Awe Kualawaache Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan intervention for foam heel protection intended to prevent skin breakdown for 1 (#3), which increased the risk for recurrence of pressure related skin breakdown for a resident with a history of pressure ulcers to both heels, and the facility staff failed to revise and implement a comprehensive, person-centered care plan to address the use of a high-risk anticoagulant medications, and interventions necessary to monitor for and minimize potential adverse consequences, which increased the risks for unrecognized adverse consequences, including bleeding complications associated with anticoagulant use, for 1 (#5) of 14 sampled residents.

Inspectors wroteBased on the interview and record review, a facility staff member failed to notify nursing staff of a resident's initial fall for the immediate assessment to be completed by the nurse to determine the resident's clinical condition or if there were injuries after the fall, and the staff member failed to follow the fall program policies and procedures related to fall reporting, for 1 (#10) of 14 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a fortified diet was implemented as ordered for a resident who was at risk for weight loss for 1 (#2) of 14 sampled residents. This failure increased the risk for the resident's continued weight loss and compromised nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring was in place for a resident for adverse consequences associated with the use of an anticoagulant medication that increased the risk of unrecognized adverse drug consequences and complications associated with anticoagulant therapy, for 1 (#5) of 14 residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff kept a urinary catheter drainage bag off the floor for 1 (#35); and failed to ensure oxygen tubing was changed to prevent contamination of respiratory equipment for a resident who was dependent upon oxygen for 1 (#2) of 14 sampled residents.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Ombudsman Office when a resident was transferred to the hospital and failed to provide the resident with contact information for the State Ombudsmans Office for 3 (#s 13, 127, and 177) of 20 sampled residents. This deficient practice left the residents without an advocate related to the transfers in the event there were concerns.

Inspectors wroteBased on interview and record review, a resident was acting out aggressively, and the staff restrained the resident for a Period of Imminent Danger to the Safety and Well being of others, and failed to ensure the required steps were taken to address the emergency restraint immediately after it occurred, or for future events in which a restraint may have been needed for this resident, for 1 (#2) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update a resident's individualized care plan for personal preferences related to communication and the provision of ADL care from male staff who had the ability to speak the resident's native language. When male staff assisted the resident, and used the resident's native language when communicating, the resident would exhibit less agitation and aggression, for 1 (#2) of 7 sampled residents.

Inspectors wroteBased on interview and record review, facility failed to ensure all nursing staff working with a resident who exhibited aggressive behaviors towards others, was educated to the extent necessary and competent to provide services for the resident's needs to be met for behaviors and use of restraints; and to ensure restraint use was utilized properly for resident safety, in the event of an emergency situation; and failed to ensure all staff working with the resident when a restraint was applied had necessary training for physicial restraint use, for 1 (#2) of 7 sampled residents. The deficient practice resulted in a resident being physically restrained for up to one hour without nursing oversight.

Inspectors wroteBased on interviews and record review, the facility failed to review and update the facility assessment to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population for residents with behavioral health needs. This practice had the potential to affect residents with behavioral health needs admitted to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral health training for staff; consistent with the needs of the residents in the facility for 2 (#s 2 and 3) of 4 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent resident abuse in the form of a physical altercation with a staff member for 1 (#2) of 4 residents sampled.

Inspectors wroteBased on interview and record review, the facility failed to assess for the root cause or triggers of behavioral outbursts for 1 (#2); and failed to provide the behavioral health services outlined in a PASRR Level II for 1 (#4) of 4 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure prn psychotropic drugs were limited to 14 days or had documented rationale for extended prn usage; and failed to ensure prn anti-psychotic drugs were limited to 14 days and not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for 1 (#2) of 4 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to revise and update a care plan for 1 resident (#26) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the nurse competencies and skills set was sufficient to provide services for resident care, which included wound care services, for 1 (#26) of 2 sampled residents with wounds.

Inspectors wroteBased on interview and record review, the facility failed to accurately submit Payroll Based Journal (PBJ) data for RN coverage, eight consecutive hours per day for five days and 24-hour licensed nurse coverage for 25 days in Quarter One of Fiscal Year 2024. The failure to have a RN on duty increased the risk of negative resident outcomes for any resident needing RN services.