Inspection Reports for
Sibley Specialty Care

The visit was triggered by a complaint/investigation of a facility-reported incident where Resident #1 exited the building unsupervised. The complaint was substantiated as the facility failed to prevent the incident.

The facility failed to provide adequate nursing supervision to prevent a resident with severe memory impairment from leaving the facility unsupervised. The resident was found outside by local hospital staff and returned safely with no injuries. Staff training was conducted following the incident.

The complaint investigation found that Resident #1 was let out of the facility by Staff A without notifying other staff, resulting in the resident leaving the premises. The resident was located and returned safely with no injuries. The facility reported a total census of 40 residents. Staff received extensive training after the incident.

The facility failed to provide adequate supervision to prevent Resident #1, who has severe memory impairment, from leaving the facility unsupervised. The resident was found off premises but returned safely with no injuries. Staff training was conducted following the incident.

The facility failed to serve full food portions as per the menu, maintain sanitary conditions in the kitchen and during meal service, and ensure proper hand hygiene during wound care. Deficiencies were noted in food portioning, kitchen cleanliness, food handling practices, and infection control procedures.

The facility was found deficient in food service portion control and sanitation practices, including failure to serve full meal portions and inadequate kitchen sanitation. Infection prevention and control deficiencies were also identified, including improper hand hygiene during wound care and food preparation.

The complaint investigation was substantiated with findings that Staff E, a Certified Nursing Assistant, struck Resident #1 on the left upper arm after the resident was aggressive. The resident reported the incident and staff interviews corroborated the event. The facility took immediate action by separating the staff member and notifying appropriate parties.

The facility failed to appropriately implement interventions to protect one resident from physical abuse by a nurse aide. The investigation found that the nurse aide struck the resident on the left upper arm after the resident was verbally and physically aggressive. No physical injury was observed, but the incident was confirmed through staff interviews and resident statements.

The complaint investigation was related to physical abuse of Resident #1. The facility reported incident #121441-M was reviewed, including statements from multiple staff and interviews with the resident. The complaint was substantiated by evidence of staff hitting and verbally abusing the resident.

The investigation found that Staff E was verbally and physically aggressive towards Resident #1, including hitting the resident. The facility failed to implement appropriate interventions to protect the resident from abuse. Staff received additional training and corrective actions were planned.

The facility failed to obtain required resident or representative signatures on Medicare Non-Coverage notification forms for 2 residents, did not complete required Iowa Criminal Background checks for 1 of 5 employees reviewed, and failed to notify the Long Term Care Ombudsman for 2 residents transferred to the hospital. The deficiencies were assessed as minimal harm with few or some residents affected.

The facility failed to obtain required signatures for consent on Notice of Medicare Non-Coverage forms for sampled residents, failed to develop and implement adequate abuse/neglect policies including background checks for new hires, and failed to notify the Long Term Care Ombudsman of resident transfers as required.

The facility failed to refer one resident with a negative Level I PASRR result for a required Level II evaluation despite diagnoses indicating serious mental disorders. Additionally, the facility failed to include side effects of antidepressant medication in the care plan for one resident. The facility reported censuses of 60 and 40 residents respectively in the two findings.

The facility failed to coordinate PASARR assessments properly, including failure to refer one resident for PASARR evaluation and failure to follow up on care plan side effects for antidepressant medication for another resident. The facility also lacked a care plan policy.

Complaint #97987-C was investigated and found not substantiated. Incidents #87682-I and #100274-I were also not substantiated.

The facility was found deficient in maintaining privacy and dignity for a resident with an indwelling urinary catheter by failing to conceal the catheter bag properly. Additionally, deficiencies were found in food safety practices, including improper storage of kitchen utensils and lack of eye protection among dietary staff during food service.