9 Reports
Inspection Report — Sep 11, 2025
Renewal
Date: Sep 11, 2025
Visit Reason
The facility underwent a renewal inspection to assess compliance with licensing requirements.
Findings
Five deficiencies were identified related to administrator continuing education, staff training, furnishings, resident call system, and oxygen tank storage.
Deficiencies (5)
37.106.2814-3 Administrator: the administrator did not receive the required 16 contact hours of annual continuing education in 2024.
37.106.2816-5 Assisted living facility staffing: three direct care staff files lacked documentation of training in the abdominal thrust maneuver and basic first aid.
37.106.2836-1 Furnishings: the facility did not meet the minimum construction equipment requirements as evidenced by the emergency call system design.
37.106.2838-7 Resident toilets and bathing: the audible emergency call signal could be silenced at the master station instead of only at the resident’s location.
37.106.2853-4 Oxygen use: two portable oxygen tanks in a resident room were not secured and properly stored.
Inspection Report — Sep 13, 2021
Renewal
Date: Sep 13, 2021
Visit Reason
The survey was a renewal inspection of Great Falls Plaza dba Golden Eagle Plaza.
Findings
Deficiencies were found in the disaster plan, resident toilets, medication records, and resident files. The facility lacked proper documentation and emergency systems, and resident assessments were missing.
Deficiencies (5)
37.106.322-3 Minimum standard for all health care facilities: disaster plan: the disaster plan lacked provisions for additional blankets, water, or food when sheltering in place, had no documentation of annual staff review, and did not maintain a written agreement for an off-site evacuation point.
37.106.2838-7 Resident toilets and bathing: the main lobby restrooms did not have emergency call systems signaling to a staff location.
37.106.2849-2 Medications: records and documentation: medication administration records showed over 31 days of the same initials signing out medications, and the initials did not always correspond to the person administering the medication.
37.106.2821-3 Resident application and needs assessment: no initial resident needs assessments were found in the six resident files reviewed.
37.106.2822-3 Resident service plan: category A: resident needs assessments were missing for two residents admitted in 2017 and 2018.
Report Facts
resident_files_reviewed: 6
resident_MARs_reviewed: 6
days_of_same_initials_signing: 31
Inspection Report — Oct 27, 2020
Renewal
Date: Oct 27, 2020
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements.
Findings
Two deficiencies were identified: the administrator had only 11 annual continued education hours, and a discharged resident file was missing the disposition of personal belongings.
Deficiencies (2)
37.106.2814-3 Administrator: the administrator had only 11 annual continued education hours, which is insufficient.
37.106.2829-2 Resident file: a discharged resident file was missing the disposition of personal belongings.
Report Facts
continued_education_hours: 11
resident_files_reviewed: 3
Inspection Report — Sep 19, 2019
Renewal
Date: Sep 19, 2019
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements.
Findings
Four deficiencies were identified related to staffing levels, resident file documentation, physical plant maintenance, and fire code inspections. Staffing was insufficient on the morning shift, resident files lacked documentation of personal possessions, kitchen equipment and surfaces required repair or replacement, and fire inspection documentation was outdated.
Deficiencies (4)
37.106.2816-6 Assisted living facility staffing: the morning shift had only two staff scheduled for 35 residents despite multiple tasks including meals, medication passes, and showers.
37.106.2829-2 Resident file: there was no documentation regarding the disposition of personal possessions in a resident's closed file.
37.106.2865-6 Physical plant: a kitchen refrigerator leaked water inside, the steam table had an inoperative hot food well, and the nurse station sink countertop was stained and needed replacement.
37.106.2866-7 Construction, building and fire codes: the last fire inspection documentation was dated over two years prior to the survey.
Inspection Report — Oct 12, 2017
Renewal
Date: Oct 12, 2017
Visit Reason
The survey was conducted as a renewal inspection of the assisted living facility.
Findings
Two deficiencies were found: employee orientation and training did not include required topics, and the facility's exterior window trim was damaged from a hailstorm, risking water leakage and physical deterioration.
Deficiencies (2)
37.106.2816-3 Assisted living facility staffing: employee orientation and training did not include an overview of facility policies, services provided, or the Montana Long-Term Care Resident Bill of Rights Act.
37.106.2865-6 Physical plant: approximately 90-95% of the facility's exterior window trim was damaged from a hailstorm, risking water leakage and physical deterioration.
Report Facts
employee_files_reviewed: 8
window_trim_damage_percentage: 90
Inspection Report — Aug 3, 2017
Complaint Investigation
Date: Aug 3, 2017
Visit Reason
The complaint inspection was conducted following concerns related to resident care and medication management.
Complaint Details
The cited findings involved failure to notify the resident's practitioner or family after a fall and deficiencies in medication orders and documentation.
Findings
The facility failed to notify the resident's practitioner or family in a timely manner after a fall with injuries. Additionally, medication orders and documentation were incomplete or missing for a resident's medication management.
Deficiencies (3)
37.106.2843-3 Personal care services: the facility failed to notify the resident's practitioner or family promptly after a fall with injuries, delaying treatment.
37.106.2849-2 Medications: records and documentation: the facility administered medication without a proper order and lacked documentation for medication administration.
37.106.2849-4 Medications: records and documentation: no order was found allowing the resident to keep medication in her room and self-administer it responsibly.
Report Facts
time: 2017-04-21T22:00:00
time: 2017-04-22T01:58:00
time: 2017-04-21T13:00:00
time: 2017-04-20T16:30:00
time: 2017-04-21T22:00:00
Inspection Report — Dec 8, 2016
Complaint Investigation
Date: Dec 8, 2016
Visit Reason
The complaint inspection was conducted to investigate concerns related to staffing and meal service at the facility.
Complaint Details
The complaint inspection identified deficiencies related to inadequate kitchen staffing and insufficient food portions served to residents.
Findings
The facility was operating with reduced kitchen staff, which affected meal preparation and service. Residents received small food portions, and the cook was unaware of proper portion sizes.
Deficiencies (1)
37.106.2816-6 Assisted living facility staffing: the kitchen staff was operating with two fewer serving positions, which affected meal preparation and service, and small portions were given to residents due to the cook's lack of awareness of proper food portions.
Inspection Report — Sep 20, 2016
Renewal
Date: Sep 20, 2016
Visit Reason
The facility underwent a renewal inspection as part of its licensing requirements.
Findings
Six deficiencies were identified related to administrator continuing education, policy review, employee files, resident call light accessibility, food labeling, and fire inspection documentation.
Deficiencies (6)
37.106.2814-3 Administrator: employee file review found that one employee's file was unable to verify 16 contact hours of continuing education units.
37.106.2815-1 Written policies and procedures: the policy and procedure manual was last reviewed on 10/24/2014, indicating it was not current.
37.106.2817-1 Employee files: one employee's file lacked employee evaluations and another did not contain a signed job description or required orientations including resident bill of rights and abuse prevention.
37.106.2838-7 Resident toilets and bathing: pull cords for call lights were wrapped around grab bars in bathrooms, making them unusable.
37.106.2860-1 Food service: seven items removed from original containers and placed in the refrigerator lacked labels or dates.
37.106.2866-7 Construction, building and fire codes: there was no documentation of a fire inspection for 2015 in the facility maintenance file.
Inspection Report — Sep 18, 2014
Renewal
Date: Sep 18, 2014
Visit Reason
The survey was a renewal inspection of Great Falls Plaza dba Golden Eagle Plaza.
Findings
Deficiencies were found in policy review documentation, laundry procedures, resident service plan reviews, and medication record keeping.
Deficiencies (4)
37.106.330-1 Minimum standards for all health care facilities: there were no documented annual reviews of the policy and procedure manual.
37.106.331-1 Minimum standards for all health care facilities: laundry baskets used for clean and dirty laundry were not solid or covered, and staff were observed not wearing gowns or clothing coverings while handling laundry.
37.106.2822-1 Resident service plan: category A: eight resident service plans lacked indication of a required 60-day review, and staff were unaware of this requirement.
37.106.2849-2 Medications, records and documentation: multiple medications were missing reasons for use on residents' MARs, and four resident MARs lacked documentation of all scheduled medications.
Report Facts
count: 8
count: 4
Viewing
Loading inspection reports...
