Billings Rehab: Physical Restraint Violations - MT
Federal inspectors found the 74-year-old amputee pulling at the tan-colored wrap binding his left leg stump to the wheelchair's footrest during their November visit to Billings Rehabilitation and Nursing LLC. When asked if he could remove the compression wrap himself, the resident shook his head no.
The facility had been using the restraint "for quite a while" without documenting it in the resident's care plan or recording his repeated refusals to wear his prescribed prosthetic brace, according to inspection records.
Staff member G told inspectors they tied the resident's stump to the leg rest because "his stump will not stay on the leg rest, and he will not wear his [prosthetic] brace." She admitted the compression wrap wasn't included in his care plan and said she wasn't aware if staff were documenting his brace refusals.
Another staff member, identified as L, said she had never documented or reported when the resident refused his brace. She hadn't checked his care plan regarding the compression wrap and was simply told by other staff "it was ok to use."
The resident's comprehensive care plan from July 29 listed his prosthetic brace as an intervention for potential skin problems related to his limited mobility and diabetes. But it included no goals for addressing skin integrity issues.
By September 21, when the facility updated his quarterly assessment, the care plan still contained no mention of the compression wrap restraint or the resident's brace refusals. Federal regulations require facilities to revise care plans when residents refuse treatments or when new interventions like restraints are implemented.
The facility's own restraint policy, dated April 11, requires care plans to be "updated accordingly to include development and implementation of interventions, to address any risks related to the use of the restraint."
Inspectors observed the resident sitting by the nursing station at 4:04 p.m. on November 3, his left below-the-knee amputation secured to the wheelchair's left footrest. The compression wrap prevented him from repositioning his stump or removing the restraint independently.
The case illustrates how nursing homes sometimes implement physical restraints without proper authorization or documentation. Federal guidelines classify any device that restricts a resident's movement and cannot be easily removed as a restraint, regardless of the medical justification.
The facility failed to follow its comprehensive care plan policy requiring interdisciplinary team review and revision of resident plans. Staff continued using the compression wrap despite the resident's clear inability to consent to or control the restraint.
The resident's refusal to wear his prescribed brace should have triggered a care plan conference to explore alternatives or address underlying issues causing the refusal. Instead, staff improvised a restraint solution without clinical oversight or documentation.
Medical professionals typically prescribe prosthetic braces for amputees to maintain proper stump shape, prevent contractures, and prepare the limb for prosthetic fitting. When patients refuse these devices, care teams must evaluate whether the refusal stems from discomfort, poor fit, psychological factors, or other treatable causes.
The compression wrap restraint posed additional risks by limiting the resident's ability to reposition his stump, potentially affecting circulation and skin integrity. The resident's diabetes already put him at elevated risk for poor wound healing and skin breakdown.
Inspectors found the violation caused minimal harm but noted the potential for actual harm given the restraint's prolonged use without proper monitoring or care plan authorization.
The facility's failure to document the resident's brace refusals also prevented proper assessment of whether his resistance indicated pain, psychological distress, or equipment problems that could be addressed through alternative approaches.
Federal regulations require nursing homes to use restraints only as a last resort and with comprehensive documentation of risks, benefits, and alternatives considered. The compression wrap restraint continued for months without meeting these basic requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Billings Rehabilitation and Nursing LLC from 2025-11-20 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: June 20, 2026 · Our methodology
BILLINGS REHABILITATION AND NURSING LLC in BILLINGS, MT was cited for violations during a health inspection on November 20, 2025.
When asked if he could remove the compression wrap himself, the resident shook his head no.
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.