Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quiburi Mission Nursing & Rehabilitation during CMS and state inspections, most recent first.
Failure to notify the Ombudsman of a resident discharge. A resident with metabolic encephalopathy, DM2, and HTN was admitted for therapy, then the family raised concerns about room space and chose to take the resident home AMA. Record review and staff interview showed the discharge notice was not sent to the Ombudsman, despite the regulatory requirement to do so.
A resident with severe cognitive impairment and a history of aggression physically assaulted another resident with similar cognitive challenges. Despite a care plan addressing behavioral issues, the aggressive resident was able to push and allegedly punch the other resident. Staff interviews confirmed prior behavioral concerns and incomplete documentation of the incident, highlighting a failure to protect residents from abuse.
The facility failed to notify the Ombudsman of transfers and discharges for two residents, both cognitively intact, as required by policy. The administrator admitted to not notifying the Ombudsman, which is against regulatory expectations. The Social Service Director also confirmed the lack of communication, highlighting a deficiency in the facility's discharge process.
A medication blister pack containing Metformin was found unattended at a nurse's station, accessible to residents. An LPN confirmed it should have been stored securely, as per facility policy, to prevent potential allergic reactions or hypoglycemia. The DON acknowledged the lapse in meeting facility expectations.
A resident with a suprapubic catheter was observed multiple times with the catheter bag dragging on the floor, contrary to facility policy. Staff interviews confirmed awareness of proper catheter care, yet the deficiency persisted, posing risks of injury and infection.
A facility failed to assess a resident for the safe use of enabler bars and did not inform them of the risks and benefits. The resident, with moderate cognitive impairment and requiring extensive assistance, had enabler bars installed without documented assessment or informed consent. Staff interviews revealed inconsistencies in the assessment process, and the facility's policy requiring medical necessity and informed consent was not followed.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a notice of discharge to the State Ombudsman for one resident. Resident #59 was admitted with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and hypertension, and the hospital discharge summary showed the resident was transferred to the facility for therapy services. The discharge planning and discharge progress notes dated 2/15/2026 documented that the resident arrived with family, and the family expressed concern that the assigned room did not have adequate space for the resident's belongings. The same documentation showed the family elected to take the resident home against medical advice, and the electronic medical record, including the AMA Release Form dated 2/15/2026, showed the resident was discharged home with the responsible party. During record review, the Administrator was asked to provide documentation of discharge notices sent to the Ombudsman for the prior 6 months. The Administrator documented that the Ombudsman did not require the facility to send discharge notices directly to her, while also acknowledging that discharge notices had not been sent and that the facility would send notices for discharged residents moving forward. The Ombudsman stated she had periodically received discharge notices in the past but had not received discharge notices from the facility after 12/4/2026, and confirmed the facility is required to provide discharge notices per regulation.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of agitation and aggression was not adequately protected from engaging in abusive behavior toward another resident. The resident, who had diagnoses including Alzheimer's disease, epilepsy, and depression, was known to display aggressive behaviors and had a care plan in place to address these issues. Despite interventions intended to minimize disruptive behavior, the resident was involved in an incident where he physically assaulted another resident, who also had severe cognitive impairment and multiple medical conditions. On the evening of the incident, the aggressive resident was observed pushing another resident against a door and allegedly punching him in the ribs. Documentation indicated that an x-ray was ordered to rule out injuries, and monitoring for bruising was initiated, but there were no findings of injury in the clinical record, and no x-ray results were documented. Staff interviews confirmed awareness of the resident's behavioral issues and the altercation, with staff describing the behavior as abusive and noting that the resident had previously exhibited aggression, including an incident involving a butter knife, though details of that event were not documented elsewhere. Facility policy required protection of residents from all forms of abuse, including physical abuse by other residents. However, the facility failed to prevent the altercation, and documentation and follow-up regarding the incident were incomplete. The aggressive resident was subsequently sent to the hospital for placement, but the deficiency centers on the failure to protect residents from abuse and to ensure thorough documentation and assessment following the incident.
Failure to Notify Ombudsman of Transfers/Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of transfers and discharges for two residents, leading to a deficiency in compliance with regulatory requirements. Resident #23, who was cognitively intact with a BIMS score of 15, was transferred to the hospital twice without notification to the Ombudsman. The facility's administrator admitted that they do not notify the Ombudsman of any transfers or discharges, which is against the facility's policy and regulatory expectations. Similarly, Resident #2, also cognitively intact with a BIMS score of 15, was discharged without the Ombudsman being informed. The Social Service Director confirmed that the Ombudsman was not updated about any discharges, and the administrator acknowledged the need for improvement in the discharge process. The facility's policy requires notification of the Ombudsman for facility-initiated transfers or discharges, but this was not adhered to, resulting in a failure to meet regulatory standards.
Unattended Medication Poses Hazard
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards due to unattended medications. During an observation, a medication blister pack containing Metformin Hydrochloride 500 mg was found unattended at the nurse's station, accessible to residents. This medication had been discontinued for a resident, and a Licensed Practical Nurse (LPN) confirmed it should have been stored in the medication room and the pharmacy notified for pickup. The LPN acknowledged the risk of allergic reactions or hypoglycemia if the medication was ingested by a resident without diabetes. The Director of Nursing (DON) confirmed that leaving medication unattended did not meet facility expectations and acknowledged the potential risks, such as upset stomach or allergy, if the medication was taken by residents. The facility's policy mandates that medications be stored in a locked medication cart, drawer, or cupboard, accessible only to authorized personnel. The incident highlighted a deviation from this policy, as the medication was left unsecured and accessible, posing a potential hazard to residents.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, leading to a deficiency in maintaining professional standards. The resident, who has a suprapubic catheter due to an anatomical abnormality, was observed on multiple occasions with the catheter bag dragging on the floor while seated in a wheelchair. This was noted during observations conducted on March 4 and March 6, 2024. The facility's policy clearly states that catheter tubing should never touch the floor to prevent urethral injury and infection, yet the catheter bag was repeatedly seen on the floor, posing a risk of tension and potential injury. Interviews with staff, including a CNA and an LPN, revealed that they were aware of the importance of keeping catheter bags off the ground and monitoring the output. However, despite this knowledge, the catheter bag was not properly managed, as evidenced by the observations. The LPN acknowledged the issue and noted that the tubing needed to be changed. The Director of Nursing also confirmed that catheter bags should not touch the ground, citing infection control concerns. The facility's failure to adhere to its own catheter care policy resulted in a deficiency that could increase the risk of resident discomfort, injury, and infection.
Failure to Assess and Document Enabler Bar Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the safe use of enabler bars prior to their installation and was not informed of the associated risks and benefits. The resident, who was admitted with multiple diagnoses including muscle wasting, anxiety disorder, and moderate cognitive impairment, was observed to have enabler bars on their bed without any documented assessment or informed consent. The resident's care plan indicated a need for extensive assistance with transfers and bed mobility, yet there was no evidence of a physician's order or an assessment for the use of enabler bars in the resident's electronic health record. Interviews with various staff members, including CNAs, LPNs, and the Maintenance Director, revealed a lack of clarity and consistency in the process of assessing and documenting the use of enabler bars. While staff believed that assessments were conducted, there was no documentation to support this for the resident in question. The facility's policy required a medical necessity supported by a resident assessment and informed consent, neither of which were present in the resident's records. The deficiency could impact the resident's knowledge of the risks and benefits of enabler bars and potentially cause injury if the resident was not an appropriate candidate for their use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Benson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Sierra Vista | 27 mi | — | 14 | 0 |
| Haven Of Sierra Vista, Llc | 27.3 mi | — | 4 | 0 |
| Haven Of Saguaro Valley | 38.2 mi | — | 1 | 0 |
| Sandstone Estates Rehab Centre | 39.5 mi | — | 5 | 0 |
| Devon Gables Rehabilitation Center | 39.6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.