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Complaint Investigation

Bigfork Valley Communities

November 14, 2025 · Bigfork, MN · 258 Pine Tree Drive
Citations 1
CMS Rating 5/5
Beds 40
Provider ID 245529
Healthcare Facility
Bigfork Valley Communities
Bigfork, MN  ·  View full profile →
Inspection Summary

BIGFORK VALLEY COMMUNITIES in BIGFORK, MN — inspection on November 14, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0585
Resident Rights Deficiencies
Potential for More Than Minimal Harm

later. 11/4/25, R1 placed his call light on at 7:57 a.m.

Staff responded to the light at 9:07 a.m., one hour and 10 minutes later.11/4/25, R4 placed the call light on at 12:31 p.m.

Staff responded to the light at 2:01 p.m., one hour and thirty minutes later.11/5/25, R1 placed the call light on at 8:05 a.m.

Staff responded to the light at 9:07 a.m., one hour and two minutes later.11/5/25, R4 placed the call light on at 12:26 p.m.

Staff responded to the light at 1:41 p.m., one hour and 15 minutes later.11/7/25, R4 placed the call light on at 12:35 p.m.

Staff responded to the light at 1:39 p.m., one hour and 4 minutes later.11/8/25, R1 and R4 both placed their call lights on at 8:11 a.m., the lights were answered by staff at 9:10 a.m., 58 minutes later.11/11/25, R4 placed the call light on at 8:17 p.m.

Staff responded to the call light at 9:20 p.m., one hour and three minutes later.11/11/25, R4 placed the call light on at 12:43 p.m.

Staff responded to the light at 1:42 p.m., 59 minutes later.11/12/25, R1 placed the call light on at 5:15 p.m., Staff responded to the call light at 6:54 p.m., one hour and 38 minutes later.11/13/25, R1 placed the call light on at 8:09 a.m.

Staff responded to the light at 9:45 a.m., one hour and 35 minutes later.11/13/25, R4 placed the call light on at 8:20 a.m.

Staff responded to the light at 9:35 a.m., one hour and fourteen minutes later.11/13/25, R1 placed his call light on at 12:33 p.m., Staff responded to the light at 1:36 p.m., one hour and three minutes later.11/14/25, R4 placed her call light on at 8:06 a.m.

The call light was answered by staff at 9:03 a.m., 57 minutes later.On 11/14/25 at 11:33 a.m., NA-A and NA-B were interviewed. NA-B stated they were able to monitor call lights on the unit outside the secured area and carried pagers and a monitor that showed up red when a call light was on. NA-B said because they were on a dementia unit they were told safety on that unit came first. NA-B said staff were not assigned to the three residents outside the secured unit. NA-A said sometimes they got over there on time and some days it took longer. NA-B said cares always got done but lights took longer to answer.During interview on 11/14/25 at 12:49 p.m., licensed social workier (LSW)-A stated the facility had been tracking the call light times and having been trying to bring in more staff. LSW-A said the facility lost a lot of staff when school started. LSW-A said R1 and R4 required to people for cares and had noticed some of the other two person assists also waited for additional staff assistance.A policy related to call light response was requested but not received.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BIGFORK, MN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BIGFORK VALLEY COMMUNITIES or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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