Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Awe Kualawaache Care Center during CMS and state inspections, most recent first.
The facility failed to ensure the infection preventionist was adequately trained and knowledgeable, did not maintain documentation of infection control audits, and lacked a comprehensive water management program to prevent Legionella. Staff did not consistently follow proper transmission-based precautions for a resident with C. diff, and a nurse did not perform hand hygiene between glove changes during wound care. These deficiencies increased the risk of infection for all residents.
The facility did not notify the State Ombudsman Office or provide required ombudsman contact information to residents during hospital transfers or discharges. Staff interviews revealed a lack of awareness about these requirements, and review of transfer/bed hold notices for several residents confirmed the omission. The facility was unable to provide documentation of ombudsman notification for these events.
A resident in a LTC facility was physically restrained for an hour without following proper procedures. The charge nurse directed staff to restrain the resident to administer an antipsychotic injection due to aggressive behavior. The facility failed to obtain a practitioner's order, ensure the least restrictive restraint, and provide ongoing monitoring, violating F604 - Restraints guidelines.
A facility failed to update a resident's care plan to include his preference for male staff who spoke his native Crow language, which reduced his agitation and aggression. Despite staff awareness and discussion of this preference, it was not documented in the care plan, leading to a deficiency in personalized care.
A facility failed to ensure nursing staff were adequately trained and competent in managing a resident with aggressive behaviors and the use of restraints. A resident was physically restrained for an hour without proper oversight after an intramuscular antipsychotic injection. The nurse involved was a new graduate, and staff reported a lack of training in restraint use, with no documentation of training in their personnel files.
The facility's assessment failed to accurately reflect the care required for residents with behavioral health needs, as staff expressed concerns about their ability to manage aggressive behaviors. Despite the facility's claims of offering mental health services, interviews revealed a lack of appropriate skills and resources to care for these residents.
The facility failed to provide adequate behavioral health training for staff, leading to unawareness of care plan interventions for residents with aggressive behaviors. Staff expressed uncertainty in handling incidents, with some relying on seeking help from the DON or other nurses. Residents with known behavioral issues, such as one with paranoid schizophrenia, were monitored by sitters who were not informed or trained on managing behaviors. The lack of training and awareness contributed to the deficiency identified by surveyors.
A resident was involved in a physical altercation with a CNA, who aggressively pulled the resident's hands behind her back and pulled her to the ground. The incident was captured on security footage, showing the resident pushing her walker towards the CNA, who then restrained and pulled the resident down, despite other staff attempting to de-escalate the situation. The CNA was identified as easily angered and a bully, leading to their removal and termination.
The facility failed to assess the root causes of a resident's behavioral outbursts and did not provide necessary mental health services for another resident with schizophrenia. One resident exhibited aggression without root cause assessments, while another lacked documentation of receiving required outpatient mental health services. Staff reported challenges in coordinating care with the only available provider.
A facility failed to limit PRN psychotropic medications to 14 days or provide documented rationale for extended use. A resident received Ativan and Olanzapine without physician documentation for continued use or stop dates. Staff indicated the physician visited monthly and pharmacy reviews for stop dates were pending.
The facility failed to update the care plan for a resident with a chronic non-pressure ulcer and did not include daily weight monitoring as instructed by an emergency room physician. Staff interviews revealed that care plan updates were delayed due to the resignation of the previous DON.
The facility failed to ensure nurse competencies for wound care, resulting in a resident with diabetes and chronic ulcers not receiving necessary treatments for several days. The admitting physician's orders were incomplete, and the wound clinic could not be contacted over the weekend and holiday for clarification.
The facility failed to accurately submit PBJ data for RN coverage and 24-hour licensed nurse coverage for multiple days in Quarter One of Fiscal Year 2024. Discrepancies were found between the submitted data and employee timecards, and staff interviews revealed that the data was based on outdated schedules.
Infection Control Deficiencies: Training, Waterborne Illness Prevention, and PPE Compliance
Penalty
Summary
The facility failed to ensure that the infection preventionist was properly trained and knowledgeable in key infection control practices. The infection preventionist reported not receiving the required education for the position, was unable to provide documentation of hand hygiene and PPE audits, and was unsure about the frequency of mandatory infection control education. Additionally, the infection preventionist did not have quick reference materials for determining appropriate precautions for specific infections, was uncertain about which diseases were reportable to the state, and incorrectly stated that alcohol-based hand rubs were preferable to handwashing for Clostridioides difficile (C. diff) cases, contrary to CDC guidance. The facility also failed to implement and document safety measures to prevent waterborne illnesses such as Legionella. Staff interviews revealed that there was no log of toilet flushing or clear understanding of the requirements for weekly flushing to prevent Legionella growth. Testing for Legionella was limited to swab testing a countertop in the kitchen, and there was no evidence of a comprehensive water management program as outlined in facility policy, including monitoring, control limits, and documentation. Deficiencies were also observed in the application of transmission-based precautions and hand hygiene. One resident with C. diff was placed on droplet precautions, but staff entered the room without appropriate PPE, left the door open, and were unclear about the correct precautions. Another staff member failed to perform hand hygiene between glove changes while providing wound care to a resident, despite facility policy requiring handwashing after glove removal. These lapses in infection control practices had the potential to affect all residents in the facility.
Failure to Notify State Ombudsman and Provide Contact Information During Resident Transfers
Penalty
Summary
The facility failed to notify the State Ombudsman Office when residents were transferred to the hospital or discharged, and did not provide residents with the required contact information for the State Ombudsman Office. This deficiency was identified for three sampled residents who experienced transfers or discharges, as their transfer/bed hold notices lacked the necessary ombudsman contact details. Staff interviews revealed a lack of awareness regarding the requirement to notify the ombudsman and to include their contact information on transfer/discharge forms. Additionally, the facility was unable to provide documentation showing that the ombudsman had been notified of these transfers or discharges. Facility policy indicated that notice of transfer or discharge should be provided to the resident, their representative, and the LTC ombudsman when practicable. However, review of the records for the affected residents showed that this policy was not followed, as the required notifications and contact information were missing. Staff confirmed that notification to the ombudsman was only done in specific circumstances, such as incident reports, and not routinely for all transfers or discharges.
Improper Use of Physical Restraints on Resident
Penalty
Summary
A deficiency was identified in a long-term care facility where a resident was physically restrained without following the required procedures. The incident involved a resident who was acting aggressively towards staff and other residents. The charge nurse directed staff to physically restrain the resident to administer an intramuscular injection of an antipsychotic medication. The restraint continued for an hour, which exceeded the initial 15 minutes intended for the medication to take effect. The staff did not ensure the least restrictive restraint was used, nor did they verify with the nurse if it was safe to continue restraining the resident. The facility failed to follow the necessary steps outlined in the State Operations Manual, Appendix PP, under F604 - Restraints. These steps include obtaining an order from a practitioner during or immediately after the application of the restraint, ensuring the restraint is a last resort, and providing ongoing monitoring and assessment of the resident's condition. Additionally, the facility did not document the incident properly, including the resident's behavior, interventions attempted, and whether the use of a physical restraint was ordered by a practitioner. Interviews with staff members revealed that the charge nurse did not verify the least restrictive method of restraint and did not ensure continuous monitoring of the resident's condition. The staff members involved in the restraint did not consistently apply the restraint and failed to assess other interventions that could address the resident's aggressive behavior. The facility did not take steps to address future potential episodes of imminent danger involving the resident.
Failure to Update Care Plan with Resident's Language and Gender Preferences
Penalty
Summary
The facility failed to update a resident's individualized care plan to reflect personal preferences related to communication and the provision of Activities of Daily Living (ADL) care. Specifically, the care plan did not include the resident's preference for male staff who could speak his native Crow language, which was observed to reduce his agitation and aggression. During an observation, the resident was seen interacting positively with a male staff member who spoke his native language, indicating that this preference was beneficial for his well-being. Interviews with staff members revealed that the resident's preference for male Crow-speaking staff was known and discussed during the facility's daily meetings. However, this preference was not documented in the resident's care plan, which was last revised on 11/18/24. Staff acknowledged the oversight and mentioned that they were working on improving the development of individualized care plans. The omission of this critical information in the care plan led to a deficiency in providing personalized care that could potentially mitigate the resident's aggressive behaviors.
Inadequate Training and Oversight in Restraint Use
Penalty
Summary
The facility failed to ensure that all nursing staff working with a resident who exhibited aggressive behaviors were adequately educated and competent to provide necessary services for the resident's needs, particularly concerning behaviors and the use of restraints. On a specific incident, a charge nurse directed staff to physically restrain a resident who was aggressive towards staff and other residents. The restraint was applied to administer an intramuscular antipsychotic injection, and staff were instructed to continue restraining the resident for an additional 15 minutes to allow the medication to take effect. However, the resident was restrained for a total of one hour without proper nursing oversight or reassessment, as the charge nurse did not reassess or document the resident's condition every 15 minutes during the restraint period. Interviews revealed that the nurse involved was a new graduate who had just passed her nursing boards and was having difficulty managing the situation. Staff members involved in the restraint reported a lack of training on how to restrain a resident, with one staff member indicating it was his first time having physical contact with a resident. The facility's records failed to show documentation of training or education regarding resident care or restraint use for the staff involved. The incident highlighted a deficiency in ensuring that nursing staff had the appropriate competencies to manage residents with aggressive behaviors and the proper use of restraints.
Inadequate Behavioral Health Care Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment to accurately reflect the care required for residents with behavioral health needs. This deficiency was identified through interviews and record reviews, revealing that the facility's assessment did not consider the specific needs of residents with aggressive behaviors. Staff members expressed concerns about their ability to manage these behaviors, indicating a lack of appropriate skills and resources. The facility's assessment, dated 12/13/22, claimed to offer services for mental health and behavior management, but staff interviews contradicted this claim, highlighting a gap between documented capabilities and actual practice. During interviews, staff members expressed their inability to care for residents with behavioral health needs adequately. One staff member mentioned that a resident required a one-to-one sitter due to behaviors and was awaiting a psychological evaluation. Another staff member, new to the facility, was unaware of the facility assessment's claims regarding behavioral health care. Additionally, a staff member reported that there were seven residents with aggressive behaviors on the unit, and the CNAs lacked the skills to manage these behaviors effectively. These findings indicate a significant discrepancy between the facility's stated capabilities and the actual care provided to residents with behavioral health needs.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide adequate behavioral health training for staff, which was inconsistent with the needs of the residents. During observations and interviews, it was revealed that staff members were not aware of the specific behaviors or care plan interventions for residents with aggressive behaviors. Staff members expressed uncertainty about how to handle aggressive incidents, with some stating they would seek assistance from the Director of Nursing or other nurses. The lack of training and awareness of care plans was evident among multiple staff members, who were responsible for monitoring residents with known behavioral issues. Resident #2, who has a history of paranoid schizophrenia and aggressive behavior, was observed to have a sitter who was not informed about the resident's past behaviors or trained on how to manage them. The care plan for Resident #2 included non-pharmacologic interventions and monitoring, but staff were unaware of these interventions and did not know the resident's triggers. Similarly, Resident #3 exhibited aggressive behaviors during care activities, and staff reported feeling overwhelmed and untrained to manage such behaviors effectively. The facility's documentation, including care plans and progress notes, indicated a lack of identification of triggers and root causes for the residents' behaviors. Staff interviews highlighted a general feeling of burnout and inadequacy in handling aggressive behaviors, with some staff expressing fear of potential abuse incidents due to the facility's inability to manage such residents. The absence of a structured training program for managing behavioral health needs contributed to the deficiency identified by the surveyors.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to prevent resident abuse involving a physical altercation between a resident and a staff member. The incident involved a resident and her assigned one-on-one Certified Nursing Assistant (CNA) in the doorway to the dining room. The CNA was observed pulling the resident's hands behind her back in an aggressive manner and subsequently pulling the resident to the floor. This altercation was captured on security camera footage, which showed the resident walking into the dining room with her walker, followed by the CNA at a distance. The resident turned and pushed her walker towards the CNA, who then grabbed the resident by her arms, turned her around, and pulled her to the ground, despite other staff members arriving to help de-escalate the situation. Interviews revealed that the staff member involved, identified as easily angered and a bully, was removed from the shift and later terminated. The incident was reported to a staff member who reviewed the security footage and began an investigation.
Failure to Assess Behavioral Outbursts and Provide Required Mental Health Services
Penalty
Summary
The facility failed to assess the root cause or triggers of behavioral outbursts for one resident and did not provide the necessary behavioral health services for another resident as outlined in their PASRR Level II. Resident #2 exhibited a pattern of agitation and aggression, including assaulting another resident and aggressive behavior towards staff. Despite these incidents, no root cause assessments were conducted to identify trends or triggers. Staff interviews revealed that the facility was advised to send the resident to the emergency room during a crisis, but logistical challenges made this difficult. Additionally, attempts to find new placements for the resident were unsuccessful due to her behaviors. Resident #4, who had a history of schizophrenia and required specialized outpatient mental health services, did not have any documentation in their electronic medical record indicating they were receiving or refusing these services. Staff reported ongoing difficulties in coordinating behavioral health services with the only available provider in the area. During the exit conference, it was noted that the facility intended to send the requested behavioral health documentation to the State Survey Agency, but no documentation was received.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days or had documented rationale for extended use, and did not ensure that PRN antipsychotic drugs were renewed only after evaluation by a physician. A resident had PRN orders for Ativan and Olanzapine, both starting on July 1, 2024. The resident received Ativan seven times and Olanzapine twice in July, but there was no physician documentation justifying the continued PRN use of these medications, nor were there stop dates listed. Staff member B indicated that the physician visited the facility once a month and was otherwise available by phone, and that pharmacy reviews to catch stop dates had not been completed for July 2024.
Failure to Update Care Plan for Wound Care and Daily Weights
Penalty
Summary
The facility failed to revise and update the care plan for a resident with a chronic non-pressure ulcer on the right lower extremity. Despite a physician's order to clean the wound and apply specific treatments, the care plan did not include these interventions. Additionally, after the resident was seen in the emergency room for excess fluid retention, the emergency room physician instructed the facility to weigh the resident daily, but this intervention was also not added to the care plan. Interviews with staff revealed that care plan conferences and updates were not completed following the resignation of the previous Director of Nursing, leading to a backlog in care plan updates and meetings.
Failure to Ensure Nurse Competencies for Wound Care
Penalty
Summary
The facility failed to ensure that the nurse competencies and skills were sufficient to provide wound care services for a resident with diabetes and chronic ulcers. The resident's electronic medical record showed an admission diagnosis of diabetes Type 2 with other skin ulcer and a non-pressure chronic ulcer of the right lower leg. The physician's admission order included an order for Gentamicin Sulfate ointment to be applied once a day, but it did not specify which wound was to be treated. The treatment record showed that the wound treatment was not completed on three consecutive days, and there was no documentation explaining why the treatments were not completed. Additionally, the medical records did not show any attempt to contact a medical provider to clarify the wound care orders during this period. A late entry nursing progress note indicated that the orders were hard to read and understand, and it was only on 1/1/24 that the wound care orders were clarified and documented properly. However, the Gentamicin ointment was not available from the pharmacy to be administered on that day. Staff member D confirmed that the admitting physician was not the regular doctor for the resident's wounds and that the wound clinic could not be contacted over the weekend and holiday for order clarification. The deficiency was further highlighted during an interview with staff member D, who acknowledged that the admission orders did not include the complete wound treatment because the admitting physician was not familiar with the resident's wound care needs. The staff member also mentioned that the wound clinic, which had been treating the resident prior to admission, was closed for the weekend and holiday, making it impossible to obtain order clarification until 1/1/24. This delay in obtaining and clarifying wound care orders resulted in the resident not receiving the necessary wound treatments for several days, as documented in the medical records and treatment logs.
Inaccurate PBJ Data Submission for RN and Licensed Nurse Coverage
Penalty
Summary
The facility failed to accurately submit Payroll Based Journal (PBJ) data for Registered Nurse (RN) coverage, specifically 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 review of the Quarter One report showed no RN hours for specific dates and failed to have licensed nursing coverage 24 hours per day for multiple dates. Employee timecards, however, indicated that RN hours and licensed nurse coverage were present on those dates, suggesting discrepancies in the data submitted to the PBJ system. During interviews, staff members revealed that the data submitted was based on a schedule provided by the Assistant Director of Nursing (ADON) to the business office at the beginning of each month. If changes were made to the schedule during the month, the business office did not receive an updated schedule. Staff member H admitted that she did not use employee timecards to enter data, leading to inaccuracies in the PBJ submissions. Staff member A confirmed that during a Quality Assurance and Performance Improvement (QAPI) meeting, it was identified that licensed staff hours were not correctly submitted to the PBJ, and the facility was working on developing a new process to report actual working hours for licensed staff.
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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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