Skyline Heights Nursing And Rehabilitation

During an interview on 1/28/25 at 9:17 a.m., resident #339 was sitting on his bed. Resident #339 stated he had recently been in the hospital with pneumonia and was transferred to the long-term care facility on 1/23/25, to regain his strength, so he could continue to live independently at home. Resident #339 stated he started working with physical therapy on 1/24/25 and participates in therapy five days a week.

During an interview on 1/30/25 at 11:45 a.m., staff member C stated baseline care plans were developed by the admitting nurse, and would then be updated by the interdisciplinary team, if any changes occurred prior to the comprehensive care plan being developed.

Review of resident #339's electronic medical record, showed on 1/22/25, the resident was to transfer to a subacute rehab facility due to his deconditioned status to maximize resident #339's functional independence before returning to home.

Review of Resident #339's baseline care plan, dated 1/24/25, failed to address respiratory support and rehabilitation therapy services.

Review of a facility document titled, Care Plans-Baseline, showed the following information: Policy Interpretation and Implementations

• The baseline care plan includes instructions needed to provide effective, person-centered care of

the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: - . b.

Physician orders; d.

Therapy services; .

275020 01/30/2025

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

Review of resident #13's current care plan showed a gel cushion was to be placed on the recliner on 3/29/23. On 1/18/25, the care plan showed bed linens should be wrinkle free, and a specialty air mattress was to be used.

During an observation on 1/27/25 at 1:46 p.m., resident #13 was sitting in her recliner chair, and she was asleep.

There was no gel cushion in resident #13's recliner.

During an interview on 1/27/25 at 3:29 p.m., NF1 said resident #13 had slept in a recliner for fifteen or twenty years. NF1 said resident #13 recently developed a sore on her buttocks.

Due to this, the care plan interventions of the bed linens and speciality air mattress would not be applicable as the resident slept in a recliner.

During an observation on 1/28/25 at 8:40 a.m., resident #13 was sitting in her recliner chair, and there was no gel cushion observed in the recliner.

During an interview on 1/29/25 at 9:14 a.m., staff member B stated resident #13 definitely needed a gel cushion on her chair.

Staff member B went to resident #13's room and returned to the interview.

Staff member B said the gel cushion was not on her chair.

• During an observation and interview on 1/28/25 at 8:20 a.m., resident #14 was sitting in his

wheelchair in his room. Resident #14 stated he went to dialysis on Mondays, Wednesdays, and Fridays. Resident #14 then pointed to a catheter on his right upper chest and stated, It's for dialysis.

During an interview on 1/30/25 at 11:45 a.m., staff member C stated enhanced barrier precautions apply to all residents with wounds or indwelling catheters.

Staff member C stated resident #14's care plan should include enhanced barrier precautions.

Staff member C stated he was conducting an audit of all residents to make sure enhanced barrier precautions were listed on all resident care plans to whom it would apply.

Review of resident #14's care plan, dated 11/22/24, failed to show an intervention for enhanced barrier precautions related to the resident's right jugular catheter.

Review of a facility document titled, Enhanced Barrier Precautions, showed the following information: Policy Interpretation and Implementation - . 5. EBP's are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .

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

Review of resident #346's care plan, dated 1/13/25, showed: .Focus: Skin integrity impaired to Sacral Region, Buttocks .Interventions: .Turn and reposition frequently and as resident allows for prevention of further breakdown. [sic]

• During observation and interview on 1/28/25 at 9:11 a.m., resident #347 was observed sitting on

the edge of her bed; her hair was oily and unkempt. Resident #347 stated, I am supposed to get showers every two days. I have only had one shower since I got here on January 21st.

During an interview on 1/29/25 at 9:54 a.m., resident #347 stated, I haven't received a bed bath. I try to clean myself in my bathroom, but the staff don't want me going in there by myself. I do try to clean up my lady parts. I don't like feeling dirty, and I prefer showers.

Review of resident #347's medical record showed a document titled, Bath Preference Questionnaire, dated 1/21/25.

This document showed, We offer routine bathing two to three times per week - does this meet or exceed your expectations? An x was next to yes.

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

During an observation on 1/28/25 at 7:46 a.m., resident #346 had a PICC line in his right arm.

The bandage was rolled down and closer to his elbow.

During an observation and interview on 1/28/25 at 1:43 p.m., resident #346's PICC line bandage was rolled up near his elbow on his right arm.

The PICC line port moved around when the resident moved his arm. NF4 stated, The bandage on his right arm for the PICC line has not been changed. It looked like it was going to come out the other day, so I used some gauze that he had on his dresser and wrapped it around his arm so it would be more stable. I don't think the staff have changed it since I wrapped it.

During an interview on 1/29/25 at 7:19 p.m., staff member E stated, We (staff) don't have enough time to complete everything that is expected of us.

The residents don't understand that, and they shouldn't have to. We try to explain that we are too busy, and we try to get to everything, but it seems impossible most days.

During an observation and interview on 1/30/25 at 8:14 a.m., resident #346's PICC line was no longer in his right arm. Resident #346 stated, .It (PICC Line) got pulled out about four inches last night, so I went to the Emergency Department, and they removed it (PICC Line).

They (Emergency Department) put in an IV port for my antibiotics, but it was stuck to my pajamas this morning when I woke up. I think they (facility staff) are going to have to schedule me to get another PICC line put in.

Review of resident #346's physician orders, dated 1/20/25, showed, Change PICC line dressing every day shift every Mon.

Review of resident #346's MAR/TAR failed to show any documentation of a PICC line dressing change being done on 1/20/25 or 1/27/25.

Review of a facility document titled, Peripheral and Midline IV Dressing Changes, with a revision date of March 2022 showed, Purpose: This purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings.

General Guidelines:

• Perform site care and dressing change at established intervals or immediately if the integrity of the

dressing is compromised (e.g., damp, loosened or visibly soiled)

• Maintain sterile dressing .
• Change the dressing if it becomes damp, loosened or visibly soiled and:
• at least every 7 days . [sic]

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

Review of resident #13's January 2025 treatment record sheets showed there were no nurse signatures from 1/1/25 through 1/25/25.

There was no documentation to show the wound treatments and dressing changes had been done during this 25-day period.

During an observation on 1/27/25 at 1:46 p.m., resident #13 was sitting in her recliner chair, asleep.

There was no gel cushion in resident #13's recliner for pressure relief.

During an interview on 1/27/25 at 3:29 p.m., NF1 said resident #13 had slept in a recliner for fifteen or twenty years. NF1 said resident #13 recently developed a sore on her buttock.

During an observation on 1/28/25 at 8:40 a.m., resident #13 was sitting in her recliner chair.

There was no gel cushion in the recliner for pressure relief on her buttock.

During an interview on 1/29/25 at 8:59 a.m., staff member D said the facility only changes resident #13's buttock wound dressing, as needed, if the dressing comes off.

Staff member D said Hospice changes the dressings and measures the wound.

Staff member D said the dressing was not scheduled to be changed every day.

Staff member D was not sure when Hospice was coming next.

During an interview on 1/29/25 at 9:14 a.m., staff member B stated resident #13 definitely needed a gel cushion on her chair.

Staff member B went to resident #13's room and returned to the interview.

Staff member B said the gel cushion was not on her chair.

Review of resident #13's current care plan, showed the resident was to have a gel cushion placed in the recliner on 3/29/23. On 1/18/25, the care plan showed bed linens should be wrinkle free and a specialty air mattress was to be used. Resident #13 did not sleep in a bed, she slept in a recliner, so the interventions would not be beneficial for pressure relief for her wound.

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

During an observation and interview on 1/28/25 at 9:11 a.m., resident #347 stated, I was doing nebulizer treatments at home, and I wonder if I should have my daughter-in-law bring my machine to me. I feel like my breathing is getting worse, and I have had more breathing attacks lately. No nebulizer machine was observed in resident #347's room.

During an observation and interview on 1/29/25 at 9:54 a.m., resident #347 stated, I still haven't received any nebulizer treatments. I was taking them every four hours at home.

There was still no nebulizer machine observed in her room.

During an interview on 1/29/25 at 7:46 p.m., staff member J stated, . I have never administered a nebulizer treatment to her (resident #347).

She does have an order for them in her MAR.

Review of resident #347's physician orders, dated 1/22/25, showed, (Nebulizer) Resident has a diagnosis of: acute respiratory failure and exhibits intermittent acute airway obstruction requiring treatment with respiratory medications via inhalation.

Administer respiratory medications via inhalation as needed for evidence of acute airway obstruction.

Document medication administered on mar every 2 hours as needed for SOB/Wheezing related to ACUTE RESIPRATORY FAILURE WITH HYPOXIA for 30 days. [sic] Review of resident #347's EHR failed to show documentation of a nebulizer treatment being administered, documentation of the nebulizer being offered, or documentation of the resident refusing nebulizer treatments.

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

During an interview on 1/29/25 at 10:08 a.m., staff member I stated, There are only two CNAs scheduled for this hall, and there are 23 residents. We are stretched so thin.

These residents are here for therapy, and they have a high acuity. We never have enough time to do all our tasks. We are even expected to do baths. It just doesn't get done (resident care) .

During an interview on 1/29/25 at 7:19 p.m., staff member E stated, .

Cares aren't getting done.

There is not enough help. We don't even get our breaks.

The residents get frustrated because they don't understand why things aren't getting done or why we don't have enough help.

They shouldn't have to worry about that.

The residents are the ones suffering .

During an interview on 1/29/25 at 7:46 p.m., staff member J stated, We don't get to everything when it comes to our tasks. We could use another CNA.

For days they schedule two CNAs and nights only one CNA .

During an interview on 1/30/25 at 9:00 a.m., staff member R said there were not enough CNAs to get everything done some days.

Staff member R said the residents don't always get baths because there aren't enough staff.

Staff member R said the lack of shower rooms also makes it difficult to get the residents showers done.

Staff member R said staff from other halls bring their residents to the Rimview unit because there were two functioning shower rooms on Rimview.

Staff member R said the staff must work on the priorities, like answering call lights, making sure the residents have meals, and getting them to the bathroom.

Staff member R said baths were often not a priority when there was not enough staff.

During an interview on 1/30/25 at 9:36 a.m., staff member C said the schedule starts out looking pretty good for the month.

The cause of the staffing shortages was due to the number of staff calling off for their shifts.

Replacing the absent staff was difficult, and it led to staffing shortages.

During an interview on 1/30/25 at 9:32 a.m., staff member A stated he had filled in as the facility infection prevention staff member, when there was not coverage, 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 starting in her position.

Staff member A stated the facility had worked on a skin action plan as part of a recent POC related to showers. He stated they started it, then some of it fell apart, and they had to restart it due to staff turnover.

275020 01/30/2025

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

Review of resident #63's medication administration record for January 2025 showed the following: - Olanzapine 20 mg by mouth every day which was ordered on 6/12/24 - Clonazepam 0.5 mg by mouth every day ordered 6/12/24 - Trazodone 150 mg by mouth at bedtime every day ordered 6/12/24 - Paroxetine 20 mg by mouth every day ordered 7/11/24 Review of the facility's Monthly Medication Reviews, for resident #63, dated June 2024 through January 2025, showed: - 7/22/24, a request was made to get an appropriate diagnosis for Olanzapine - 10/24/24, a request was made to get an appropriate diagnosis for Olanzapine, and a note which showed, GDR on 4 medications.

The pharmacy review failed to identify or make appropriate recommendations as to what medication dosage should be changed or reduced. Resident #63's medication administration record showed no dose reductions were attempted for those medications since the initiation of the medications.

The medication administration record showed the Olanzapine diagnosis was not changed, and an appropriate diagnosis was not identified.

During an interview on 1/30/25 at 11:15 a.m., staff members A and Q said the facility was aware of the problems with the pharmacy.

Staff members A and Q said the current pharmacy had not been tracking psychotropic medications, and there was no follow up on recommendations.

Staff members A and Q said the pharmacy does not take a deep dive into the medical record to make appropriate suggestions for the monthly drug regimen review.

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

Review of a facility policy titled, Tapering Medications and Gradual Drug Dose Reduction, dated July 2022, showed: .

Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated .

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

During an observation on 1/27/25 at 1:45 p.m., the Rimview medication room showed seven red top

vacutainers expired on 10/30/24.

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

During an interview and observation on 1/27/25 at 3:16 p.m., resident #36 stated she had a missing upper right tooth that she felt was embarrassing.

She stated she also had a left lower tooth that needed a crown because it would hurt sometimes.

Observation of resident #36's left lower molar showed a deep space in the middle of the tooth with some cracks, and a yellowish color throughout the top surface of the tooth. Resident #36 stated, I would like to get that taken care of because that bugs me. Resident #36 was admitted to the facility on [DATE].

Review of resident #36's MDS, dated [DATE], showed: No for the following categories: Broken or loosely fitting full or partial denture . and Mouth or facial pain, discomfort .

During an interview on 1/28/25 at 8:53 a.m., resident #11 stated her dentures did not fit correctly, were uncomfortable to eat with, and she stated, I gave up on wearing them. Resident #11 stated she had asked the facility about getting dentures properly fitted, but nothing had changed.

Review of resident #11's EHR showed a weight loss of 3.82% in three months (An admission weight on 11/11/24 was 183.2 pounds. A current weight on 1/26/25 was 176.2 pounds).

During an interview on 1/28/25 at 9:12 a.m., resident #66 stated her dentures did not properly fit. Resident #66 stated she would prefer to eat with dentures as it would make chewing easier. Resident #66 was admitted to the facility on [DATE].

A request was made on 1/28/25 at 1:48 p.m. , for dental appointments, notes, or referrals for residents: #11, 36, and 66.

During an interview on 1/28/25 at 3:50 p.m., staff member A stated they did not have any appointments, notes, or referrals for residents: #11, 36, and 66.

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

During an observation on 5/13/25 at 1:22 p.m., room trays were being delivered on the 300 hallway.

During an interview on 5/13/25 at 1:28 p.m., staff member M stated the lunch meal was usually served around noon time.

Staff member M stated the lunch meal was served late on this day.

During an interview on 5/13/25 at 1:30 p.m., resident #11 stated her meal was served late.

During an interview and observation on 5/13/25 at 1:44 p.m., resident #22 stated, This food is so late, I don't know what the problem is.

The food is barely warm, I don't know what to do about it, but I eat it anyway, it's just barely warm.

During an interview on 5/13/25 at 4:35 p.m., resident #12 stated room trays are not served hot. Resident #12 stated staff will heat the food up for him, but It's the principle that our food should be served hot.

During an interview and observation on 5/14/25 at 8:23 a.m., resident #13 was in his room and said he had not eaten breakfast yet, and stated, They are nuking it. Resident #13 stated he did not like cold eggs, and his breakfast was served not hot enough, on a regular basis.

Staff member K was observed bringing resident #13 his room tray and stated, Let it cool off if you need to, I don't want to hear later that you have burned your tongue, this (the food being warmed) is one and half minutes in the microwave.

During an interview on 5/14/25 at 8:58 a.m., resident #5 was waiting in the doorway of his room and stated he did not receive a meal tray yet this morning. Resident #5 was concerned because he was a diabetic and needed to eat something before he had to leave for an appointment at 9 a.m. Resident #5 said breakfast was served at 8 a.m., But around here you never know, it's often served about 9, it's a real problem.

The food is not always served hot, I have gotten used to eating cold food.

Review of a facility document titled Meal Service Times, not dated, showed Breakfast was served from 7:30 a.m. to 8:30 a.m., and it was served in the dining room at 8:00 a.m. to 8:30 a.m.

Lunch was served 12:00 p.m. to 1:00 p.m., and it was served in the dining room at 12:00 p.m. to 12:30 p.m.

Dinner was served at 5:00 p.m. to 6:00 p.m. and it was served in the dining room from 5:00 p.m. to 5:30 p.m.

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

followed, and the employee gave an example, and stated diabetics were served regular syrup.

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

dated February 2020, showed:

describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the

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.

275020 01/30/2025

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

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:

• Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention

to reduce the spread of multi-drug resistant organisms . to residents .

• EBPs employ targeted gown and glove use during high contact resident care activities .
• EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds

and/or indwelling medical devices .

• 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 .

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

275020 01/30/2025

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

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 .

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.

275020

Form Approved OMB

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