Inspection Reports for
Skyline Heights Nursing and Rehabilitation
1807 24th St W, Billings, MT 59101, MT, 59101
Back to Facility Profile13 CMS Surveys
Inspection Report — Dec 31, 2025
Renewal
Date: Dec 31, 2025
Visit Reason
The survey was a renewal inspection of Skyline Heights Nursing and Rehabilitation.
Findings
The facility failed to properly inform residents about changes in incontinence products, submit timely reports of incidents, and update residents' comprehensive care plans to reflect changes in incontinence care.
Deficiencies (3)
F 0552 Ensure that residents are fully informed and understand their health status, care and treatments: the facility failed to educate residents about changes to incontinence products, causing frustration and lack of understanding among residents.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to submit a Facility Reported Incident to the State Survey Agency within the required five-day deadline.
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 update residents' comprehensive care plans with new interventions and education related to incontinence care.
Report Facts
Residents sampled: 8
Residents affected: 2
Days late: 2
Inspection Report — Nov 19, 2025
Renewal
Date: Nov 19, 2025
Visit Reason
The survey was conducted to assess compliance with regulations related to resident care, wound management, and staff competencies.
Findings
The facility failed to identify, monitor, and treat a diabetic foot ulcer for one resident, resulting in hospitalization and amputation of the right great toe. Staff did not properly assess or document the wound, delayed care planning and treatment, and lacked competencies in wound care management.
Deficiencies (3)
F 0656 Administrator: the facility failed to ensure a resident's comprehensive care plan included timely and accurate information about a diabetic foot ulcer, missing preventative interventions and history of foot wounds.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to properly assess, document, treat, and monitor a diabetic ulcer, contributing to deterioration and amputation of the resident's right great toe.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: staff lacked skills to identify, assess, document, and monitor a diabetic ulcer, increasing risk of infection and resulting in hospitalization and amputation.
Report Facts
Sampled residents: 13
Skin checks reviewed: 7
Medication doses: 0
Days delay: 9
Pain scale: 10
Inspection Report — Mar 27, 2025
Renewal
Date: Mar 27, 2025
Visit Reason
Routine renewal inspection of Skyline Heights Nursing and Rehabilitation to assess compliance with health and safety regulations.
Findings
The facility failed to provide timely and necessary medications, including antibiotics and pain management, to newly admitted residents, resulting in negative health outcomes such as re-hospitalization, discharge against medical advice, and opioid withdrawal. Additionally, the facility did not ensure proper PICC line care and failed to provide meals according to the approved menu, affecting resident satisfaction and nutrition.
Deficiencies (5)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility neglected to ensure newly admitted residents #73, #81, and #109 received timely antibiotic and pain medications, resulting in resident #73 leaving against medical advice, resident #81 being re-hospitalized, and resident #109 returning to the emergency room for treatment.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: nursing staff failed to provide treatment according to standards for PICC lines for resident #109, including lack of documentation and failure to replace the PICC line after removal by the 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 physician-ordered medications at the prescribed dose and frequency for residents #73, #81, and #109, resulting in re-hospitalization, discharge against medical advice, and opioid withdrawal symptoms.
F 0760 Ensure that residents are free from significant medication errors: the facility failed to ensure necessary medications were available and administered timely for residents #73, #81, and #109, causing negative outcomes including untreated infections, pain, and withdrawal symptoms.
F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident: the facility failed to provide palatable food and did not follow the approved menu, substituting mashed potatoes for vegetables and serving disliked foods to residents #1, #37, #46, #69, and #92, negatively affecting resident satisfaction and nutrition.
Report Facts
Medication doses missed: 12
IV antibiotic doses missed: 2
Vancomycin doses missed: 1
Residents sampled: 24
Residents affected by dietary deficiencies: 5
Inspection Report — Jan 30, 2025
Renewal
Date: Jan 30, 2025
Visit Reason
The survey was conducted to assess compliance with licensing requirements and investigate complaints regarding medication management, care planning, wound care, staffing, and infection control.
Findings
The facility failed to ensure proper medication management, including self-administration and pharmacist review, timely and appropriate care planning, wound care, bathing, and personal care. Staffing shortages led to delayed call light responses and unmet resident needs. Infection control practices and immunization tracking were inadequate, and therapeutic diets were not consistently followed.
Deficiencies (16)
F0554 Allow residents to self-administer drugs if determined clinically appropriate: the facility failed to ensure medications and narcotics were properly supervised during medication administration for a resident who self-administered medications.
F0655 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 a baseline care plan addressing respiratory support and rehabilitation therapy services for a newly admitted resident.
F0657 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 follow a resident's care plan for pressure ulcer prevention and failed to update the care plan for a resident requiring enhanced barrier precautions.
F0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide showers and repositioning for dependent residents, resulting in poor hygiene and skin breakdown.
F0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to ensure physician-ordered PICC line dressing changes were performed and documented.
F0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to ensure wound dressings were changed as ordered and failed to provide sufficient wound documentation for residents with pressure ulcers and wounds.
F0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility had insufficient nursing staff leading to unmet resident needs, delayed call light responses, and inadequate personal care.
F0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: the facility failed to ensure the pharmacist adequately addressed and documented monthly medication regimen reviews for residents receiving psychotropic medications.
F0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited: the facility failed to ensure gradual dose reductions were implemented or documented as clinically contraindicated for residents receiving psychotropic medications.
F0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: the facility failed to ensure medications were properly labeled and failed to properly dispose of expired medications and medical supplies, allowing expired and undated items to remain available for use.
F0791 Provide or obtain dental services for each resident: the facility failed to ensure three residents received dental services, resulting in embarrassment, discomfort, and giving up use of dentures.
F0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: the facility failed to ensure meals were served timely and at a palatable temperature, resulting in cold food and late delivery for residents receiving room trays.
F0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law: the facility failed to ensure physician-ordered therapeutic diets were followed, including renal and carbohydrate-controlled diets.
F0865 Have a plan that describes the process for conducting QAPI and QAA activities: the facility failed to utilize and maintain a QAPI system to identify and address performance improvement issues related to staffing, resident showers, and infection control, and failed to show how the QAPI committee was involved in addressing these issues.
F0880 Provide and implement an infection prevention and control program: the facility failed to ensure consistent enhanced barrier precautions were provided and failed to provide staff education on proper PPE use, increasing risk of infection transmission.
F0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: the facility failed to ensure resident immunizations were up to date with CDC recommendations.
Report Facts
Residents sampled: 40
Residents affected by bathing deficiencies: 3
Residents affected by dental deficiencies: 3
Residents affected by infection control deficiencies: 4
Residents affected by therapeutic diet deficiencies: 7
Residents affected by immunization deficiencies: 3
Staff CNAs scheduled: 2
Residents requiring mechanical lifts: 13
Residents requiring Hoyer lifts: 6
Days without wound dressing documentation: 25
Minutes call light unanswered: 29
Minutes call light unanswered: 105
Minutes call light unanswered: 105
Minutes call light unanswered: 60
Minutes call light unanswered: 19
Minutes call light unanswered: 15
Minutes call light unanswered: 15
Minutes call light unanswered: 20
Minutes call light unanswered: 10
Minutes call light unanswered: 20
Minutes call light unanswered: 5
Minutes call light unanswered: 18
Minutes call light unanswered: 10
Minutes call light unanswered: 30
Weight loss (%): 3.82
Medication psychotropic count: 4
Medication psychotropic count: 6
Medication psychotropic count: 3
Expired vacutainers: 52
Expired needles: 13
Expired COVID test kits: 7
Expired ostomy pouches: 10
Inspection Report — Nov 20, 2024
Renewal
Date: Nov 20, 2024
Visit Reason
The survey was a renewal inspection of Skyline Heights Nursing and Rehabilitation.
Findings
The facility failed to ensure timely transcription and initiation of physician medication orders for a resident returning from the hospital, resulting in a five-day delay in starting prescribed medications. Staff interviews and record reviews indicated systemic issues with order communication and processing.
Deficiencies (1)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to ensure nursing staff transcribed and initiated physician orders of prescribed medications timely, causing a five-day delay in starting medications for a resident returning from the hospital.
Report Facts
Days delay: 5
Medication administration days: 5
Medication administration days: 7
Inspection Report — Oct 3, 2024
Renewal
Date: Oct 3, 2024
Visit Reason
The survey was a renewal inspection of Skyline Heights Nursing and Rehabilitation.
Findings
The facility failed to provide necessary bathing and grooming assistance to dependent residents, resulting in residents feeling unkempt. Additionally, the facility failed to provide adequate supervision for a resident with dementia left unattended at a medical appointment and failed to have appropriate catheter supplies available, causing an allergic reaction and delayed medical notification.
Deficiencies (3)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide bathing and grooming assistance at least every seven days for dependent residents, causing residents to feel unkempt.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide supervision for a resident with dementia who was left unattended at a medical appointment, placing the resident at risk of elopement.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: the facility failed to have necessary catheter supplies available, causing an allergic reaction in a resident and failed to notify the medical provider in a timely manner.
Report Facts
Days without shower: 47
Days without shower: 44
Days without shower: 34
Days without shower: 29
Days without shower: 25
Residents per staff: 15
Assessment Reference Date: Aug 15, 2024
Assessment Reference Date: Aug 21, 2024
Assessment Reference Date: Jul 7, 2024
Assessment Reference Date: Jul 24, 2024
Assessment Reference Date: Oct 30, 2023
Inspection Report — May 20, 2024
Renewal
Date: May 20, 2024
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements.
Findings
The facility failed to provide required assistance with meals to a resident with weight loss and did not ensure proper hand hygiene practices during meal service, posing potential risks to residents.
Deficiencies (2)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide meal assistance to a resident with weight loss who required cueing and supervision, resulting in the resident not eating her noon meal.
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 ensure food was served in a sanitary manner and staff did not perform hand hygiene between serving meals to different residents.
Report Facts
Residents affected: 8
Residents affected: 1
Inspection Report — Jan 18, 2024
Complaint Investigation
Date: Jan 18, 2024
Visit Reason
The survey was conducted following complaints regarding resident grievances, resident-to-resident abuse, failure to develop baseline care plans, inadequate catheter care, and food service issues.
Complaint Details
The complaint investigation revealed failures in grievance documentation and policy, resident protection from abuse, reporting of verbal abuse incidents, baseline care planning, catheter care, and food service quality and safety.
Findings
The facility failed to maintain grievance documentation and ensure grievance policy compliance. It did not protect residents from abuse or report verbal abuse incidents properly. The facility also failed to develop baseline care plans within 48 hours for a resident, provide appropriate catheter care resulting in a urinary tract infection, and serve food at safe and appetizing temperatures.
Deficiencies (6)
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 maintain evidence of resolution of a resident's grievance and the grievance policy lacked the name and contact information for the grievance official.
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 residents from actual or potential physical and psychosocial harm due to roommate aggression and did not adequately address residents displaying abusive behaviors.
F 0610 Respond appropriately to all alleged violations: the facility failed to report findings of an allegation of resident-to-resident verbal abuse to the State Survey Agency and did not provide investigation documentation.
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 a baseline care plan within 48 hours that included care for an indwelling urinary catheter and a newly established colostomy for a resident.
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 obtain a valid indication for catheter use and did not provide or document ongoing catheter care, resulting in a urinary tract infection for a resident.
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: the facility failed to serve food that was palatable and at a safe temperature, with multiple residents reporting cold, undercooked, or unappetizing food, and staff observed reheating cold meals prior to serving.
Report Facts
Sampled residents: 46
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 5
Food temperature (°F): 138
Food temperature (°F): 94
Food temperature (°F): 117
Food temperature (°F): 80
Inspection Report — Jan 18, 2024
Complaint Investigation
Date: Jan 18, 2024
Visit Reason
Complaint investigation of resident care, abuse, medication management, transfers, assessments, and food service.
Complaint Details
The complaint investigation identified multiple deficiencies including failure to maintain grievance documentation, protect residents from abuse, report verbal abuse incidents, provide timely transfer notifications, complete resident assessments, update PASARR screenings, develop comprehensive care plans, monitor wounds, provide appropriate catheter care, administer medications as ordered, maintain medication security, serve palatable and safe food, and maintain sanitary food service areas.
Findings
The facility failed to maintain grievance documentation, protect residents from abuse, report verbal abuse incidents, provide timely transfer notifications, complete resident assessments, update PASARR screenings, develop comprehensive care plans, monitor wounds, provide appropriate catheter care, administer medications as ordered, maintain medication security, serve palatable and safe food, and maintain sanitary food service areas.
Deficiencies (16)
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 maintain evidence of resolution of a resident's grievance and the grievance policy lacked the name and contact information for the grievance official.
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 residents from physical and psychosocial harm related to roommate aggression and failed to adequately address verbal and physical abuse behaviors among residents.
F 0610 Respond appropriately to all alleged violations: the facility failed to report findings of an allegation of resident-to-resident verbal abuse to the State Survey Agency.
F 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged: the facility failed to provide pertinent medical information to the receiving facility at the time of transfer for one resident.
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 Notice of Transfer/Discharge to three residents or their representatives.
F 0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months: the facility failed to complete the Annual MDS assessment for one resident, which was 60 days overdue.
F 0638 Assure that each resident’s assessment is updated at least once every 3 months: the facility failed to complete Quarterly MDS assessments for two residents, which were 49 and 54 days overdue.
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: the facility failed to ensure an updated PASARR was submitted for a resident with serious mental illness and escalating dangerous behaviors.
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 comprehensive, person-centered care plans for two residents, including care related to physical functioning deficits and colostomy care.
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 update a resident's care plan to address worsening vision and related needs.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to monitor and consistently document a resident's wound status and dressing changes.
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 obtain a valid indication for an indwelling urinary catheter and failed to provide routine catheter care, resulting in a urinary tract infection.
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 physician-ordered medications at the prescribed dose and frequency for three residents and failed to ensure availability of prescribed medications, resulting in borrowing medication from another resident.
F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: the facility failed to ensure all medication carts were securely locked when unattended.
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: the facility failed to serve food that was palatable and at a safe and appetizing temperature, with multiple residents reporting cold, undercooked, or unappetizing food and staff observed reheating meals due to cold temperatures.
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 label and date food items and maintain sanitary conditions in the kitchen and food storage areas, including dirty equipment, buildup of grease and debris, and unlabeled food containers.
Inspection Report — Oct 12, 2023
Renewal
Date: Oct 12, 2023
Visit Reason
The survey was a renewal inspection of Skyline Heights Nursing and Rehabilitation.
Findings
The facility failed to ensure staff provided adequate personal hygiene and therapeutic communication, timely care assistance, proper pressure ulcer treatment, and appropriate gluten-free diets as ordered. Several staff performance issues were substantiated and addressed, but quality assurance improvements were lacking.
Deficiencies (3)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: staff failed to provide adequate hygiene and therapeutic communication to residents, causing feelings of intimidation and reluctance to ask for help, and delayed assistance for dependent residents.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to follow prescribed wound dressing changes for a resident, resulting in a six-day delay in treatment.
F 0800 Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs: the dietary department failed to provide a gluten-free diet as ordered for a resident with celiac disease, resulting in multiple meals containing gluten being served.
Report Facts
Residents sampled: 8
Residents sampled: 1
Residents sampled: 3
Delay in dressing changes (days): 6
Duration left on toilet (minutes): 45
Inspection Report — Mar 21, 2023
Date: Mar 21, 2023
Visit Reason
Respond appropriately to all alleged violations.
Findings
The report states that deficiencies were identified but the specific deficiency text is not available.
Inspection Report — Feb 2, 2023
Renewal
Date: Feb 2, 2023
Visit Reason
The survey was conducted to assess compliance with state and federal regulations related to resident care, safety, staffing, and infection control.
Findings
The facility failed to ensure residents were free from abuse, provide adequate bathing and feeding assistance, prevent falls and injuries, maintain proper medication administration, provide therapeutic diets as ordered, maintain adequate staffing levels, and enforce infection control practices including mask wearing during a COVID-19 outbreak.
Deficiencies (9)
F 0600 Protect each resident from all types of abuse: the facility failed to prevent verbal and emotional abuse by staff toward residents, substantiated by resident and staff interviews.
F 0610 Respond appropriately to all alleged violations: the facility failed to investigate neglect and misappropriation allegations timely and thoroughly, and failed to provide staff education on abuse and neglect.
F 0677 Provide care and assistance to perform activities of daily living: the facility failed to provide adequate bathing assistance to six residents and feeding assistance to one resident, resulting in residents not receiving showers as often as ordered.
F 0684 Provide appropriate treatment and care according to orders: the facility failed to change a wound vacuum dressing as ordered for a diabetic ulcer, causing increased skin breakdown.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision: the facility failed to prevent falls resulting in significant injuries including fractures, skin tears, and burns for multiple residents.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to provide adequate staffing, resulting in long call light response times, delayed care, decreased bathing, and resident complaints of neglect.
F 0760 Ensure that residents are free from significant medication errors: the facility administered an incorrect dosage of aripiprazole for three days to one resident, resulting in seizure-like activity.
F 0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian: the facility failed to provide food with the correct texture as ordered for one resident, placing the resident at risk for choking and inadequate intake.
F 0880 Provide and implement an infection prevention and control program: the facility failed to maintain proper infection control practices by allowing nursing staff to not wear masks during a COVID-19 outbreak, increasing risk of infection spread.
Report Facts
Showers received: 8
Showers received: 2
Showers refused: 2
Showers received: 2
Late medication doses: 24
Late medication doses: 36
Call light wait times >15 minutes: 6
Call light wait times >15 minutes: 28
Call light wait times >15 minutes: 6
Call light wait times >15 minutes: 16
Call light wait times >15 minutes: 7
Call light wait times >15 minutes: 12
Call light wait times >15 minutes: 14
Call light wait times >15 minutes: 9
Call light wait times >15 minutes: 2
Showers received: 1
Falls: 5
Days between showers: 13
Inspection Report — Feb 2, 2023
Renewal
Date: Feb 2, 2023
Visit Reason
Routine renewal inspection of Skyline Heights Nursing and Rehabilitation in Billings, MT.
Findings
The facility had multiple deficiencies including failure to provide adequate nursing staff leading to delayed care, failure to maintain sanitary kitchen conditions, failure to provide appropriate therapeutic diets, failure to prevent falls and injuries, failure to maintain proper infection control practices, and failure to provide adequate care plans and services for residents' medical and psychosocial needs.
Deficiencies (22)
F 0554 Allow residents to self-administer drugs if determined clinically appropriate: the facility failed to assess one resident for self-administration of medication and lacked documentation of practitioner orders for self-administration.
F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: the facility failed to notify a physician of severe weight loss for one resident.
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 ensure residents were free from abuse for two residents, substantiating verbal abuse allegations.
F 0610 Respond appropriately to all alleged violations: the facility failed to investigate neglect and misappropriation allegations timely and failed to provide staff education addressing recurring abuse and neglect allegations.
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 implement a baseline care plan including minimum healthcare information for one 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 accurate person-centered care plans for five residents, including lack of oxygen care, hearing loss interventions, and assistance with ADLs.
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 and update a resident's care plan to meet current catheter care and oxygen needs.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide adequate assistance with bathing for six residents and assistance with eating for one resident.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to change a wound vacuum dressing on a diabetic ulcer, causing increased skin breakdown.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to prevent development of a Stage 4 pressure ulcer caused by improper use of a lift sling.
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason: the facility failed to provide necessary restorative or range of motion services for two 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 prevent falls with significant injuries for multiple residents and failed to protect a resident from burns.
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 assess a resident's indwelling catheter for removal and failed to provide a bladder retraining program for another resident.
F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to provide ongoing monitoring and interventions to prevent severe weight loss in one resident.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to provide adequate nursing staff resulting in delayed responses to call lights, decreased bathing, late medication administration, and resident distress.
F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life: the facility failed to provide assistance in obtaining mental health services for a resident experiencing anxiety and emotional distress.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: the facility failed to ensure medication irregularities identified by the pharmacist were addressed by the provider.
F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service: the facility failed to maintain a sanitary kitchen and had inadequate dietary staffing.
F 0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law: the facility failed to provide food with the correct diet texture as ordered, placing a resident at risk for choking and inadequate intake.
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 ensure physician progress notes were received and scanned timely into the resident medical records.
F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse: the facility failed to maintain an arbitration agreement that explicitly granted a resident or representative the right to rescind the agreement within 30 days.
F 0880 Provide and implement an infection prevention and control program: the facility failed to maintain proper infection control practices by nursing staff failing to wear masks while caring for a resident and in care areas during a COVID-19 outbreak.
Report Facts
Weight loss (%): 22.67
Resident showers received: 8
Resident showers received: 2
Resident showers received: 2
Resident showers received: 2
Medication late administration count: 24
Medication late administration count: 36
Freezer temperature (°F): 40
Freezer temperature (°F): 41
Freezer temperature (°F): 26
Resident call light wait times (minutes): 88
Resident call light wait times (minutes): 85
Resident call light wait times (minutes): 78
Resident call light wait times (minutes): 70
Resident call light wait times (minutes): 69
Resident call light wait times (minutes): 49
Resident call light wait times (minutes): 44
Resident call light wait times (minutes): 38
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