Billings Rehab: Care Plan Deficiencies - MT
Federal inspectors found resident #4 sitting by the nursing station on November 3rd, his left stump bound to the wheelchair's footrest with a tan compression wrap. When asked if he could remove the wrap, the resident shook his head no. He was observed pulling at the restraint but unable to free himself.
Staff member G told inspectors the next morning that 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 [NAME] brace." She said staff had been using the compression wrap "for quite a while" but admitted it wasn't included on his care plan.
The staff member wasn't aware if anyone was documenting the resident's brace refusals.
Staff member L confirmed she had never documented or reported when resident #4 refused his prescribed brace. She said she hadn't checked his care plan regarding the compression wrap use and was simply told by other staff "it was ok to use."
Nobody had updated the resident's care plan.
Resident #4's comprehensive care plan from July 29th listed his prescribed brace under interventions, with instructions to "monitor under brace." The plan identified him as having potential for altered skin integrity due to limited mobility, diabetes, and poor wound healing, but included no specific goals for addressing these risks.
By September 21st, when the facility completed its quarterly assessment, the care plan remained unchanged. It contained no mention of the resident's brace refusals, no authorization for the compression wrap restraint, and no assessment of risks related to tying his stump to the wheelchair.
The facility's own restraint policy, dated April 11th, 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."
The comprehensive care plan policy mandates that plans "will be reviewed and revised by the interdisciplinary team." Neither happened for resident #4.
Federal regulations require facilities to develop complete care plans within seven days of comprehensive assessments and to revise them based on residents' changing conditions and preferences. The facility failed to document the resident's consistent refusal of his prescribed brace or address the unauthorized restraint use.
The compression wrap functioned as a physical restraint, preventing the resident from moving freely or repositioning his stump. Staff implemented this restraint without proper assessment, documentation, or care plan authorization, violating federal requirements for restraint-free environments.
Inspectors found the facility had no system for tracking or reporting residents' refusals of prescribed medical devices. Staff operated on informal instructions from colleagues rather than documented care protocols.
The resident's situation illustrates how facilities can circumvent restraint protections through improvised solutions that staff view as helpful but regulators classify as unauthorized restraints. The compression wrap kept his stump positioned on the leg rest, but also prevented him from moving independently.
For months, resident #4 remained tied to his wheelchair during daily activities, unable to reposition himself or remove the restraint. Staff continued the practice without medical authorization, risk assessment, or documentation of the resident's preferences regarding his prescribed brace.
The facility's interdisciplinary team never evaluated alternatives to either the refused brace or the improvised restraint. No goals were established for addressing his skin integrity risks or mobility limitations.
Resident #4's care plan remained frozen in July while staff improvised restraint solutions through September, leaving him bound to his wheelchair without proper oversight or documentation of his actual care needs.
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 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.