Quiburi Mission Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Quiburi Mission Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF623Mar 8, 2024

  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). […]

• No harm, potential for more than minimal, patternF689Mar 8, 2024

  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. […]

• No harm, potential for more than minimal, patternF644Jun 24, 2021

  Based on staff interviews, review of the clinical record, and policy and procedure, the facility failed to ensure one sampled resident (#14) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Preadmission Screening and Resident Review (PASRR) Level I Screening Document dated August 28, 2014 revealed the resident had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .e., paranoid), mood disorder, or [CONDITION(S)]. Despite documentation that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF656Jun 24, 2021

  Based on clinical record reviews, observations, resident and staff interviews, and review of policy and procedure, the facility failed to ensure a care plan was developed for one resident (#41) related to [CONDITION(S)], for one resident (#47) related to anticoagulant use, and for one resident (#10) related to skin condition/treatment. The sample size was 15. The lack of care plan development has the potential for staff to be unaware of the residents identified problems, how care and services are to be delivered, and the staff who are responsible to provide the necessary care and services. Findings include: -Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF725Jun 24, 2021

  Based on observation, staff and resident interviews, facility documentation and policy and procedure, the facility failed to ensure sufficient staff were available on a 24-hour basis to provide nursing care to residents in a timely manner. The facility census was 52. The deficient practice resulted in residents needs not being met timely. Findings include: During the initial phase of the survey, 5 out of 15 sampled residents identified concerns of not having enough staff as they had to wait anywhere from 30 minutes to over 2 or more hours for call lights to be responded to, on no specific shifts, resulting in incontinence, undue pain, and residents becoming agitated due to the long call light response times. […]