Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 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.
Failure to protect residents from abuse by another resident: a resident with severe dementia, aphasia, and repeated aggressive behaviors repeatedly entered other residents’ rooms, hit, grabbed, and threw objects at them, and struck multiple residents including while they were seated or sleeping. Interviews and notes showed residents were afraid of her, avoided her, and used measures like shutting doors and placing a garbage can in front of the door to keep her out; staff reported they could not always intervene in time.
Failure to report resident-to-resident abuse: A resident with advanced dementia and repeated aggressive behaviors entered other residents’ rooms, hit, kicked, bit, and threw objects at them, causing fear and mental anguish among multiple residents. Staff interviews confirmed several assaults and acknowledged that residents were upset and afraid, but the interim DON stated the incidents were not reported to the SA because the aggressive resident had dementia and no physical injuries occurred, despite policy requiring alleged abuse to be reported within 24 hours.
Failure to investigate and protect residents from resident-to-resident abuse: A resident with severe dementia, aphasia, and repeated aggressive behaviors repeatedly entered other residents’ rooms and physically assaulted multiple residents, including pushing one resident’s wheelchair into a post, striking residents, grabbing an arm, and hitting another resident in the face. Staff documented many events in progress notes, but only one incident report could be located, and interviews showed staff were unsure about reporting requirements and relied on informal interventions such as 1:1 supervision, closing doors, and placing stop signs on room doors.
Failure to Reassess Lorazepam Use as Ordered: A resident with Alzheimer's disease, anxiety, and depression was ordered lorazepam 0.5 mg TID with a required reassessment after 30 days. The chart did not show the reassessment or provider notification occurred, and the RN acknowledged she failed to complete the reassessment and fax the MD as ordered.
Daily staffing postings failed to include the resident census and the actual hours worked by nursing staff. Surveyors observed a posting that listed RN, LPN, NA, and orientation hours, but it did not show the census or divide hours by shift. The DON stated there was no place in the facility showing the census or the number and type of staff working on a particular shift, despite the facility policy requiring those details.
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 Protect Residents from Another Resident’s Abuse
Penalty
Summary
The facility failed to protect residents from mental and physical abuse by another resident, R4, affecting R5, R6, R7, R8, and R9. R4 had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and aphasia, and her assessments and care plan documented severe cognitive impairment, daily behaviors toward staff and other residents, yelling, taking belongings and food, and safety concerns related to impulsiveness and being non-redirectable. Her progress notes documented repeated episodes of entering other residents’ rooms, screaming, hitting staff and residents, grabbing a resident’s arm, breaking bracelets, throwing objects, and striking residents in the face, chest, arm, leg, and while they were seated or sleeping. The record shows multiple resident-to-resident incidents involving R4 and the affected residents. R4 pushed R5 in a wheelchair into a post and later struck R5 on the arm and chest with a baby doll. R4 hit R9 in the leg, chest, and face. R4 grabbed R6’s arm when she wandered into R6’s room and broke R6’s bracelets. R4 hit R7 in the face with an open hand and later threw an object that hit R7. Staff notes also described R4 entering rooms throughout the evening, taking bedding from a sleeping resident, and throwing another resident’s belongings on the floor. Interviews confirmed that residents were fearful of R4 and altered their behavior to avoid her. R8 stated residents had to be locked in their rooms because R4 went on rampages and said everyone was terrified of her. R6 said she shut her door and placed a garbage can in front of it so it would make noise if R4 tried to enter. RN staff stated R4 was on a rampage with screaming, hitting, scratching, biting, and kicking, and that staff could not always catch her in time. Staff also stated R7 was afraid of R4 and would go out of her way to avoid her, R5 had been hit by R4, and R8 and R9 were afraid or had been involved in altercations with her. Facility documentation and interviews showed that despite repeated incidents, residents continued to be exposed to R4’s aggressive behaviors.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report resident-to-resident abuse to the state agency within the required timeframe. The deficiency involved a resident with advanced dementia, aphasia, and a history of daily behavioral disturbances, including entering other residents’ rooms, screaming, hitting staff, and aggressive acts toward other residents. The resident’s behaviors were documented repeatedly in progress notes, including incidents of entering rooms, preventing staff from entering, hitting staff, kicking doors, and escalating aggression in common areas and dining areas. The record showed multiple incidents in which this resident physically struck or otherwise assaulted other residents. These included pushing one resident in a wheelchair into a post and striking that resident on the arm, hitting another resident in the leg and chest, grabbing a resident’s arm and breaking bracelets, hitting a resident in the face with an open hand, striking another resident in the common area, and throwing an object that hit a resident. Staff interviews confirmed that the resident frequently became agitated, entered other residents’ rooms, and hit, kicked, scratched, bit, and yelled at residents and staff. Several residents were described as afraid of the resident, with one resident stating that everyone was terrified and another stating she was very afraid and had to rely on staff to help her avoid the resident. The affected residents had varying cognitive and physical abilities, including severe cognitive impairment, moderate cognitive impairment, intact cognition, and dependence on staff for transfers and wheelchair mobility. Interviews with residents and staff showed that the incidents caused fear and distress among residents, and staff acknowledged that the resident’s behavior upset others and that they used stop signs and closed doors to keep residents separated. The interim DON stated the resident-to-resident incidents were not reported because the aggressive resident had dementia and no physical injuries had occurred, despite the facility policy requiring alleged abuse to be reported to the state agency within 24 hours when there was no serious bodily injury.
Failure to Investigate and Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and failed to implement protection interventions for resident-to-resident abuse involving multiple residents, including R4, R5, R6, and R7. R4 was admitted with Alzheimer’s disease, dementia with behavioral disturbance, aphasia, and severe cognitive impairment. Her assessments and care plan documented frequent behaviors such as screaming, entering other residents’ rooms, taking belongings and food, and becoming agitated in crowds and during care. The care plan included interventions for agitation, mealtime anxiety, and wandering, but it did not show evidence of interventions specifically addressing abuse toward other residents. Progress notes documented repeated incidents in which R4 entered other residents’ rooms, screamed, hit staff, and became physically aggressive toward other residents. These incidents included R4 pushing R5 in a wheelchair into a post, striking R5 on the arm, hitting another resident in the leg and chest, grabbing R6’s arm and breaking R6’s bracelets, hitting R7 in the face with an open hand, and throwing an object that hit R7. Additional notes described R4 wandering into rooms, taking bedding and belongings, and continuing to display aggressive behavior toward residents and staff over multiple days. During interviews, staff stated they tried to keep eyes on R4, step between residents, and use interventions such as a baby doll, one-to-one supervision, music, folding towels, and closing resident doors. However, the LSW stated only one incident report related to resident-to-resident altercations could be located, and other staff stated that incidents were documented in progress notes rather than incident reports. The LSW also stated staff should have completed incident reports and followed up with skin checks and emotional status after incidents. R7’s family member stated he had not been aware R7 had been hit by R4, and RN-B stated R7 was afraid of R4 and placed a trash can in front of her door at night.
Failure to Reassess Lorazepam Use as Ordered
Penalty
Summary
The facility failed to complete a medication reassessment per physician order for a resident with moderate cognition and diagnoses of Alzheimer's disease, anxiety, and depression. The resident's annual MDS showed the resident received antianxiety medication for 4 days and antidepressant medication for 7 days during the assessment period. A nurse communication form dated 11/5/25 documented that the resident continued to tolerate lorazepam 0.5 mg three times daily, had no increased lethargy or sedation, and requested continuation of the medication with reassessment in 30 days; the form was signed by the MD on 11/6/25. The signed medication order dated 11/5/25 directed lorazepam 0.5 mg by mouth three times a day for anxiety and to re-assess on 12/6/25. The resident's medical record did not show that the resident was reassessed on 12/6/25 as ordered. The DON stated there was a TAR reminder for the nurse to reassess the resident and notify the doctor, and RN-B had signed the reminder on 12/6/25, but the record did not contain documentation of reassessment or notification to the doctor. RN-B stated she failed to reassess the resident according to orders and failed to fax the doctor, and also stated that even though the family would not allow the lorazepam to be discontinued, staff still needed to fax the doctor with updates and obtain a continued order.
Daily Staffing Postings Missing Census and Actual Hours Worked
Penalty
Summary
The facility failed to include the resident census and the actual hours worked by nursing staff on the daily staffing postings. On 12/10/25 at 7:59 a.m., surveyors observed staff postings on a corkboard next to the Aspen Circle entrance, with postings grouped together dated 12/10/25 through 12/21/25. The posting for 12/10/25 identified the date, RN hours, LPN hours, NA hours, and additional orientation hours, but it did not identify the resident census or the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. At 12:10 p.m. on 12/10/25, the DON stated there was not a place within the facility that showed the resident census or how many and what type of staff were working on a particular shift. The DON stated the daily staff posting was updated every day and included the facility name, date, and hours for RN, licensed staff, and NAs, but it did not include the census and the hours were not divided between shifts. The facility policy, Posting Direct Care Daily Staffing Numbers, approved 1/25, required daily posting of the resident census at the beginning of the shift, the 24-hour shift schedule, the type and category of nursing staff working during that shift, the actual time worked during that shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working for the posted shift.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 8 | 1 |
| Grand Village | 34.9 mi | ★★★★★ | 11 | 0 |
| The Emeralds At Grand Rapids Llc | 37.8 mi | ★★★★★ | 12 | 1 |
| Guardian Angels Health & Rehab Center | 39.5 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bigfork Valley Communities.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.