Inspection Reports for
Billings Nursing and Rehab

The facility was found deficient in ensuring residents were free from unauthorized physical restraints, completing baseline care plans within 48 hours of admission, developing comprehensive care plans addressing resident needs such as dental status, and revising care plans to reflect changes in resident condition and preferences. Deficiencies involved failure to have physician orders for restraints, incomplete or missing care plans, and lack of documentation and monitoring.

The complaint investigation was substantiated with findings including delayed meal service for multiple residents, failure to notify the Ombudsman of discharges for three residents, a resident elopement due to inadequate supervision, improper catheter care and infection control, severe weight loss without proper follow-up, and insufficient staffing causing late meals.

The facility was found deficient in timely resolution of grievances related to meal delays affecting multiple residents, failure to notify the Ombudsman of discharges for three residents, inadequate supervision resulting in a resident elopement, improper suprapubic catheter care and infection control practices for one resident, failure to address severe weight loss for one resident, and insufficient staffing leading to late meal service for several residents.

The complaint investigation found that Resident #31 eloped from the facility on 7/27/25 by removing her wander guard and exiting through the main doors. The resident was gone for approximately 45 minutes before being located by law enforcement. The resident had a high cognitive status (BIMS 13) and was able to remove the wander guard by cutting it with scissors obtained from another resident. The facility had made referrals to locked units and was implementing a Performance Improvement Project for elopement prevention.

The facility failed to ensure adequate supervision to prevent elopement of Resident #31, who removed her wander guard by cutting it off and exited the facility unnoticed, resulting in a 45-minute absence before being found by law enforcement. The facility had assessed the resident as at risk for elopement and had implemented wander guards and monitoring, but these measures were circumvented by the resident.

The complaint investigation involved multiple incidents on 6/2/25 where resident #8 was involved in physical altercations with residents #7, #11, and #13, resulting in injuries and transfers to the emergency department. The facility failed to provide adequate supervision and documentation of these incidents.

The facility failed to prevent and protect residents from abuse and altercations involving resident #8 and others, failed to ensure timely and correct medication administration for several residents, and failed to maintain accurate and complete medical records documenting incidents and resident conditions.

The facility was found deficient in multiple areas including failure to cover catheter bags for resident dignity, inadequate supervision of self-administered insulin, failure to maintain a clean and safe environment, incomplete investigations of staff misconduct and missing resident belongings, delayed reporting of abuse allegations, failure to provide required transfer and bed hold notices, inaccurate resident assessments, incomplete care plans, failure to provide appropriate dialysis and respiratory care, improper medication administration by unlicensed staff, unmet dental care needs, failure to accommodate resident dietary preferences, and improper food storage practices.

The visit was complaint-related involving neglect and abuse allegations for residents #14 and #52. Resident #14 was left on the toilet unattended and resident #52 was transported naked in a public hallway. The facility failed to timely report and thoroughly investigate these incidents.

The facility failed to ensure residents were free from neglect and abuse, including leaving resident #14 on the toilet without assistance for 40 minutes and exposing resident #52 while transporting him to the shower. The facility also failed to timely report abuse allegations and complete thorough investigations, resulting in staff terminations and warnings.

The complaint investigation was substantiated based on observation, interview, and record review showing the resident was left unattended in a bathroom at the dialysis center, posing a safety risk due to the resident's cognitive impairment and elopement risk.

The investigation found that the transportation driver left the resident unattended in the dialysis center bathroom, resulting in the resident missing his dialysis appointment. The resident was later found needing assistance to exit the bathroom. The resident was examined and required further evaluation unrelated to the incident. Interviews and camera footage review confirmed the lack of supervision and failure to ensure the resident's safety.

The complaint was substantiated based on the facility's investigation and resident interview confirming missed medication doses causing pain.

The facility failed to provide pain medication as ordered to relieve chronic pain for one resident, resulting in the resident experiencing pain. The medication doses scheduled for 1:00 a.m. and 5:00 a.m. on 8/6/24 were either held without documented reason or not administered.

The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, failure to provide timely transfer and bed hold notices, incomplete PASARR screening, lack of baseline care plans, inadequate activity programming, failure to assist residents with transfers, improper respiratory care, medication administration errors, failure to accommodate dietary preferences, and unsafe food storage and handling practices.

The complaint involved resident #1 who was denied re-entry to the facility after leaving the hospital against medical advice on 5/23/24. The resident was left sitting outside in the rain and cold for several hours, resulting in immediate jeopardy to his health and safety. The facility staff failed to follow administrative directives, did not assess or assist the resident, and did not obtain readmission orders. Additionally, the facility failed to timely report 11 incidents involving abuse, neglect, or injury for multiple residents to the State Survey Agency within the required timeframes.

The facility failed to prevent immediate jeopardy neglect by refusing re-entry to a resident who left the hospital AMA, resulting in the resident sitting outside in inclement weather for several hours. The facility also failed to timely report multiple incidents of suspected abuse and neglect to the State Survey Agency within the required timeframes.

The complaint investigation substantiated neglect of resident #15 who was left on the toilet for two hours leading to a fall. Resident #66 experienced verbal and physical abuse from a roommate, with staff failing to adequately investigate or intervene despite multiple complaints. The facility failed to follow up with resident #15, re-educate staff on abuse and neglect, and include abuse and neglect in their quality assurance program.

The facility failed to protect two residents from abuse and neglect. Resident #15 was left on the toilet for at least two hours resulting in a fall, and resident #66 experienced ongoing verbal and physical abuse from a roommate without adequate staff intervention or follow-up.

The visit was complaint-related due to allegations of inadequate infection control practices leading to COVID-19 spread. Immediate jeopardy was identified and later removed after corrective actions.

The facility had 38 out of 73 residents contract COVID-19, with several residents hospitalized due to COVID-19 related illnesses. Staff were observed not following proper infection control procedures, including improper donning and doffing of PPE and failure to clean or discard face shields. Management did not monitor or correct staff on improper PPE use.