Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Bigfork Valley Communities during CMS and state inspections, most recent first.
Two residents with significant mobility and care needs experienced repeated delays in call light response, with documented wait times often exceeding one hour. Despite grievances being reported and tracked, staff interviews and call light logs confirmed ongoing delays due to staffing shortages and prioritization of other units. The facility did not provide a policy on call light response when requested, and failed to promptly resolve the grievances as required.
A resident with sinus cavity cancer and other health issues was not provided with necessary personal hygiene assistance as per their care plan. Observations showed the resident with dried blood on their face, greasy hair, and wearing the same clothes over consecutive days. Staff interviews revealed inconsistent care, and the facility's policy on ADLs was not provided.
A resident with severe cognitive impairment and a history of falls was repeatedly assisted with ambulation without the use of a transfer belt, contrary to their care plan. Various staff members, including activity staff and nursing assistants, were observed assisting the resident by holding their hand or placing an arm around their back instead of using the required transfer belt. Interviews revealed a lack of adherence to the care plan and understanding of the belt's importance for safety.
A facility failed to ensure an appropriate physician response to a GDR for a resident on lorazepam. Despite a pharmacist's recommendation to reduce the dose, the family rejected the change, and the physician's order reverted to the original dosage without documented justification. Interviews revealed that the facility's staff were aware of the family's refusal, but no further action was taken to document a justified use of the medication.
A facility failed to ensure proper behavior monitoring and justification for the continued use of lorazepam for a resident with moderate cognitive impairment. Despite recommendations for a gradual dose reduction (GDR), the family rejected the request, and the physician did not provide documented justification. Observations indicated the resident was calm and did not exhibit behaviors necessitating the medication. The facility's policy required monitoring and reporting of irregularities, but the pharmacist relied on the physician's response to the family's refusal, leading to the deficiency.
A resident with multiple diagnoses, including sinus cavity cancer and diabetes, did not receive proper infection control during insulin administration. A nurse failed to clean the insulin pen's rubber stopper and did not wear gloves when assisting the resident, contrary to facility policy. The resident required enhanced barrier precautions due to an indwelling urinary catheter, but these were not addressed in the care plan.
Failure to Address Grievances Regarding Delayed Call Light Response
Penalty
Summary
The facility failed to follow up on grievances related to call light response times for two residents who required substantial assistance for mobility, transfers, and toileting due to conditions such as paraplegia, neuromuscular dysfunction, and multiple sclerosis. Both residents were dependent on staff for bed mobility and transfers using a mechanical lift, and their care plans identified them as high risk for pressure injuries and self-care deficits. Despite these needs, documented grievances and interviews revealed that call lights were not being answered in a timely manner, with multiple instances of response times exceeding one hour. Facility grievance forms and call light logs showed repeated concerns about long wait times for call light responses, particularly during morning and afternoon shifts. Staff interviews confirmed that call lights for these residents, who required two-person assistance, were often delayed due to staffing shortages and prioritization of other units. The logs documented numerous occasions where call lights remained unanswered for over an hour, and both residents reported experiencing significant delays in receiving assistance for their care needs. Interviews with staff indicated that monitoring systems were in place, but response times were still prolonged, especially for residents outside the secured dementia unit. The facility was unable to provide a policy related to call light response when requested. The lack of prompt response to call lights and insufficient follow-up on grievances demonstrated a failure to honor residents' rights to voice grievances without discrimination or reprisal and to make prompt efforts to resolve those grievances.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to assist a resident, identified as R17, with personal hygiene as directed by the care plan. R17, who was cognitively aware and had diagnoses including sinus cavity cancer, type 2 diabetes, heart failure, and hypertension, required extensive assistance from one staff member for personal hygiene. However, observations revealed that R17 was not provided with the necessary assistance. On multiple occasions, R17 was found with dried blood on his face and beard, greasy and disheveled hair, and wearing the same clothes over consecutive days. Additionally, R17's pillowcase was soiled with dried blood, and staff did not offer clean linens or personal hygiene assistance during medication administration. Interviews with staff members, including RN-A, RN-B, and NA-D, indicated a lack of consistent care for R17's personal hygiene needs. RN-A administered medication without offering hygiene assistance or clean linens, while RN-B and NA-D acknowledged R17's condition and the need for assistance. The Director of Nursing expected staff to provide immediate basic care, including clean linens, but this was not consistently done. R17 himself stated that he did not receive daily showers and was often left to manage on his own. The facility's policy regarding ADLs was requested but not provided, highlighting a deficiency in the facility's adherence to care plans and hygiene protocols.
Failure to Use Transfer Belt During Resident Ambulation
Penalty
Summary
The facility failed to ensure the use of a transfer belt during the ambulation of a resident with severe cognitive impairment and a history of falls. The resident, who required supervision and assistance for walking, was observed multiple times being assisted without a transfer belt by various staff members, including activity staff, trained medication assistants, and nursing assistants. Despite the resident's care plan specifying the need for a transfer belt due to fall risk, staff members were seen holding the resident's hand or placing an arm around the resident's back instead of using the belt. Interviews with staff revealed a lack of adherence to the care plan and an understanding of the importance of using a transfer belt for the resident's safety. One staff member admitted to not using the belt because the resident could be resistive, and was unsure of the care plan requirements. The Director of Nursing confirmed that all staff were expected to follow the care plan to ensure resident safety, and that training on patient care and ambulation was provided during orientation and annually. The facility's policy required staff to implement care plan interventions to achieve resident care goals.
Failure to Ensure Physician Response to Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure an appropriate physician response to a gradual dose reduction (GDR) for a resident taking lorazepam for anxiety. The resident, who has moderate cognitive impairment and diagnoses including Alzheimer's disease, anxiety, and depression, was prescribed lorazepam 0.5 mg three times a day. The consultant pharmacist recommended a GDR, suggesting a change to 0.5 mg every morning and at bedtime with 0.25 mg at noon. Although the physician initially agreed to this change, the resident's family rejected the GDR, and the physician's order reverted to the original dosage without documented justification for continued use. Interviews revealed that the facility's director of nursing and registered nurse were aware of the family's refusal to consent to the GDR, but no further action was taken to document a justified use of lorazepam. The consultant pharmacist believed the family's refusal was a justifiable reason for continued use, but acknowledged that physician documentation and education would be warranted over time. The facility's policy requires the pharmacist to monitor psychotropic medications monthly and report any irregularities, such as lack of rationale for medication use or lack of documented justification for GDR, to the attending physician and director of nursing.
Failure to Ensure Justification and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper behavior monitoring and gradual dose reduction (GDR) or justification for the continued use of psychotropic medication for a resident with moderate cognitive impairment and diagnoses including Alzheimer's disease, anxiety, and depression. The resident was prescribed lorazepam, an antianxiety medication, to be taken three times a day. Despite recommendations from the consultant pharmacist for a GDR, the family rejected the request, and the physician did not provide documented justification for the continued use of lorazepam. Observations and interviews revealed that the resident did not exhibit behaviors that would necessitate the continued use of lorazepam at the prescribed dosage. The resident was described as calm, relaxed, and easy-going by staff members, and did not show signs of anxiety or agitation. The facility's staff, including the Director of Nursing (DON), did not engage with the family or the physician to address the lack of documented justification for the medication's continued use. The facility's policy required the consultant pharmacist to monitor psychotropic medication use and report any irregularities, such as lack of rationale for medication use or inadequate monitoring. However, the pharmacist relied on the physician's response to the family's refusal of GDR and did not pursue further review. The facility's failure to document behavior monitoring and provide a justified rationale for the continued use of lorazepam led to the deficiency.
Failure to Follow Infection Control Procedures During Insulin Administration
Penalty
Summary
The facility failed to adhere to standard and enhanced barrier precautions (EBP) and proper infection control procedures during insulin administration for a resident. The resident, who was cognitively aware, had multiple diagnoses including sinus cavity cancer, type 2 diabetes, heart failure, and hypertension, and required assistance with personal hygiene. The resident also had an indwelling urinary catheter and required sinus irrigation twice daily with contact precautions. However, the care plan did not address the need for EBP precautions due to the indwelling device. During an observation, a registered nurse (RN) did not clean the rubber stopper of the resident's insulin pen before administering the medication and failed to don gloves when entering the resident's room. The RN assisted the resident with a soiled pillowcase without wearing gloves and administered the insulin injection without proper protective equipment. Interviews with other staff members and the director of nursing revealed that the facility's policy required cleaning the insulin pen's rubber stopper and donning appropriate personal protective equipment (PPE) during direct care and when in contact with bodily fluids, which was not followed in this instance.
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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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Nursing homes near Bigfork
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Essentia Health Homestead | 28.7 mi | — | 7 | 1 |
| Grand Village | 34.9 mi | — | 0 | 0 |
| The Emeralds At Grand Rapids Llc | 37.8 mi | — | 1 | 0 |
| Guardian Angels Health & Rehab Center | 39.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.