Inspection Report
Renewal
Deficiencies: 5
Sep 11, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with licensing requirements and regulations.
Findings
Multiple deficiencies were identified including the administrator not completing required continuing education, direct care staff lacking documented training in abdominal thrust and first aid, issues with furnishings, the emergency call system allowing the audible signal to be silenced at the master station, and unsecured portable oxygen tanks in a resident room.
Deficiencies (5)
| Description |
|---|
| Administrator did not receive 16 contact hours of annual continuing education in 2024. |
| Three direct care staff files lacked documentation of training in abdominal thrust maneuver and basic first aid. |
| Furnishings deficiency noted during on-site inspection. |
| Audible emergency call signal can be silenced at the master station by pressing the yellow ‘Tone Off’ button. |
| Two portable oxygen tanks in resident room 124 were not secured and properly stored. |
Report Facts
Administrator continuing education hours required: 16
Number of direct care staff files reviewed: 3
Number of portable oxygen tanks unsecured: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Lindquist | Administrator | Named in deficiency for not completing required continuing education |
| Brett Christian | Survey Team Leader | Led the renewal inspection |
Inspection Report
Renewal
Deficiencies: 5
Sep 13, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Great Falls Plaza dba Golden Eagle Plaza facility to assess compliance with regulatory standards.
Findings
The inspection identified multiple deficiencies including an incomplete disaster plan lacking provisions for additional supplies and off-site evacuation agreements, absence of emergency call systems in resident restrooms, medication administration record discrepancies with repeated use of the same staff initials, missing initial resident needs assessments in all reviewed files, and inability to locate resident needs assessments for specific residents.
Deficiencies (5)
| Description |
|---|
| Disaster Plan did not include acquisition of additional blankets, water or food when sheltering in place; no documentation of annual Disaster Plan review with staff; no written agreement for off-site evacuation point. |
| Main lobby restrooms do not have emergency call systems signaling to a staff location. |
| Medication Administration Records showed over 31 days of the same person's initials signing out medications for almost every shift; initials on MAR not always matching the person administering medication. |
| No initial resident needs assessments found in 6/6 resident files reviewed. |
| Unable to locate Resident Needs Assessments for Resident #1 and Resident #2. |
Report Facts
Resident files reviewed: 6
Resident MARs reviewed: 6
Days of repeated initials on MAR: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Lindquist | Administrator | Named in relation to statements about restroom use and resident needs assessments |
| Noelle Markland | Survey Team Leader | Leader of the renewal inspection team |
| Staff #2 | PCA | Discussed medication administration issues |
| Staff #3 | PCA | Discussed medication administration issues and internet problems affecting sign-off |
Inspection Report
Renewal
Deficiencies: 2
Oct 27, 2020
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection found that the administrator had only 11 annual continued education hours and that one discharged resident file was missing the disposition of personal belongings.
Deficiencies (2)
| Description |
|---|
| Administrator had only 11 annual continued education hours. |
| Discharged resident file missing disposition of personal belongings. |
Report Facts
Annual continued education hours: 11
Resident files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Lindquist | Administrator | Named in relation to administrator education hours deficiency |
| Noelle Markland | Survey Team Leader | Led the renewal inspection |
Inspection Report
Renewal
Census: 35
Deficiencies: 4
Sep 19, 2019
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with staffing, resident file documentation, physical plant conditions, and fire safety codes.
Findings
The inspection identified staffing shortages on the morning shift, missing documentation in a resident file, physical plant issues including a leaking refrigerator and inoperative steam table, and outdated fire inspection documentation.
Deficiencies (4)
| Description |
|---|
| Morning shift staffing insufficient with only 2 staff for 35 residents during breakfast, lunch, medication passes, and showers. |
| Resident file #1 lacked documentation regarding disposition of personal possessions. |
| Physical plant issues: leaking refrigerator with pan to catch water, inoperative largest steam table well, and stained sink countertop needing replacement. |
| Last fire inspection documentation dated 7/14/2017, indicating outdated fire safety inspection. |
Report Facts
Residents present: 35
Staff scheduled: 2
Survey date: Sep 19, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Lindquist | Administrator | Acknowledged staffing and fire inspection issues |
| Harry Dziak | Survey Team Leader | Led the renewal inspection |
Inspection Report
Renewal
Deficiencies: 2
Oct 12, 2017
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility Great Falls Plaza dba Golden Eagle Plaza.
Findings
The inspection identified deficiencies in employee orientation and training, specifically missing key components such as an overview of facility policies, services provided, and the Montana Long-Term Care Resident Bill of Rights Act. Additionally, physical plant issues were noted, including damage to the outer window trim caused by a hailstorm, which could lead to water leakage and physical deterioration.
Deficiencies (2)
| Description |
|---|
| Employee orientation and training did not include an overview of facility policies, services provided, and the Montana Long-Term Care Resident Bill of Rights Act. |
| Physical damage to approximately 90-95% of the outside window trim due to a hailstorm, risking water leakage and physical deterioration. |
Report Facts
Employee files reviewed: 8
Window damage percentage: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Lindquist | Administrator | Named as the facility administrator during the renewal inspection. |
| Harry Dziak | Survey Team Leader | Led the renewal inspection survey team. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 3, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns related to resident care and medication management at Great Falls Plaza dba Golden Eagle Plaza.
Findings
The investigation found that the facility failed to notify the resident's practitioner or family in a timely manner after a fall with injuries, and there were medication record discrepancies including lack of physician orders for Codeine/Guaifenesin and for the resident to self-administer medication.
Complaint Details
Complaint inspection triggered by concerns about resident fall and medication administration. Substantiation status not explicitly stated.
Deficiencies (3)
| Description |
|---|
| Failure to notify resident practitioner or family and seek timely treatment after resident fall with injuries. |
| Medication records showed two different log records for Codeine/Guaifenesin without a valid physician order. |
| No order found for resident to keep medication in her room and self-administer correctly. |
Report Facts
Facility License Number: 13369
Incident Date: Apr 21, 2017
Incident Date: Apr 22, 2017
Medication doses: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara Wooten | Survey Team Leader | Led the complaint inspection |
| Judy Lindquist | Administrator | Facility administrator named in report header |
| Stacy | Hospice Nurse | Notified MD and checked resident after fall |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 8, 2016
Visit Reason
The inspection was conducted as a complaint investigation regarding staffing and meal service issues at the assisted living facility.
Findings
The administrator and kitchen supervisor acknowledged a slowdown in kitchen operations due to staffing shortages, specifically two vacant serving positions, which affected meal preparation and service. The cook admitted to giving small portions and being unaware of adequate and proper food portions.
Complaint Details
Complaint inspection triggered by concerns about assisted living facility staffing and meal service adequacy.
Deficiencies (1)
| Description |
|---|
| Staffing shortages in the kitchen leading to slowed meal preparation and service; inadequate food portions given to residents. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Lindquist | Administrator | Named in relation to acknowledgment of kitchen staffing shortages and meal service issues. |
| Harry Dziak | Survey Team Leader | Led the complaint inspection. |
Inspection Report
Renewal
Deficiencies: 6
Sep 20, 2016
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for Great Falls Plaza dba Golden Eagle Plaza.
Findings
The inspection identified multiple deficiencies including incomplete employee files lacking required documentation and evaluations, outdated policy and procedure manual review, unusable call light pull cords in resident bathrooms, unlabeled food items in the refrigerator, and missing documentation of a 2015 fire inspection.
Deficiencies (6)
| Description |
|---|
| Employee #1 file unable to verify 16 contact hours of CEUs. |
| Policy and Procedure manual was last reviewed on 10/24/14 per administrator's signature. |
| Employee #2's file does not contain any employee evaluations. Employee #1's file does not contain a signed job description, orientation to resident bill of rights, orientation to service plans, patient rights, or Montana elder and persons with DD abuse prevention act. |
| Pull cords for call lights were wrapped around the grab bars in the bathrooms of rooms 110 and 126, rendering them unusable. |
| Seven items that had been removed from their original containers and placed in the refrigerator did not have a label or date. |
| There is no documentation of a fire inspection for 2015. |
Report Facts
Number of unlabeled food items: 7
Required contact hours of CEUs: 16
Inspection Report
Renewal
Deficiencies: 4
Sep 18, 2014
Visit Reason
The inspection was conducted as a renewal inspection of the Great Falls Plaza dba Golden Eagle Plaza facility to assess compliance with regulatory standards.
Findings
The inspection identified multiple deficiencies including lack of documented annual reviews of the policy and procedure manual, improper laundry handling practices, failure to conduct required 60-day reviews of resident service plans, and incomplete medication administration records with missing reasons for use and documentation.
Deficiencies (4)
| Description |
|---|
| No documented annual reviews of the policy and procedure manual. |
| Laundry baskets used for both clean and dirty laundry were not solid and had no cover; staff did not wear gowns or clothing coverings while handling laundry as required. |
| Eight resident service plans reviewed did not have indication of a 60-day review. |
| Multiple medications missing reason for use on residents' MARs; four resident MARs lacked documentation of all scheduled medications. |
Report Facts
Resident service plans lacking 60-day review: 8
Resident MARs lacking documentation: 4
Loading inspection reports...
