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Deficiency Records for Awe Kualawaache Care Center
A list of the most recent deficiencies for Awe Kualawaache Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Awe Kualawaache Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-30 | 2024-08-23 | Y |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-07-30 | 2024-08-23 | Y |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-07-30 | 2024-08-23 | Y |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-07-30 | 2024-08-23 | Y |
Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-07-30 | 2024-08-23 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-04-25 | 2024-05-16 | N |
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-04-25 | 2024-05-16 | N |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-04-25 | 2024-05-16 | Y |
Provide properly protected cooking facilities. | Fire Safety | 2024-04-29 | 2024-05-16 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-29 | 2024-05-16 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-29 | 2024-05-16 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-29 | 2024-05-16 | N |
Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-04-29 | 2024-05-16 | N |
Ensure each resident receives an accurate assessment. | Health | 2023-04-27 | 2023-05-31 | N |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-04-27 | 2023-05-31 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-27 | 2023-05-31 | N |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-27 | 2023-05-31 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-27 | 2023-05-31 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-05-01 | 2023-05-23 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-01 | 2023-05-23 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-28 | 2022-06-30 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-03 | 2022-06-15 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-28 | 2022-05-28 | Y |
Respond appropriately to all alleged violations. | Health | 2022-04-28 | 2022-05-28 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-28 | 2022-05-28 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-04-28 | 2022-05-28 | N |
Ensure each resident receives an accurate assessment. | Health | 2022-04-28 | 2022-05-28 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-04-28 | 2022-05-28 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-28 | 2022-05-28 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-28 | 2022-05-28 | N |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-04-28 | 2022-05-28 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-04-28 | 2022-05-28 | N |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-04-28 | 2022-05-28 | N |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-04-28 | 2022-05-28 | N |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-04-28 | 2022-05-28 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-28 | 2022-05-28 | N |
Provide and implement an infection prevention and control program. | Health | 2022-04-28 | 2022-05-28 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-28 | 2022-05-28 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-22 | 2022-01-21 | Y |
Respond appropriately to all alleged violations. | Health | 2021-12-22 | 2022-01-21 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-22 | 2022-01-21 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-22 | 2022-01-21 | Y |
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