Billings Rehab: Care Plan Failures Found - MT
Federal inspectors found resident #4 sitting by the nursing station on November 3rd, his left residual limb bound to the wheelchair's footrest with a tan compression wrap. When asked if he could remove it, the resident shook his head no.
Staff member G told inspectors the next morning 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 [prescribed] brace." She admitted staff had been using the compression wrap "for quite a while" but said it wasn't included in his care plan.
The resident had consistently refused his prescribed prosthetic brace. Rather than document these refusals or assess the restraint risks, staff improvised their own solution.
Staff member L revealed she had never documented or reported when the resident refused his brace. She said she hadn't checked his care plan regarding the compression wrap and "was told by other staff it was ok to use."
The resident's comprehensive care plan from July 29th included interventions for his prescribed brace and monitoring underneath it. But when inspectors reviewed his updated care plan from September 21st, they found no mention of his brace refusals or the compression wrap restraint.
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."
Federal regulations require care plans to be revised within seven days when circumstances change. The facility failed to update the resident's plan despite implementing what amounted to a physical restraint system over a period spanning at least two quarterly assessment periods.
The resident's care plan listed a focus area for "potential for altered skin integrity" related to limited mobility and diabetes, but included no goals for managing this risk. The plan mentioned monitoring under his prescribed brace but provided no guidance for staff when he refused to wear it.
The improvised restraint system created exactly the kind of unmonitored risk the care planning process is designed to prevent. By tying the resident's residual limb to his wheelchair, staff potentially compromised circulation and skin integrity at the amputation site.
Staff member G acknowledged she wasn't sure if anyone was documenting the resident's brace refusals, suggesting a broader breakdown in communication between nursing staff and the care planning team.
The facility's comprehensive care plan policy requires interdisciplinary team review and revision, but the team apparently never addressed how to manage the resident's consistent refusal of his prescribed medical device.
Instead of following established protocols for restraint assessment and documentation, staff created an unauthorized workaround that left the resident unable to move his residual limb freely.
The inspection found the resident pulling at the compression wrap but unable to remove it, illustrating how the makeshift restraint system restricted his movement and autonomy.
Federal inspectors classified this as a care planning violation affecting few residents with minimal harm. But the case reveals how informal staff decisions can circumvent patient safety protections when proper procedures aren't followed.
The resident's refusal to wear his prescribed brace should have triggered a care plan conference to explore alternatives and assess risks. Instead, staff implemented an undocumented restraint that potentially created new medical complications for a vulnerable amputee.
The facility's failure to document the resident's preferences or the restraint's risks left him tied to his wheelchair without the safety monitoring that federal regulations require for any physical restraint system.
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 it, 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.