Billings Rehab: No Care Plan, No Correction - MT
Resident #4, who had a left below-knee amputation, was discovered sitting by the nursing station on November 3rd with his stump bound to the wheelchair's left footrest using a tan compression wrap. When an inspector asked if he could remove the wrap, the resident shook his head no. He was observed pulling at the binding but couldn't free himself.
The facility had been using this method "for quite a while," according to staff member G, who explained the next morning that they tied the resident's stump down "because his stump will not stay on the leg rest, and he will not wear his brace."
But staff weren't documenting the resident's refusals of his prescribed brace. Staff member G admitted she wasn't aware if anyone was recording these refusals. More critically, she confirmed the compression wrap restraint wasn't included on the resident's care plan at all.
Staff member L, interviewed the same day, revealed the depth of the documentation failures. She had never documented or reported when resident #4 refused his brace. She had never checked his care plan regarding the compression wrap use. Other staff simply told her "it was ok to use."
The resident's comprehensive care plan from July 29th listed his prescribed brace and monitoring requirements under skin integrity concerns. It identified risks from "limited mobility, diabetes, poor wound healing" but included no goals for addressing potential skin problems.
By September 21st, when the facility completed its quarterly care plan review, nothing had changed. The updated plan contained no mention of the resident's brace refusals. No documentation of the compression wrap restraint. No assessment of risks from tying his stump to the wheelchair.
The facility's own policies required care plan updates when restraints were implemented. Their "Restraint Free Environment" policy, dated April 11th, specifically mandated that "the care plan be updated accordingly to include development and implementation of interventions, to address any risks related to the use of the restraint."
Their comprehensive care planning policy required interdisciplinary team review and revision of care plans. Neither happened for resident #4.
The compression wrap created a physical restraint the resident couldn't remove himself. Federal regulations require facilities to assess restraint risks, document resident preferences, and update care plans when restraints are used. Billings Rehabilitation did none of this.
The facility failed to recognize that binding an amputee's stump to prevent movement constituted restraint use requiring proper assessment and documentation. Staff implemented the intervention based on informal communication rather than clinical assessment or care plan direction.
The resident's diabetes and poor wound healing made proper stump positioning critical for preventing skin breakdown. Yet staff chose a restraint method without evaluating alternatives or documenting the clinical rationale for overriding the resident's preference to refuse his brace.
The inspection found the facility used the compression wrap restraint for months without updating the resident's care plan during the quarterly review period between July 29th and September 21st. Staff continued the practice based on verbal instructions rather than documented clinical decisions.
Resident #4's situation illustrates how informal care decisions can become routine restraint use without proper oversight. His repeated brace refusals went undocumented. His inability to remove the compression wrap went unassessed. His care plan remained unchanged despite fundamental changes in his treatment approach.
The facility's interdisciplinary team never formally reviewed the restraint use or developed alternatives that might respect the resident's preferences while addressing his medical needs. The compression wrap became the default solution to a complex problem requiring individualized assessment and planning.
Federal inspectors cited the facility for failing to revise care plans based on resident needs and preferences, specifically regarding restraint assessment findings and risks related to the resident's brace refusals.
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 an inspector asked if he could remove the wrap, 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.