least once every six months for one resident. | F |
| Failure to ensure medication destruction was properly documented and witnessed. | D |
| Failure to maintain accurate records of medication administration including type, date, time, refusals, and instructions. | C |
| Medication storage did not meet requirements for locked and secure storage. | F |
| Failure to maintain separate resident files with required documentation and confidentiality safeguards. | F |
| Failure to prepare evaluations of residents' ability to perform activities of daily living as required. | D |
Report Facts
Licensed beds: 8
Resident census: 5
Residents sampled: 5
Employee files reviewed: 3
Severity 2 deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Diana Roberts | Administrator | Named as the administrator responsible for facility compliance and cited in findings |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 9
Jan 18, 2022
Visit Reason
This inspection was an annual State Licensure survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including incomplete personnel and resident medical records, failure to meet background check requirements for employees, missing physical examinations for residents, lack of medication profile reviews, improper medication destruction and storage, inaccurate medication administration records, incomplete tuberculosis testing, and missing annual Activities of Daily Living assessments.
Severity Breakdown
Level 2: 8
Level 1: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Administrator failed to ensure personnel records and resident medical records were complete and accurate. | Level 2 |
| Facility failed to ensure 3 of 3 employees met background check requirements including fingerprint submission and clearance letters. | Level 2 |
| Facility failed to ensure physical examinations were completed prior to admission or annually for 5 of 7 residents. | Level 2 |
| Administrator failed to ensure medication profile reviews were performed at least every six months for 4 of 7 sampled residents. | Level 2 |
| Facility failed to ensure expired medication was destroyed for 2 of 7 sampled residents. | Level 2 |
| Facility failed to ensure Medication Administration Records (MAR) were accurate for 4 of 7 residents. | Level 1 |
| Facility failed to ensure medications were secured in a locked area; medications were found unsecured in the refrigerator accessible to residents. | Level 2 |
| Facility failed to ensure tuberculosis (TB) testing requirements were met for 7 of 7 residents, including missing initial two-step TB tests and annual tests. | Level 2 |
| Facility failed to ensure annual Activities of Daily Living (ADL) assessments were completed for 2 of 7 residents. | Level 2 |
Report Facts
Licensed beds: 8
Current census: 7
Deficiency severity Level 2: 8
Deficiency severity Level 1: 1
Resurvey fee: 600
Inspection Report
Original Licensing
Capacity: 8
Deficiencies: 0
Apr 15, 2021
Visit Reason
This inspection was conducted as an initial State Licensure survey for a Residential Facility for Groups to approve a license for eight beds for elderly and disabled persons.
Findings
No regulatory deficiencies were identified during the survey. The license was approved, and three employee files were reviewed.
Report Facts
Licensed beds: 8
Category I residents: 3
Category II residents: 5
Employee files reviewed: 3
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