Quiburi Mission Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of facility documents and policy, the facility failed to send a notice of discharge to the State Ombudsman for one resident (#59). The deficient practice could result in the residents not being followed up for transfer or discharges concerns. Findings include:Resident #59 was admitted to the facility on [DATE], with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and hypertension.The Resident's Hospital Discharge Summary revealed that the Resident was discharged from the hospital to the facility for therapy services.The Discharge Planning/Discharge progress notes dated 2/15/2026, revealed that the Resident arrived at the facility accompanied by his family. Documentation indicated the resident's family member expressed concern that the assigned room did not have adequate space for the resident's belongings. Documentation further revealed the family elected to take the resident home against medical advice (AMA).Review of the electronic medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#100) to be free from abuse by another resident (#200). This deficient practice could result in further instances of resident to resident abuse. Findings include:-Resident #100 (Perpetrator) was admitted to the facility on [DATE], with diagnosis that include Alzheimer's disease, epilepsy, and depression.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment. A review of a behavior care-plan Initiated November 19, 2025 revealed that resident #100 has a behavior problem related to agitation and aggression towards other residents and staff, with a goal of the resident will have fewer episodes of behaviors, and noted interventions of anticipate and meet the resident's needs, and minimize potential for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, review of the State Agency Database and interviews the facility failed to ensure one resident was treated with respect and dignity. The deficient practice could result in residents not feeling safe. Findings include: Resident #1 was admitted on [DATE] with diagnoses that include obesity, unspecified mood disorder, and acute cholecystitis. The quarterly Minimum Data Set (MDS) assessment was completed on May 1, 2024. During the MDS assessment a Brief Interview for Mental Status (BIMS) was conducted and revealed that resident #1 had a score of 15 which indicated the resident was cognitively intact. A report was received by the State Agency (SA) on April 15, 2024 that indicated a resident was being mistreated by a Certified Nursing Assistant (CNA). The facility conducted an initial investigation which included an interview with resident #1 on April 15, 2024. Resident #1 indicated that staff #12 had taken over an hour to assist her when the call light…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of policy, the facility failed to notifiy the Ombudsman of transfer/discharge for two residents (#23, #2). Findings included: -Resident #23 was admitted to the facility on [DATE] with diagnoses of respiratory failure unspecified with hypoxia, heart failure, and transient cerebral ischemic attack. Review of the most recent MDS (Minimum Data Set) revealed a BIMS (brief interview of mental status) score of 15, indicating no cognitive impairment. Facility census list revealed resident #23 was on a hospital leave on August 8, 2023 until August 14, 2023 and again on September 2, 2023 until September 9, 2023. An interview was conducted on March 6, 2024 at 2:18 P.M. with the Administrator (staff #12) and Director of Nursing (DON\staff #57). Staff #12 stated that no notification of transfer to the hospital was given to the family of resident #23 because resident was her own representative. In addition, the administrator stated they do not notify the ombudsman of any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure the environment remained free of accident hazards existing from unattended medications. The deficient practice of unattended medications does not align with accepted professional standards of practice and may result in undesirable medication-induced harm. Findings included: On March 6, 2024 at 9:14 AM a medication blister pack was observed unattended at the nurse's station where it was accessible to residents. The medication was Metformin Hydrochloride 500 milligram, a medication for diabetes mellitus. This observation prompted an interview with a nearby Licensed Practical Nurse (LPN/Staff # 77) who stated overhearing that a nurse had removed it from the medication cart after learning it had been discontinued for a resident (# 28). Staff #77 stated it should not have been left where it was but instead be placed in the medication room and notify pharmacy to have the medication picked up. Staff # 77 counted how many tablets were left on the blister pack which were 55 total.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure that a resident (#52) was free from abuse from another resident (#53). Failure to ensure the resident was free from abuse resulted in an trochantric hip fracture. Findings include: -Resident #53 was admitted on [DATE] with diagnoses of dementia, emotional lability, and post traumatic stress disorder. Review of this resident's care plan did not include interventions for aggressive behaviors towards other residents. A progress note dated 9/13/23 included, Resident has been restless throughout the shift, unable to get R to sit down for any length of time. Resident has been going in and out of other R rooms taking things and then giving them to other Rs. Resident becomes verbally aggressive with other R and staff when redirect is attempted . A self report filed on 10/15/23 included Residents (#53) and (9#) both reside in the special care unit. Resident (#9) pushed on the entry/exit door, causing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical records, staff interviews, and the facility policy and procedures, the facility failed to follow the catheter care in accordance with professional standards for one resident #18. The deficient practice could increase the risk for resident discomfort, injury and infection. Findings include: Resident #18 was admitted on [DATE] with diagnosis including muscle wasting and atrophy, nutritional deficiencies, anxiety disorder, adult failure to thrive, age-related physical debility, protein-calorie malnutrition and palliative care. A review of the quarterly MDS (minimum data set) dated September 06, 2023 revealed a BIMS (brief interview of mental status score of 08, suggesting moderate cognitive impairment. The MDS further revealed that resident #18, currently has an in-dwelling catheter in place. A review of the physician orders revealed an order dated May 17, 2022 for a suprapubic catheter size 16 French with a 10 ml balloon, contingent on drainage. A review of the care plan dated December 20, 2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, and policy review, the facility failed to ensure one resident #18 was assessed for the safe use of enabler bars prior to installation and informed of the risks and benefits of their use. The sample size was 16. The deficient practice could impact the residents knowledge of the risks and benefits of enabler bars and cause potential injury if the resident was not an appropriate candidate for enabler bars. Findings include: Resident #18 was admitted on [DATE] with diagnosis including muscle wasting and atrophy, anxiety disorder, adult failure to thrive, age-related physical disability, protein-calorie malnutrition, and palliative care. A review of the quarterly MDS (minimum data set) dated September 06, 2023 revealed that the resident has a BIMS (brief interview of mental status) score of 08, suggesting moderate cognitive impairment. Section G of the MDS revealed that resident #18 is an extensive 2-person assist with transfers, and bed-mobility. Section P of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to ensure that one resident (#45) received the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) prior to the service end date. The sample size was 3. The deficient practice could result in unforeseen charges to the resident. Findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included primary hypertension, unspecified fracture of left pubis, sequela, and Alzheimer's disease. Review of the SNF Beneficiary Protection Notification Review form presented to the facility to complete, revealed the resident Medicare Part A Skilled Services Episode start date was 01/11/22. The form contained a handwritten note that from 01/11/22 to 03/25/22, the resident was discharged to the hospital. Next to the question how was the Medicare Part A Service Termination/Discharge determined, was written 04/03/22 - 04/28/22. The form also indicated a NOMNC and SNFABN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record and staff interviews, the facility failed to ensure that a Level 2 PASARR (pre-admission screening and resident review screening tool) was completed for one sampled resident (#15). The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #15 was admitted on [DATE] with diagnoses that included morbid obesity, type 2 diabetes mellitus, and enterocolitis. Review of the care plan dated 3/19/21 revealed the resident was receiving an antidepressant medication due to depression, and psychopharmacological medication due to schizoaffective disorder. Review of a Level I PASARR dated 4/5/2021 included diagnoses of Schizoaffective Disorder, Major Depression, Paranoid Disorder, and Anxiety Disorder were marked. However, further record review revealed resident #15 did not have any other PASARRs or a Level II that was submitted for further recommendation in services. Review of the physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to ensure a complete discharge summary was completed regarding one resident (#49). The sample size was 2. The deficient practice could result in an ineffective transition to post-discharge care and increases the risk factors leading to preventable readmission. Findings include: Resident #49 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, chronic kidney disease, and hypertension. The resident was discharged [DATE]. Review of the discharge minimum data set assessment dated [DATE] included a BIMS score of 15, which indicated the resident had intact cognition. Review of physician orders revealed an order dated 8/11/2022 for home health to evaluate and treat for skilled nursing, safety evaluation, physical therapy (PT)/occupational therapy (OT) after hospital stay for subdural hematoma with subsequent craniotomy; and an order dated 8/12/2022 for home…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to ensure two residents (#26 and #39) did not receive unnecessary medications. The sample size was 5. The deficient practice increases the risk for residents to receive medications unnecessarily. Findings include: -Resident #26 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to occlusion or stenosis of small artery, hemiplegia affecting the left non-dominant side, and vascular dementia. A potential for dehydration/fluid deficit care plan revised 01/09/20 related to diuretic use had a goal to be free from symptoms of dehydration and to maintain moist mucous membranes and skin turgor. Interventions included weighing the resident on Monday, Wednesday, and Friday. Review of the physician orders included: -Furosemide (diuretic) 20 milligrams (mg); give 20 mg in the morning every Monday, Wednesday, and Friday related to localized edema. Hold for systolic blood pressure (SBP) less than 110. Start date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the Facility Assessment, staff interview, and review of policy and procedure, the facility failed to ensure that the facility-wide assessment was thoroughly completed, by failing to ensure the Facility Assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's need. The deficient practice could result in inadequate staffing levels. Findings include: Per the facility assessment, the facility staffs based on census number and acuity of residents. Staffing assignments are adjusted based on resident acuity and needs. If it is determined that current staffing levels/assignments are no longer effective, the Quality Assurance and Performance Improvement (QAPI) principles and model for improvement will be used to reevaluate and redesign staffing practices in order to meet acuity and needs of residents. However, further review of the assessment did not reveal an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.