Awe Kualawaache Care Center

In the surveyor’s words

From the most serious findings on record at Awe Kualawaache Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF692Apr 28, 2022

  Based on observation, interview, and record review, the facility failed to timely assess, identify, implement, monitor, and revise nutritional interventions for 2 (#s 5 and 10) of 6 sampled residents. Resident #5 had a weight loss of - 10.36% in six months. Resident #10 had a weight loss of - 12.57% in six months. Findings include: IMMEDIATE JEOPARDY On 4/28/2022 at 9:33 a.m., the facility Administrator and Director of Nursing was notified that an Immediate Jeopardy existed in the area of F692 - Nutritional Services. The Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy lowered to a G. […]

• Actual harm, isolatedF686Apr 15, 2021

  Based on observation, interview, and record review, the facility failed to treat and identify a pressure ulcer after admission for 1 (#8), and failed to prevent and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: During an observation and interview on 4/14/21 at 9:05 a.m., staff member J provided pericare for resident #8. An open area was observed below the resident's coccyx. Staff member J stated the area had always been there, and the CNAs put a barrier cream on it twice a day. After resident #8's care was completed, the resident was positioned on her back. Review of resident #8's Admission Screening, dated 3/11/21, showed the presence of a Stage II pressure area to the coccyx, and a Stage I pressure area to the left toe. […]

• Actual harm, isolatedF692Apr 15, 2021

  Based on observations, interview, and record review, the facility failed to identify, implement interventions, and monitor a resident's weight to prevent significant weight loss for 1 (# 8) and severe weight loss for 1 (#12) of 3 sampled residents. Findings include: 1. During an observation on 4/14/21 during lunch, resident #8 was not able to eat more than 25 percent of the roast beef and none of the vegetable. A substitution was not provided by staff in place of the items not eaten. During an observation on 4/15/21 during breakfast, resident #8 was not able to eat the bacon, and was not provided a substitute by the staff. Review of resident #8's Care Plan, dated 3/29/21, showed The resident will comply with recommended diet for weight reduction [sic] . […]

• No harm, potential for more than minimal, widespreadF880May 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure the infection preventionist was properly trained; failed to ensure the safety measures were in place to prevent the growth of a waterborne illness (such as Legionella); failed to identify appropriate Transmission-Based Precautions for a resident with Clostridioides difficile (C. diff) for 1 (#178); and staff member D failed to adhere to proper infection control practices related to not performing hand hygiene between doffing and donning gloves, while performing wound care for 1 (#22) of 20 sampled residents. These deficient practices had the potential to affect all residents in the facility increasing the risk for infections overall. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF727Apr 27, 2023

  Based on interview and record review, the facility failed to have an RN working at least eight hours per twenty-four hour period, seven days per week. This deficient practice had the potential to affect all residents who received skilled nursing services. Findings include: Record review of the October, November, and December 2022 schedules, for licensed nursing, showed the following dates did not have eight hours of RN coverage documented in a twenty-four hour period: - 10/22/22, 10/23/22, 10/29/22, 10/30/22, - 11/5/22, 11/6/22, 11/12/22, 11/13/22, 11/19/22, 11/20/22, 11/26/22, 11/27/22, - 12/4/22, 12/11/22, 12/17/22, 12/18/22. […]