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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeview Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
Failure to prevent verbal abuse by a CNA. A resident reported that while receiving bedtime care, the CNA spoke to her in gruff language and said things she did not like, leading the resident to refuse further care from that CNA. A witness confirmed the resident’s account, and facility leadership noted the CNA was a new hire who had already received abuse and resident rights training at orientation and prior education about rude, hurried communication with residents.
A facility failed to document required discharge information for a resident who was transferred out by family. The chart only noted that the resident left via transport, belongings were packed, and meds were sent; it did not include a discharge planning assessment, discharge summary, destination, or communication to the receiving facility, despite the facility policy requiring pertinent care-related information and a discharge summary.
Failure to provide regular bathing to a resident. Staff reported residents were bathed at least weekly and refusals were documented, but the unit staff could not find shower documentation for the resident during the period reviewed. EHR review showed the resident went without bathing for 22 days.
Menu Not Followed as Posted: Staff did not follow the planned and posted menu, and residents were served different breakfast items than those listed. A cook thawed ham because the needed menu items were not available, and staff said substitutions were only verbally relayed to the dietician without documentation. Another staff member said the breakfast days were mixed up and swapped, while the dietician was unavailable.
Food Served Unappetizing and Poorly Palatable: A resident on a pureed diet was served a watery, indistinguishable meal on a sectioned plate, while other residents were served dry, hard pork chops with bland, mostly white sides that were difficult to cut or chew. Two residents stated the meals tasted bad and were not appetizing, and another resident said the food lacked variety and enjoyment; a test tray confirmed the pork chop was dry, plain, and difficult to cut, with bland sides and roll.
Food was not stored, prepared, distributed, and served in sanitary conditions. An open meal cart was used to deliver room trays with uncovered dessert bowls and uncovered drinks, and staff stated there were no lids available for the items. The kitchen also had multiple sanitation issues, including dirty dish and prep areas, a stained and grooved cutting board, frost-covered freezers without thermometers, unlabeled or undated food items, missing temp log entries, and equipment with grease, crumbs, and residue.
Soiled wheelchair not cleaned or tracked: A resident's wheelchair was repeatedly observed with heavy brown and black dried debris and sticky residue on the frame, arm rests, and pedals. The resident said he could not remember the last cleaning and was bothered by the food debris. Staff reported there was no established wheelchair-cleaning process and no log to track when the chair had last been cleaned, despite the facility policy for cleaning and disinfecting resident-care equipment.
A resident with PTSD and a left-hand contracture, another resident ordered for PT, and a third resident with choking and weight loss concerns all had incomplete care plans that failed to include key diagnoses, goals, and interventions. The records showed missing trauma-related triggers, PT details such as frequency and reassessment needs, and nutrition/swallowing care areas after a choking event and diet change.
Failure to provide scheduled showers for two residents was identified. One resident with a hx of CVA had a care plan and shower schedule for twice-weekly bathing, but records showed only one shower per week and staff reported weeks when no shower was provided. Another resident reported not receiving evening showers as preferred; although the shower schedule called for twice-weekly showers, the task list showed only one shower, and staff stated there were barely enough staff to complete evening showers.
A resident was observed with a contracted left hand, but staff were unaware of the condition or could not locate orders related to it. Although the resident had a documented dx of left-hand contracture and requested therapy for the contracture, the care plan did not identify the problem, set goals, or include interventions to prevent further decline, and the admission MDS did not capture the ROM limitation.
Failure to prevent significant weight loss: A resident was observed eating a pureed breakfast after a choking incident led to a diet downgrade that the resident disliked. The resident had also been placed on a diuretic, and records showed a 12% weight loss over 41 days. Staff noted the resident was consuming most meals, but the nutrition at-risk committee had not yet reviewed the weights, and an SLP eval to assess diet upgrade was still pending.
Failure to identify trauma history and triggers: A resident with PTSD stated she had not been seen for treatment and became tearful when discussing past traumatic events. Staff said trauma-informed care assessments were not being completed, and the resident's trauma interview was only completed when requested by surveyors. Her care plan did not identify her trauma history or triggers, despite facility policy requiring use of multiple assessment sources to support trauma-informed, culturally competent care.
A resident was ordered PT for strengthening and ROM, but the facility did not ensure the therapy was delivered as ordered or reassessed after services stopped. Care plans did not reflect ongoing therapy needs, PT notes said the resident would continue to benefit from skilled care, and staff reported the resident was discharged from therapy due to financial barriers and was not reassessed because she appeared to be doing better.
Failure to Prevent Verbal Abuse by CNA
Penalty
Summary
The facility failed to prevent verbal abuse of a resident by a CNA who was a new hire and had already received additional education related to communication concerns with residents. Resident #3 reported that while receiving bedtime care, the CNA spoke to her in what she described as gruff language, and the resident did not want that CNA to provide care to her any longer. The facility’s investigation found a witness who confirmed the resident’s allegation, and the CNA was terminated for abuse. During the investigation, staff interviews showed that the resident told staff that the CNA had said things she did not like, although she could not recall the exact words. A staff member assisted the resident in writing a grievance and gave it to the DON, and another staff member helped interview a resident witness who reported seeing the resident upset after the interaction with the CNA. Facility leadership stated the CNA had been a new hire for only a few weeks and had completed abuse and resident rights training at orientation, and that prior educational conversations had already occurred with the CNA about being rude and hurried in communication with residents before the allegation.
Missing Discharge Documentation
Penalty
Summary
The facility failed to document the required information for the discharge of one resident. During interview, staff member B stated the resident’s discharge was planned and that the resident was transferred to another facility by family, but the electronic health record did not show this. Review of the resident’s record showed discharge from the facility on 2/18/26, and the nurse progress notes only documented that the resident left via a local transport company, that a family member packed personal belongings, and that medications were sent with the resident. No discharge planning assessment, discharge summary, documentation of where the resident was discharged to, or communication to the receiving facility was found in the medical record. The facility policy stated that pertinent care-related information was to be sent and a discharge summary documenting the resident’s stay was to be completed.
Failure to Provide Regular Bathing
Penalty
Summary
The facility failed to provide regular bathing to one resident. During interviews, staff member E stated residents were bathed at least once a week, with some scheduled twice weekly, and that refusals were documented after several attempts with nurse sign-off. Staff member B stated the facility may have had older shower sheets for January and February 2026 while new forms were being implemented, but later stated she could not find documentation showing the resident had showers from 1/10/26 until 2/2/26. Review of the resident’s bathing documentation from January through February 2026 showed the resident did not receive bathing from 1/11/26 until 2/2/26, a span of 22 days.
Menu Not Followed as Posted
Penalty
Summary
The facility failed to follow a planned and approved menu to ensure residents received the expected meals and nutrition. During an observation and interview on 12/1/25, a package of sliced ham was seen thawing in a black bin filled with water on the three-compartment kitchen sink. A staff member stated she had thawed the ham because she did not have what she needed to make the breakfast listed on the menu. Another staff member stated the facility made substitutions by verbally notifying the dietician, but the substitutions were not documented, and he did not know whether residents were notified of menu changes when they occurred. He also stated the dietician was on vacation and the dietary manager was out. Review of the facility menu showed breakfast was to be French toast bake, bacon, fresh fruit, and juice. However, during an observation on 12/3/25, residents were served varied eggs, a sausage patty, sliced strawberries, and toast instead of the posted breakfast of buttermilk pancake, egg of choice, and fresh fruit. A staff member stated the cook had mixed up the days when cooking on Monday and the meals were swapped. He also stated he left a message for the dietician to approve the change, but the dietician was on vacation and could not be reached. The facility policy stated menus shall be prepared at least two weeks in advance, posted at least one week in advance, followed as posted, and that deviations shall be notified as soon as practicable with substitutions of comparable nutritive value.
Food Served Unappetizing and Poorly Palatable
Penalty
Summary
The facility failed to ensure food was served with an appetizing appearance and palatable taste for residents #16, #18, and #19, and failed to serve an altered diet in an appealing manner for resident #28. During lunch service, resident #28 was observed eating a watery pureed meal on a three-way sectioned plate, with three separate white/beige purees that were not easily distinguishable from one another; the resident asked for sugar for her porridge, although porridge was not part of the meal served. Resident #16 was observed with a pork chop that appeared thin, dry, and hard, and the baked potato and cauliflower were cut up together so they were difficult to tell apart. She stated the pork chop and the entire meal were "just awful," that she could not chew the pork chop because it was so hard and dry, and that she did not want to eat anything on the plate because it tasted bad. Resident #18 was observed later with the lunch tray still on his bed; he had eaten only a bite of the pork chop, which appeared dry and hard. He stated the lunch was terrible, everything was the same white color, the pork chop was not edible, and he had to spit out the bite he took after struggling to chew it for 30 minutes. Resident #19 stated the food did not seem to have any nutritional value, everything tasted the same, and the meals were not enjoyable and often difficult to cut or chew. A test tray sampled by the survey team also contained a thin, dry, plain pork chop that could not be cut with a fork, along with bland, white-colored sides and roll; the pork chop tasted old or freezer burnt and the other items were bland. Staff interviews indicated residents had complained that the menu got old, that the facility had changed meat distributors because residents were unhappy with the prior meat, and that feedback was provided through food council, but staff were not aware residents continued to be unhappy with meal palatability.
Food Storage and Meal Distribution Not Kept Sanitary
Penalty
Summary
Food was not stored, prepared, distributed, and served in sanitary conditions. During an observation, staff member K was preparing to deliver lunch trays to residents in their rooms on an open wheeled cart with 11 uncovered dessert bowls and uncovered beverage glasses. Staff member K stated she was not aware whether the drinks or dessert bowls needed to be covered, and staff member F stated there was nothing to cover the bowls or cups. Staff member N later stated the facility had not had lids that fit the bowls and glasses and had ordered an insulated cart and lids, while staff member B stated room-service food items were expected to be covered but there was a lack of covers and general lack of oversight in the kitchen. The kitchen tour and interviews also showed multiple sanitation and food safety issues throughout the food service area. Staff member F was observed doing dishes without a hairnet, and the dish room window behind the clean-dish area had dust buildup, dead bugs, and peeling trim/paint. The tray line had a heavily stained, deeply grooved white cutting board that staff said was not a cleanable surface, and the bottom of the board and nearby metal counter were covered in milky-looking water. The upright freezer had dirty streaks outside, no thermometer, heavy frost on shelves, and freezer-burned bread and buns, including two bags of tortillas with an expiration date of 8/6/25. A stand mixer was covered with a dirty ripped plastic bag and had brown congealed spots in the bowl, while the drawers of a metal cart held utensils with crumb-covered liners and the stove, oven, toaster, microwave, and can opener all had visible grease, crumbs, shavings, spills, or congealed residue. Additional findings included a black tub of water in the three-compartment sink with a package of ham sitting in it, which staff member F said she had thawed for breakfast because she did not have the proper ingredients for the menu items. The walk-in cooler and freezer temperature logs had multiple missing entries for November, and several foods in the cooler were unlabeled or undated, including cheddar cheese, containers of green food, diced fruit, peas, and half sandwiches dated 1/30. Other shelves held flour, sugar, brown sugar, corn meal, granola, powdered sugar substance, chocolate chips, pie crusts, and crackers without dates or labels. Staff member B stated she had not been given logs for the two white freezers and had written the 12/1/25 temperature on November logs because there was no December log, and staff member N stated the two white freezers previously did not have thermometers or temperature logs.
Soiled wheelchair not cleaned or tracked
Penalty
Summary
The facility failed to ensure a resident's wheelchair was clean and well-maintained. During observations on 12/1/25, 12/2/25, and 12/3/25, resident #22's wheelchair was seen next to the bed with a large amount of piled up brown and black dried and slivered debris, along with sticky appearing debris on the frame by the locks, on the arm rests, and on the pedals. On 12/2/25, the resident stated he could not remember the last time his wheelchair was cleaned and said he preferred it to be clean because it bothered him to have so much food debris all over it. Staff interviews showed there was no established process for cleaning wheelchairs at the time of the observations. One staff member stated the expectation was to wipe down and clean resident wheelchairs weekly or as needed, but there was no log kept of when wheelchairs were cleaned. Another staff member stated the facility did not yet have a process established for cleaning wheelchairs and that it was not known when resident #22's wheelchair had last been cleaned. The facility policy stated reusable resident-care equipment would be cleaned and disinfected in accordance with CDC recommendations, and a requested wheelchair cleaning log for resident #22 was not provided by the end of the survey.
Incomplete Care Planning for Contracture, PTSD, Therapy, and Nutrition Needs
Penalty
Summary
Comprehensive, person-centered care plans were not developed and implemented for multiple residents with identified needs. Resident #25 had a diagnosis of post-traumatic stress disorder and was observed with a left-hand contracture, but the comprehensive care plan did not identify the contracture, include goals for caring for it, or list interventions to prevent further decline. The care plan also did not identify the resident’s history of trauma or the triggers related to that trauma. During interview, the resident stated she had not been seen by a provider for treatment of her PTSD and became tearful when discussing traumatic events. Staff later stated they had only recently been informed of the left-hand contracture and that nothing would be on the care plan because they were unaware of it. Resident #31 had a physician order for PT for muscle strengthening and active assisted ROM 2-3 times per week for 8-10 weeks, but the comprehensive care plan only addressed limited physical mobility related to weakness and did not list PT interventions, prior therapy effectiveness, duration, or the need for future assessment for continued therapy. Resident #28 had a diagnosis of CREST, had a choking incident requiring emergency room removal of a piece of pork chop, and was placed on a puree diet afterward, but the care plan did not include the choking incident, diet needs, or weight loss concerns. Staff stated the dietician was responsible for assessments, MDS completion, and care planning for nutrition changes, yet the care plan lacked those identified nutrition and swallowing-related care areas.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide regular showers for 2 of 14 sampled residents, including a resident with a history of CVA and another resident who reported concerns about not receiving showers as preferred. For resident #21, the baseline care plan stated a preference for showers two times per week, and the comprehensive care plan identified an ADL self-care performance deficit related to the CVA history with an intervention for bathing and showering one time per week and as necessary per preference. However, the resident’s task list for the last 30 days showed only one shower per week, even though the weekly shower schedule was updated to show showers on Tuesdays and Fridays. During interview, NF1 stated there were weeks when resident #21 did not receive a shower. For resident #31, the resident stated she preferred evening showers on Tuesdays and Fridays but did not receive showers in the evenings as preferred. Staff member C stated all residents needed supervision in the shower room and that there was no resident independent with showers, adding that there were barely enough staff to complete evening showers. The resident’s showering task list for the last 30 days showed only one shower, despite the weekly shower schedule showing showers twice a week on Tuesdays and Fridays during the night shift. The comprehensive care plan stated the resident was able to perform bathing and showering independently.
Failure to Identify and Care Plan a Resident’s Left-Hand Contracture
Penalty
Summary
The facility failed to identify a resident’s left-hand contracture, the risk factors related to that contracture, and failed to assess and implement preventative measures to prevent further decline in the contracture for 1 of 14 sampled residents. During an observation, the resident was seen with the left hand contracted. Staff interviews showed confusion and lack of awareness about the contracture: one staff member thought there might be something on the TAR but could not find an order, another was unaware of the contracture, and a third said she had only been informed of it the day before. One staff member also stated there would not be anything on the care plan because she was unaware of the contracture. Record review showed the resident had a diagnosis of left-hand contracture on admission, and the care conference summary documented that the resident wanted therapy for the knees and left-hand contractures. However, the comprehensive care plan, last reviewed on 11/26/25, did not identify the left-hand contracture, include goals for care of the contracture, or list interventions to prevent further decline. The admission MDS also did not identify the contracture on the functional range of motion assessment.
Failure to Prevent Significant Weight Loss
Penalty
Summary
The facility failed to identify the risks and put interventions in place to prevent a significant weight loss for resident #28, who lost 12 percent of body weight over 41 days. On 12/3/25, the resident was observed in the dining room eating breakfast with pureed food served in separate containers; the resident had eaten some food and was trying to open a brown sugar condiment container but did not know what it was. Staff member L later stated the resident had a choking incident on 11/9/25 and had been downgraded to a pureed diet that the resident hated, and that the resident had also been placed on a diuretic after readmission to the facility. The dietician progress note dated 11/10/25 documented a comparison weight of 130.4 lbs on 10/26/25, an 11.0 percent loss, and noted recent addition of a diuretic and consumption of 82 percent of meals. Review of weights showed 125.5 lbs on 10/24/25, 116 lbs on 11/3/25, 118 lbs on 11/11/25, 112.6 lbs on 12/2/25, and 110.4 lbs on 12/3/25, resulting in a 12 percent weight loss. Staff member B stated the facility had tried to obtain a speech therapy evaluation to determine whether the diet could be upgraded, but the therapist was not available until 12/10/25, and the nutrition at-risk committee had not yet met in December 2025 to review weights.
Failure to Identify Trauma History and Triggers
Penalty
Summary
The facility failed to identify a resident's past history of trauma and failed to identify triggers that could cause re-traumatization for resident #25, who had a diagnosis of post-traumatic stress disorder. During an observation and interview, the resident stated she had not been seen by a provider for treatment of her PTSD and became tearful when asked about her history of trauma, while also endorsing a history of traumatic events. Review of the resident's admission MDS showed PTSD listed as an active psychiatric/mood disorder diagnosis. Staff member A stated that trauma informed care assessments were not being completed. When the survey team requested the resident's trauma assessment, the Resident Trauma Interview dated 12/3/25 showed it was completed only on the day it was requested. The resident's comprehensive care plan, last reviewed on 11/26/25, did not identify her history of trauma or her trauma triggers. The facility policy stated that trauma informed care should include identifying a resident's history of trauma and triggers using multiple assessment sources.
Failure to Provide and Monitor Ordered PT Services
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were delivered as ordered for resident #31 and failed to further assess and monitor the need for continued therapy services. Resident #31 reported concern that she had not been receiving physical therapy and stated she had to ask staff when or how often therapy would see her. Records showed discharge orders for physical therapy twice weekly and a physician order for PT evaluation and treatment for muscle strengthening and active assisted ROM 2-3 times per week for 8-10 weeks. However, the baseline care plan stated no therapy was indicated at that time, and the comprehensive care plan did not list physical therapy interventions related to prior therapy effectiveness, duration, or the need for future assessment for continued therapy. Physical therapy documentation showed the resident was expected to continue benefiting from skilled care, with notes stating she would benefit from continued PT to address impairments and promote her highest level of function. Despite this, the resident was seen by PT only three times after admission, and the PT discharge note stated she was discharged due to financial barriers. Staff stated the resident could not pay the co-pay, was discharged from therapy, and was not reassessed after discharge because staff assumed she was doing better since she was no longer using a wheelchair and was using a walker. Staff also stated there was no formal agreement or contract with the therapy provider.
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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) |
|---|---|---|---|---|
| Immanuel Skilled Care Center | 14.9 mi | ★★★★★ | 11 | 0 |
| Brendan House | 15.3 mi | ★★★★★ | 0 | 0 |
| Kalispell Rehabilitation And Nursing Llc | 15.5 mi | ★★★★★ | 43 | 0 |
| Montana Veterans Home N H | 21.2 mi | ★★★★★ | 0 | 0 |
| Whitefish Care And Rehabilitation | 26 mi | — | 30 | 0 |
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