12 CMS Surveys
Inspection Report — Aug 14, 2026
Renewal
Date: Aug 14, 2026
Visit Reason
The survey was a renewal inspection of Billings Rehabilitation and Nursing LLC to assess compliance with state regulations and ensure resident safety and care quality.
Findings
The facility was cited for multiple deficiencies including failure to resolve grievances timely related to meal delays, failure to notify the State Long-Term Care Ombudsman of resident discharges/transfers, inadequate supervision leading to a resident elopement, improper catheter care and infection control practices, failure to address severe weight loss, and insufficient staffing causing late meal service.
Deficiencies (7)
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility failed to resolve grievances timely related to delayed meal service for 3 of 28 sampled residents, causing elevated nutritional and psychosocial risk.
F 0628 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies: the facility failed to provide timely notice to the State Long-Term Care Ombudsman of discharge/transfer for 3 of 28 sampled residents.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to supervise a resident at risk for elopement who left the facility unnoticed and was found by police outside.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: the facility failed to perform proper suprapubic catheter care for 1 of 28 sampled residents, resulting in untreated skin breakdown and improper securing of the catheter.
F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to follow up on a re-weigh, document refusals, and implement interventions for severe weight loss for 1 of 28 sampled residents.
F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service: the facility failed to ensure resident meals were served timely for 5 of 28 sampled and supplemental residents, causing frustration and distress.
F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure staff followed proper infection control practices related to hand hygiene and proper use of PPE during suprapubic catheter care for 1 of 28 sampled residents.
Report Facts
Residents sampled: 28
Resident weights: 163
Resident weights: 146.6
Weight loss percentage: 10.28
Temperature (°F): 89
Temperature (°F): 87
Residents with late meals: 5
Residents with grievances about meals: 3
Residents with discharge notification failures: 3
Residents with catheter care issues: 1
Residents with elopement: 1
Inspection Report — Mar 16, 2026
Renewal
Date: Mar 16, 2026
Visit Reason
The survey was a routine renewal inspection of Billings Rehabilitation and Nursing LLC conducted on 11/20/2025.
Findings
The facility failed to ensure a resident's right to be free from physical restraints, complete baseline care plans within 48 hours of admission, develop comprehensive care plans addressing all resident needs, and revise care plans based on changes in resident condition or refusals of treatment. These deficiencies affected multiple sampled residents and had the potential to cause harm or unmet needs.
Deficiencies (4)
F 0604 Administrator: the facility failed to ensure a resident's right to be free from physical restraints when a resident's stump was tied to a wheelchair with a compression wrap without physician order, assessment, or monitoring.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to complete a baseline care plan within 48 hours that included resident-specific needs for activities of daily living for one sampled resident.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to develop and implement a person-centered comprehensive care plan that assessed dental status for one sampled resident.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise a resident's care plan to reflect refusal to wear a brace and the use of a compression wrap as a restraint.
Report Facts
Sampled residents: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Inspection Report — Aug 14, 2025
Renewal
Date: Aug 14, 2025
Visit Reason
The survey was a renewal inspection of Billings Rehabilitation and Nursing LLC.
Findings
The facility failed to ensure adequate supervision to prevent elopement of a resident who removed her wander guard and left the facility unnoticed. The resident was found by police in a nearby park after being gone approximately 45 minutes.
Deficiencies (1)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to supervise a resident at risk for elopement who removed her wander guard and left the facility without staff knowledge.
Report Facts
Temperature (°F): 87
Temperature (°F): 89
Residents sampled: 28
Minutes resident gone: 45
BIMS score: 13
Inspection Report — Jun 19, 2025
Renewal
Date: Jun 19, 2025
Visit Reason
The survey was a renewal inspection to assess compliance with licensing standards.
Findings
The facility failed to prevent resident-to-resident abuse and adequately supervise a resident with behavioral issues. Medication administration was frequently late or incorrect for several residents. Additionally, the facility did not maintain accurate and complete medical records documenting incidents and resident conditions after altercations.
Deficiencies (3)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to prevent and protect four residents from abuse and failed to sufficiently monitor a resident with aggressive behaviors, resulting in multiple physical altercations and injuries.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: the facility failed to ensure medications were given on time, within one hour before or after the scheduled time, for four residents and failed to give the right medication to the right resident for two residents, including an incident where one resident was given another resident's medications.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to maintain accurate and complete medical records for three residents, lacking documentation of incidents, assessments, interventions, and resident conditions following physical altercations.
Report Facts
Residents sampled for altercations: 6
Residents affected by abuse: 4
Residents sampled for medication administration: 4
Residents affected by medication errors: 2
Residents affected by incomplete medical records: 3
Inspection Report — Feb 27, 2025
Date: Feb 27, 2025
Visit Reason
The survey was conducted to assess compliance with regulations regarding resident abuse, neglect, and reporting requirements.
Findings
The facility failed to protect residents from neglect and uphold dignity during care, failed to timely report abuse allegations and investigative findings to the State Survey Agency, and did not complete thorough investigations of reported incidents. These failures affected two residents and resulted in staff terminations and disciplinary actions.
Deficiencies (3)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility left a resident on the toilet without a call light for approximately 40 minutes and transported another resident to the shower uncovered, causing emotional distress and risk of harm.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report an abuse allegation for one resident within the required timeframe and delayed reporting investigative findings for another resident.
F 0610 Respond appropriately to all alleged violations: the facility failed to complete a thorough investigation and maintain documentation of findings for a reported incident involving a resident being transported naked and uncovered, and did not provide additional investigation notes upon request.
Report Facts
Residents sampled: 29
Time left on toilet (minutes): 40
Incident report submission delay (days): 1
Investigation report submission delay (days): 1
Inspection Report — Feb 27, 2025
Renewal
Date: Feb 27, 2025
Visit Reason
Routine renewal inspection of Billings Rehabilitation and Nursing LLC to assess compliance with Montana licensing standards.
Findings
The facility had multiple deficiencies including failure to provide adequate supervision, incomplete investigations of abuse allegations, failure to provide timely resident notifications for transfers and bed holds, incomplete and inaccurate resident assessments and care plans, improper medication administration by unlicensed staff, failure to meet residents' dental and respiratory care needs, failure to accommodate resident dietary preferences, and improper food storage practices.
Deficiencies (18)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to cover catheter bags for 2 of 29 residents, compromising resident dignity.
F 0554 Allow residents to self-administer drugs if determined clinically appropriate: the facility failed to supervise the self-administration of insulin for 1 of 29 residents, increasing risk of negative outcomes.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility failed to maintain a clean, safe, and sanitary environment for 3 of 29 residents, including unrepaired wall and floor damage and soiled bedding.
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: the facility failed to complete a thorough investigation of staff accepting money from a resident and failed to identify missing items for 3 of 29 residents.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report an abuse allegation within required timeframes for 2 of 29 residents.
F 0610 Respond appropriately to all alleged violations: the facility failed to complete a thorough investigation and maintain documentation for an abuse incident involving 1 of 29 residents.
F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: the facility failed to provide written notice of transfer reasons for 3 of 29 residents.
F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: the facility failed to provide Notice of Bed Hold for 2 of 29 residents.
F 0641 Ensure each resident receives an accurate assessment: the facility failed to accurately assess the dental needs of 1 of 29 residents, increasing risk of dental complications.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to develop and implement baseline care plans within 48 hours for 2 of 29 residents.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to implement a comprehensive care plan including dialysis care for 1 resident and failed to include dental and respiratory needs for another resident.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to complete an elopement risk evaluation for 1 resident who attempted to elope.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to change oxygen tubing as ordered for 1 resident, increasing risk of respiratory infections.
F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services: the facility failed to provide pre and post dialysis assessments for 1 resident receiving dialysis, risking complications.
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to ensure scheduled subcutaneous medications were administered by licensed staff for 1 resident.
F 0790 Provide routine and 24-hour emergency dental care for each resident: the facility failed to meet the oral health needs of 1 resident who lacked dentures and had difficulty eating.
F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options: the facility failed to accommodate dietary preferences and restrictions for 1 resident.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to store food properly, including expired and undated items and food stored on the floor.
Report Facts
Residents sampled: 29
Medication administrations by certified medication aide II: 152
Days resident #3 received glatiramer acetate: 135
Food items expired: 7
Food items undated: 13
Inspection Report — Nov 21, 2024
Renewal
Date: Nov 21, 2024
Visit Reason
The survey was conducted as a renewal inspection of Billings Rehabilitation and Nursing LLC.
Findings
The facility failed to ensure adequate supervision during offsite medical appointments, resulting in a cognitively impaired resident being left unattended in a dialysis center bathroom. The resident missed his dialysis treatment but was later evaluated and treated for an unrelated condition.
Deficiencies (1)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: a cognitively impaired resident was left unattended in a dialysis center bathroom during an offsite appointment, resulting in missed treatment and potential safety risks.
Report Facts
Residents transported: 7
BIMS score: 5
Doorbell presses: 3
Staff present: 3
Inspection Report — Sep 12, 2024
Date: Sep 12, 2024
Visit Reason
The survey was conducted to assess compliance with licensing requirements at Billings Rehabilitation and Nursing LLC.
Findings
The facility failed to provide pain medication as ordered to one resident, resulting in the resident experiencing pain. The failure involved missed doses without documented reasons.
Deficiencies (1)
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to provide pain medication as ordered to one resident, causing the resident to experience pain due to missed doses without documented reasons.
Inspection Report — Sep 12, 2024
Renewal
Date: Sep 12, 2024
Visit Reason
Routine renewal inspection of Billings Rehabilitation and Nursing LLC to assess compliance with Montana assisted living and nursing facility regulations.
Findings
The facility failed to maintain a safe and homelike environment, provide timely and proper notifications for resident transfers, develop baseline care plans, provide meaningful activities, assist residents with transfers and meals, ensure safe respiratory care, administer medications as ordered, accommodate dietary preferences, and maintain food safety standards.
Deficiencies (11)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility failed to repair a damaged wall and broken shelf in a resident's room despite maintenance requests.
F 0623 Provide timely notification to the resident and representatives before transfer or discharge: the facility failed to provide written notice of transfer reasons for two residents transferred to hospitals.
F 0625 Notify the resident or representative in writing how long the nursing home will hold the resident's bed during transfer: the facility failed to provide required bed hold notices for two residents transferred to hospitals.
F 0645 PASARR screening for mental disorders or intellectual disabilities: the facility failed to ensure a preadmission screening and resident review document was completed for one resident.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of admission: the facility failed to develop and document a baseline care plan addressing pain, wound care, and blindness for one resident.
F 0679 Provide activities to meet all resident's needs: the facility failed to provide meaningful activities or a comprehensive activity care plan for a mostly bedridden and blind resident.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to assist a resident out of bed for meals to prevent aspiration and failed to keep a storage room containing a sharp object locked.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to implement a comprehensive care plan addressing oxygen and BPAP use, contributing to lack of appropriate respiratory equipment use for one resident.
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to provide pain medication as ordered, causing a resident to experience pain.
F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options: the facility failed to follow dietary preferences for a resident who disliked carrots but was served them repeatedly.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to properly date and label open foods, dispose of expired items, and maintain safe food storage temperatures and sanitation.
Report Facts
Residents sampled: 24
Resident #1 affected: 1
Resident #4 affected: 1
Resident #47 affected: 1
Resident #41 affected: 1
Resident #57 affected: 1
Resident #28 affected: 1
Resident #27 affected: 1
Resident #69 affected: 1
Resident #50 affected: 1
Expired food items observed: 15
Days with no temperature logs: 4
Inspection Report — Jun 6, 2024
Complaint Investigation
Date: Jun 6, 2024
Visit Reason
The survey was conducted following a complaint investigation regarding the facility's failure to prevent neglect of a resident who was denied reentry after leaving the hospital against medical advice.
Complaint Details
The complaint involved the facility's neglect of a resident who was denied reentry after leaving the hospital against medical advice and the facility's failure to timely report incidents and investigation findings to the State Survey Agency.
Findings
The facility denied reentry to a resident discharged AMA from the hospital, resulting in the resident sitting outside in inclement weather for several hours, placing him at high risk of serious harm. Additionally, the facility failed to timely report multiple incidents and investigations to the State Survey Agency as required.
Deficiencies (2)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect: the facility denied reentry to a resident discharged AMA from the hospital, leaving him outside in the rain and cold for hours without assistance, placing him at high risk of serious harm.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report a resident denied reentry after leaving the hospital AMA within the required timeframe and delayed reporting investigation findings for 11 of 14 sampled residents' incidents to the State Survey Agency.
Report Facts
Temperature (°F): 46
Humidity (%): 93
Residents sampled: 14
Residents affected: 1
Days delayed: 23
Inspection Report — Sep 14, 2023
Complaint Investigation
Date: Sep 14, 2023
Visit Reason
The complaint investigation was prompted by allegations of neglect and abuse involving two residents, including failure to protect residents from abuse and inadequate follow-up by facility staff.
Complaint Details
The complaint involved allegations that a resident was left on the toilet for two hours without staff assistance and that another resident experienced ongoing verbal and physical abuse from a roommate, with inadequate staff response and follow-up.
Findings
The facility failed to protect two residents from abuse and neglect, including leaving a resident on the toilet for two hours and failing to address ongoing roommate conflicts and abuse. Documentation and follow-up actions were inadequate, and staff failed to investigate or intervene appropriately.
Deficiencies (1)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect two residents from abuse and neglect, including leaving one resident on the toilet for two hours and failing to address ongoing roommate abuse and conflicts.
Report Facts
Residents affected: 2
Residents sampled: 9
Hours resident left on toilet: 2
Inspection Report — Feb 16, 2023
Renewal
Date: Feb 16, 2023
Visit Reason
The survey was a renewal inspection focused on infection prevention and control practices during a COVID-19 outbreak.
Findings
The facility failed to implement adequate infection control measures to prevent the spread of COVID-19. Staff did not properly don and doff PPE, and management did not monitor or correct these practices, resulting in 38 of 73 residents contracting COVID-19 and several hospitalizations.
Deficiencies (1)
F 0880 Provide and implement an infection prevention and control program: staff failed to properly don and doff PPE, did not clean or discard face shields, and management did not monitor or correct these practices, contributing to COVID-19 spread among residents.
Report Facts
Residents tested positive for COVID-19: 38
Total residents: 73
Residents hospitalized: 4
Staff donning and doffing PPE education completion dates: 4
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