Skyline Heights: Staff Competency Harm Found - MT
Federal inspectors cited Skyline Heights following a complaint inspection completed November 19, 2025, finding that the facility caused actual harm to at least one resident by failing to develop a care plan that reflected his foot history or included any preventative measures to guide the staff caring for him.
The resident is identified in inspection records only as Resident 1. His care plan contained no mention of his history of issues with his feet. It listed no interventions. Staff assigned to his care had no written guidance directing them to take steps that might have prevented further damage.
Two staff members interviewed during the inspection described, in their own words, exactly what should have happened.
Staff member E told inspectors she would add any changes in a resident's condition to that resident's care plan, including interventions such as pressure-relieving mattresses, offloading boots for the feet, and other special needs. She said preventative measures for a resident should be care planned. That is the standard she described. It was not applied to Resident 1.
Staff member D, interviewed on November 5 at 1:42 p.m., said 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 the care plans and would alert a nurse if something was missing.
What was missing from Resident 1's care plan was his entire foot history, and every intervention that history should have prompted.
Offloading boots are used to relieve pressure on vulnerable areas of the foot, particularly in residents whose circulation or skin integrity is already compromised. Pressure-relieving mattresses serve a similar purpose for residents at risk of skin breakdown. These are not complicated interventions. They are standard tools. But staff can only use them consistently if the care plan tells them to. Resident 1's care plan gave them nothing.
The deficiency was cited at F0656, the federal tag covering individualized care plans, and inspectors classified the level of harm as actual harm. That classification means the failure did not represent a theoretical risk. Something happened to Resident 1 as a result of the gap in his care plan.
The inspection report does not describe what that harm looked like, whether his feet worsened, whether a wound developed, or what treatment he ultimately required. The record states only that he was affected, that the harm was real, and that the care plan offered no guidance to prevent it.
Skyline Heights sits at 1807 24th Street West in Billings. The inspection was conducted in response to a complaint, not as part of a routine survey cycle, meaning someone had already raised a concern about care at the facility before inspectors arrived.
The two staff members who spoke with inspectors did not dispute what the standard should be. They described it accurately and in detail. The care plan for Resident 1 simply did not reflect it. His foot history was not there. The interventions were not there. The guidance staff said they would follow was never written down for the person who needed it.
What Resident 1's feet looked like by the time inspectors arrived, the report does not say.
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 resident is identified in inspection records only as Resident 1.
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.