Awe Kualawaache Care Center

Name: Awe Kualawaache Care Center
Address: 10131 S HERITAGE RD, Crow Agency, MT, 59022, US
Telephone: 4066389111

10131 S Heritage Rd, Crow Agency, MT 59022 · Big Horn County · 40 certified beds · avg 24 residents/day · certified since Jun 9, 1998

5/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.78

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★★5/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (18)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 4, 2026	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 4, 2026	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 8, 2025	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 8, 2025	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Dec 4, 2024	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint
Dec 4, 2024	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Dec 4, 2024	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Jul 30, 2024	E · Potential for harm, repeated	The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint
Jul 30, 2024	E · Potential for harm, repeated	The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint
Jul 30, 2024	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jul 30, 2024	D · Potential for harm, one-off	The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Jul 30, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint
Apr 25, 2024	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 25, 2024	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Apr 25, 2024	B · Minimal risk, repeated	The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (2 → 5).

Year	Citations	Worst severity that year
2024	11	E
2025	2	F
2026	5	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Montana avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.78	4.82	3.95	top 43% in Montana; top 17% in the U.S.
Registered Nurse hours	1.65	1.17	0.69	top 19% in Montana; top 3% in the U.S.
Weekend total nurse staffing	3.99	4.26	3.50	top 48% in Montana; top 23% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.96	0.71	0.48	top 19% in Montana; top 7% in the U.S.
Total nursing staff turnover (%)	61.5	54.8	45.8	bottom 26% in Montana; bottom 14% in the U.S.
RN turnover (%)	44.4	48.3	42.9	top 45% in Montana; bottom 45% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.08, RN 1.41, weekend 3.41. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5

Who owns this facility

For profit - Individual

Owner / manager	Type	Role	Stake	Since
Crow Tribe of Indians	Organization	5% or Greater Direct Ownership Interest	100%	04/01/1998
Health Management Services, LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	03/10/2010
Little Light, Paul	Individual	W-2 Managing Employee	NOT APPLICABLE	05/15/2015

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Can you show me an example care plan, and how are families included when it's created and updated?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
"How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"What is your policy on physical restraints, and what alternatives do you try first?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

No other Medicare-certified nursing homes within 20 miles in the current records.

All facilities in Crow Agency →

Facility data as of CMS processing date 2026-08-01. CCN 275153.

The Care File

Visit checklist — Awe Kualawaache Care Center

10131 S Heritage Rd, Crow Agency, MT 59022 · 4066389111

Health inspection rating 5/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
☐ "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "What is your policy on physical restraints, and what alternatives do you try first?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 275153 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)