Bigfork Valley Communities

In the surveyor’s words

From the most serious findings on record at Bigfork Valley Communities, in the surveyor’s own words.

• Actual harm, patternF600Jul 10, 2026

  Based on observation, interview and document review, the facility failed to protect the residents' right to be free from mental and physical abuse from a resident (R4) for 5 of 6 residents (R5, R6, R7, R8, R9). This resulted in psychosocial harm for R5, R6, R7, R8, R9 who displayed and or/verbalized fear which included avoiding R4 and using garbage cans to barricade doors to prevent R4 from entering their rooms. Findings include: R4 R4's admission Record indicated she was admitted to the facility 5/21/26. R4's diagnoses included Alzheimer's disease, dementia with behavioral disturbance and aphasia (a communication disorder affecting speech, understanding, reading, and writing due to brain injury). […]

• No harm, potential for more than minimal, widespreadF880Jun 23, 2022

  Based on observation, interview and document review, the facility failed to follow standard infection control practices when handling and sorting soiled and potentially infectious resident laundry. This practice had the potential to affect all 20 residents residing in the facility and who had their personal laundry laundered at the facility. Findings include: On 6/23/22, at 10:57 a.m. the facility's laundry room was observed with housekeeper (HK)-A. There were two protective gowns and gloves in the laundry room. HK-A stated after he gathered each residents soiled laundry he sorted through it examining each item for stains, checking pockets and separating whites from [NAME], before putting the clothing into the facility washer. […]

• No harm, potential for more than minimal, patternF609Jul 10, 2026

  Based on interview and document review the facility failed to report to the state agency (SA) resident-to-resident abuse that resulted in mental anguish for 4 of 6 residents (R5, R6, R7, R8) reviewed for abuse.Findings include:R4R4's admission Record indicated she was admitted to the facility 5/21/26. R4's diagnoses included Alzheimer's disease, dementia with behavioral disturbance and aphasia (a communication disorder affecting speech, understanding, reading, and writing due to brain injury).R4's Comprehensive Behavioral assessment dated [DATE], indicated R4 had daily behaviors directed toward staff. R4's behaviors included screaming in the dining room and attempts to argue with other residents, taking other's belongings and food. […]

• No harm, potential for more than minimal, patternF610Jul 10, 2026

  Based on interview and document review the facility failed to thoroughly investigate and failed to implement protection interventions resulting in ongoing incidents of physical abuse for 4 of 6 residents (R4, R5, R6, R7) reviewed for resident-to-resident abuse.Findings include:R4R4's admission Record indicated she was admitted to the facility 5/21/26. R4's diagnoses included Alzheimer's disease, dementia with behavioral disturbance and aphasia (a communication disorder affecting speech, understanding, reading, and writing due to brain injury).R4's Comprehensive Behavioral assessment dated [DATE], indicated R4 had daily behaviors directed toward staff. R4's behaviors included screaming in the dining room and attempts to argue with other residents, taking other's belongings and food. […]

• No harm, potential for more than minimal, patternF883Nov 15, 2023

  Based on interview and document review, the facility failed to offer and provide education regarding the pneumococcal conjugate vaccine 20 variant (PVC20) education for those elegible as directed by the Centers for Disease Control (CDC) for 5 of 5 residents (R2, R4, R16, R17, R71) reviewed for immunizations. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had diagnoses including chronic obstructive pulmonary disease (COPD). R2's undated, Minnesota Immunization Information Connection (MIIC) report identified R2 received the pneumococcal polysaccharide vaccine (PPSV23) on 4/19/18, and the pneumococcal conjugate vaccine 13 variant (PCV13) on 5/20/05. […]