Bella Terra Of Billings

F-F880 - Infection Control, for findings related to the concern areas identified. Findings include:

A request was made for the facility's QAPI plan, as stated as item number 31 on the entrance conference worksheet, on 1/27/25 at 1:15 p.m. The QAPI Plan was to be provided by the facility within four hours of entrance, but the facility document for the QAPI plan only showed QAA committee members. A request was made for the facility's QAPI plan again, on 1/27/25, at 5:00 p.m. The facility provided two pages, both undated, on 1/29/25. One page showed one PowerPoint slide of a QAPI Plan - Quarterly with page number 45 on the bottom corner, and the other page showed a slide of a QAPI Plan - Yearly Goals with page number 46 on the bottom corner. The QAPI plans provided did not have a documented process of how the facility was maintaining identified concerns at acceptable levels of performance and time frames of tracking the concerns for continual improvement. The plans did not describe how the facility conducts required QAPI and or QAA committee functions for the identification and correction of quality of care and quality of life deficient practices or concerns identified.

During an interview on 1/29/25 at 8:15 a.m., staff member A stated the facility did not have requested staffing related documents because the former director of nursing had them, and did not provide them to the facility when her employment ended. Staff member A stated there was frequent turnover in nursing management positions, which affected the ability of the facility to keep up with regular staffing needs and training. Staff member A stated, We are working on getting our sixth DON hired in the one year I've been here, so we haven't had consistent management of nurse staffing issues.

During an interview on 1/30/25 at 9:32 a.m., staff member A stated he was working in his management role, along with filling in for three other administrative level positions, due to staff vacancies. Staff member A stated he had filled in as the facility infection prevention staff member, specifically when there was no coverage provided, due to turnover of ADONs and DONs. Staff member A stated infection control issues were not up to date due to the new ADON just getting started in her role. Staff member A stated the facility QAPI committee worked on a skin action plan as part of a recent POC related to showers, and they started it, some of it fell apart, and they restarted it due to staff turnover.

Review of a facility document titled, QAPI Plan - Quarterly, not dated, showed, .Employee retention - orientation to be fully implemented by the end of January, Retention team created and implemented by end of March . Reduce Re-hospitalization s - Admissions director to review all referrals to ensure level of care is appropriate for facility (on going). On going with pharmacy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 275020 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275020 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Heights Nursing and Rehabilitation 1807 24th St W Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Review of a facility document titled, QAPI Plan - Yearly Goals, not dated, showed, Employee retention- Reduce employee turnover by 10%. Reduce agency usage by 35% . Ensure all residents receive/offered Level of Harm - Minimal harm or showers in a timely manner- Continue to work POC until reasonable compliance is reached. Then continue potential for actual harm to monitor it weekly. Improve overall nursing documentation- Nursing charting will improve to 95% completion by the end of the year. Residents Affected - Many

Review of a facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, showed:

The QAPI Committee oversees implementation of our QAPI Plan, which is the written component describing

the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI Committee.

The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of

this process include:

a. Tracking and measuring performance;

b. Establishing goals and thresholds for performance measurement;

c. Identifying and prioritizing quality deficiencies;

d. Systematically analyzing underlying causes of systemic quality deficiencies;

e. Developing and implementing corrective action or performance improvement activities; and

f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 275020 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275020 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Heights Nursing and Rehabilitation 1807 24th St W Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 14005 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure consistent enhanced barrier Residents Affected - Some precautions were provided for 4 (#s 5, 6, 63, and 346) of 40 sampled residents; and the facility failed to provide staff education on proper donning and doffing of PPE, and the expectations of enhanced barrier precautions, which had an increased risk of a negative outcome to the facility population due to those staff working with or around other residents not on precautions. Findings include:

1. Review of resident #63's Weekly Head to Toe Skin Check form, dated 1/22/25, showed the resident had a below the knee amputation on the left leg. The assessment identified the incision area had three open areas to the mid incision, and one small open area, to the medial aspect of the incision line.

During an interview on 1/27/25 at 4:45 p.m., resident #63 said when the nurses change the dressing on her leg, they only wear gloves. Resident #63 said the facility is not in Covid outbreak, so the nurses don't have to wear gowns.

During an observation on 1/28/25 at 9:41 a.m., staff member H was observed doing wound care on resident #63's wound. The nurse donned gloves, removed the old dressing, and sprayed the wound with wound cleanser. Staff member H then packed the open areas with calcium alginate into the four open holes. Staff member H removed his gloves and without sanitizing his hands, and left the room to retrieve tape. Staff member H immediately came back into the room. Without donning gloves, staff member H placed an abdominal dressing pad on the wound and taped the dressing in place with his bare hands.

During an interview on 1/28/25 at 9:52 a.m., staff member H said he should have worn a gown and gloves for

the whole treatment for resident #63.

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2. During an observation and interview on 1/28/25 at 7:46 a.m., Resident #346 had dressings on both legs from a recent double amputation. Resident #346 pointed at PPE in a hanging storage rack on his bathroom door and stated, The staff just put that in here. It's never been in here before. They don't even use the gowns and stuff in there. I don't know why it is in here.

During an interview on 1/28/25 at 1:43 p.m., NF4 stated, They (staff) have never used gowns or gloves when getting him (resident #346) up. I think that is something new, but they still aren't using them (gowns and gloves).

During an interview on 1/28/25 at 3:00 p.m., NF5 stated, I have never seen them use PPE when getting him (resident #346) up. They do use gloves when doing personal care, but not a gown.

During an interview on 1/29/25 at 10:08 a.m., staff member I stated, We would use gowns and gloves for direct care if the resident has an EBP sign on their door. Direct cares would be like toileting and catheter care. Transfers would not be considered direct care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 275020 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275020 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Heights Nursing and Rehabilitation 1807 24th St W Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 1/29/25 at 7:46 p.m., staff member J stated, EBP signs are on the doors of those residents that require the use of PPE while performing cares. I can't say staff follow them (the signs) though. Level of Harm - Minimal harm or potential for actual harm 50245

Residents Affected - Some During an interview on 1/29/25 at 4:30 p.m., staff member K stated, Honestly, I'm not sure, when referring to when enhanced barrier precautions were needed. Staff member K stated the facility staff just had education

on this topic today. Staff member K stated they were not required to physically don and doff any PPE.

During an interview on 1/30/25 at 8:03 a.m., staff member B and staff member N stated education was needed for all of their staff concerning enhanced barrier precautions.

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3. During an interview on 1/28/25 at 8:28 a.m., resident #6 stated he has dressing changes on a wound done by staff, and he goes out for appointments for wound care. Resident #6 stated staff wear gloves and sanitize hands but don't wear a gown when doing catheter care.

During an interview on 1/28/25 at 9:40 a.m., resident #5 stated staff sometimes wear gowns when they perform catheter care, they usually just wear gloves. Resident #5 stated, I've had the catheter for quite a while, they use supplies, they're hanging from the bathroom door.

Review of the facility Enhanced Barrier Precaution Policy, written by Med-Pass and dated August 2022, showed activities requiring the use of gown and gloves included wound care for any skin opening requiring a dressing.

Review of a facility policy titled, Enhanced Barrier Precautions, dated August 2022, showed:

1. Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms . to residents .

2. EBPs employ targeted gown and glove use during high contact resident care activities .

5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices .

6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk .

9. Staff are trained prior to caring for residents on EBPs .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 275020 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275020 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Heights Nursing and Rehabilitation 1807 24th St W Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 50245 potential for actual harm Based on interview and record review, the facility failed to ensure resident immunizations were up to date Residents Affected - Few with the CDC recommendations for 3 (#s 10, 32, and 336) of 40 sampled residents. Findings include:

Review of resident #10's EHR showed two pneumococcal vaccines were given:

a. Pneumococcal Polysaccharide Vaccine (PPSV23) on 1/2/2017, and Pneumococcal Conjugate Vaccine (PCV13) on 7/10/2016.

According to the CDC recommendations for pneumococcal vaccines in adults, an additional vaccine (PCV20 or PCV21) was recommended to be administered for resident #10.

b. Review of resident #336's EHR showed no pneumococcal vaccines were administered.

Review of a facility document, titled Pneumococcal Vaccination Consent/Declination, dated 1/17/2025, showed a refusal by resident #336 with the comment: up to date explaining the reason for the refusal.

c. Review of resident #32's EHR showed no pneumococcal vaccines were administered.

Review of a facility document, titled Pneumococcal Vaccination Consent/Declination, dated 11/26/2024, showed a refusal by resident #32 with the comment: up to date explaining the reason for the refusal.

During an interview on 1/30/25 at 8:03 a.m., staff member B and N stated immunizations were tracked as residents were admitted . Staff member N stated staff member C was responsible for inputting the vaccines into PCC. Staff member B stated, We could do better [with tracking immunizations in the facility].

During an interview on 1/30/25 at 10:05 a.m., staff member A stated staff member O was responsible for tracking and inputting the immunizations into PCC.

During an interview on 1/30/25 at 10:47 a.m., staff member O stated they did not have any clinical background and did not track the residents immunizations. Staff member O stated they would take the residents word if a resident had enough of their vaccines or not, during the admission process. Staff member O stated they were unsure if a nurse had oversight of the immunizations. Staff member O stated they thought this process could be better and stated there was a potential for some immunizations to be missed with their current process.

Review of a facility policy, titled Pneumococcal Vaccine, revised 3/2022, showed: 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 275020