AWE KUALAWAACHE CARE CENTER MT DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/09/2009	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
12/09/2009	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Pattern	Minimal harm or potential for actual harm
12/09/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
12/09/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
12/09/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/09/2009	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Potential for minimal harm
12/07/2009	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
12/07/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/07/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
12/07/2009	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
12/07/2009	corridors or aisles that are unobstructed and are at least 8 feet in width.	Widespread	Minimal harm or potential for actual harm
12/07/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
12/07/2009	have an adequate water supply for the sprinkler system.	Widespread	Minimal harm or potential for actual harm
12/07/2009	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
12/07/2009	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
12/07/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
12/07/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
12/07/2009	a separate and independent backup electrical power source.	Isolated	Minimal harm or potential for actual harm
12/07/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
02/19/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
02/19/2009	Send and promptly deliver unopened mail to residents.	Widespread	Potential for minimal harm
02/19/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/19/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
02/19/2009	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
02/19/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/19/2009	Make sure that doctors visit residents regularly, as required.	Pattern	Minimal harm or potential for actual harm
02/19/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Potential for minimal harm
02/19/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
02/19/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
02/17/2009	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
02/17/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/17/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
02/17/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
02/17/2009	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
02/17/2009	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
02/17/2009	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
02/17/2009	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
02/17/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
02/17/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
02/17/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
02/17/2009	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
02/17/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
02/17/2009	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
02/17/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
03/27/2008	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
03/27/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
03/27/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
03/27/2008	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Minimal harm or potential for actual harm
03/27/2008	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
03/27/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
03/27/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
03/27/2008	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
03/18/2008	a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
03/18/2008	approved construction type or materials.	Pattern	Potential for minimal harm
03/18/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
03/18/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
03/18/2008	emergency lighting that can last at least 1 1/2 hours.	Pattern	Potential for minimal harm
03/18/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
03/18/2008	a fire alarm system that can be heard throughout the facility.	Pattern	Potential for minimal harm
03/18/2008	properly maintained smoke detectors.	Pattern	Potential for minimal harm
03/18/2008	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
03/18/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
03/18/2008	have an adequate water supply for the sprinkler system.	Widespread	Minimal harm or potential for actual harm
03/18/2008	portable fire extinguishers.	Pattern	Potential for minimal harm
03/18/2008	properly protected cooking facilities.	Pattern	Potential for minimal harm
03/18/2008	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
03/18/2008	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
03/18/2008	a separate and independent backup electrical power source.	Widespread	Minimal harm or potential for actual harm
03/18/2008	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm

Have you or someone you know become a victim of nursing home abuse or neglect? If so, contact one of our experienced nursing home lawyers today. Help End Nursing Home Abuse

Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death