Skyline Heights: Care Plan Failures Harm Resident - MT
Federal inspectors who visited the facility on November 19, 2025, found that the failure caused actual harm to the resident, identified in inspection records only as Resident 1.
The care plan is the document that tells every nurse and aide who walks into a resident's room what that person needs and how to provide it. Without it, the knowledge that one staff member carries in her head doesn't reach the next shift, or the new hire, or the aide covering on a weekend. For Resident 1, inspectors found that his care plan contained no mention of his foot history and no preventative interventions to guide the people responsible for his daily care.
The interventions that should have been there were not abstract. Staff member E, interviewed by inspectors, described exactly what should have been documented: pressure-relieving mattresses, offloading boots for the feet, any other special needs tied to a resident's condition. She told inspectors that any preventative measure for a resident should be care planned. She said she would add changes in a resident's condition to the care plan herself.
Staff member D, interviewed separately on November 5, 2025, said much the same thing. She told inspectors she would notify a nurse if she identified a new skin issue, and that the nurse would then care plan for the concern. She said staff read care plans and would flag anything missing.
Two staff members, in two separate interviews, described a system that should have worked. For Resident 1, it didn't.
The gap between what staff described and what the care plan actually contained is where the harm lived. Offloading boots exist to take pressure off vulnerable tissue in the feet, reducing the risk of wounds that, in residents with circulation problems or other underlying conditions, can become serious fast. A pressure-relieving mattress does the same work while a resident sleeps. These are not complicated interventions. They are standard tools. But a staff member who doesn't know a resident needs them won't use them, and a care plan that doesn't mention a foot history gives no reason to look closer.
Inspectors classified the deficiency under F0656, which covers the development and implementation of individualized care plans. The level of harm was listed as actual harm, meaning Resident 1's condition was affected, not merely put at risk.
The inspection was a complaint survey, meaning someone, whether a resident, a family member, or a staff member, had raised a concern that prompted regulators to come. The facility serves residents at 1807 24th Street West in Billings.
What the inspection record does not say is how long Resident 1's care plan went without the missing information, or what the consequences looked like for him specifically. The record describes the structure of the failure clearly: the history wasn't documented, the interventions weren't ordered, and staff had no written guidance to follow. It does not describe what his feet looked like by the time inspectors arrived.
That detail is absent from the public record. The harm finding is not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Heights Nursing and Rehabilitation from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
SKYLINE HEIGHTS NURSING AND REHABILITATION in BILLINGS, MT was cited for violations during a health inspection on November 19, 2025.
The care plan is the document that tells every nurse and aide who walks into a resident's room what that person needs and how to provide it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.