Skyline Heights Nursing And Rehabilitation
SKYLINE HEIGHTS NURSING AND REHABILITATION in BILLINGS, MT — inspection on December 31, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observation, interview, and record review, the facility failed to inform and educate residents when there was a change in incontinence treatment/products, for 2 (#s 4 and 7) of 8 sampled residents.
The lack of facility communication and explanation caused resident #4 and #7 to be upset and frustrated.
Findings include:During an observation and interview on 12/30/25 at 9:11 a.m., resident #4 stated, The staff told me I cannot wear a liner and a brief anymore because 'The State' told them they couldn't allow it. I just think the facility doesn't want to spend money.
They are making us use these reusable liners, and they are very small. I have talked to the staff about how much I don't like them, and they just say I have to use them. I want to go back to the big liners I had before. I could buy them myself, but I don't think I should have to. I am frustrated because I have had more accidents.
The facility hasn't explained to me why they changed; they just did it. Resident #4 pointed at her dresser and stated, Look, the reusable ones are up there.
The reusable liners were black in color, small, thin, and lightweight. Resident #4 appeared sad and frustrated during this conversation.
During an interview on 12/30/25 at 12:06 p.m., staff member B stated some residents want to wear a brief and a liner, so they don't need to be changed as often throughout the day.
Staff member B stated, We are trying different things with them (residents), such as toileting schedules and reusable liners that wick away moisture. We educated residents during the resident council about skin breakdown and moisture.
During an interview on 12/30/25 at 12:27 p.m., staff member A stated, Double briefing is never good, and residents need air flow down there (perineal area) to prevent skin breakdown.
We have tried several different types of incontinence products, and the reusable (products) seem to wick away more moisture. We ordered different sizes and tried them on three different residents. I went over the purpose and education that I presented to staff at the resident council meeting. I will get those minutes for you.
During an interview on 12/30/25 at 1:56 p.m., resident #7 stated, I am having too many accidents, and the little reusable pads just aren't working for me. I like the big ones. Resident #7 stated, What would happen if I had a moment and bought the big disposable ones myself.
During an interview on 12/31/25 at 8:09 a.m., staff member A stated, I could not find any documentation of us educating residents on the benefits of the reusable incontinence liners.Review of resident #4's comprehensive care plan with a revision date of 4/14/25 showed: .Focus: ADL's with bowel and bladder.Goal: Interventions with brief with insert.Interventions: I have reviewed and signed a risk vs. benefit form addressing the pros and cons with materials close to body that may cause increased infection and UTI.
Date initiated: 12/27/23. [sic]Review of resident #4's physician order, dated 12/4/2023, showed: Active: Patient may use inconsistence inserts per patient preferences.
Notify provider of any skin breakdown. [sic]A request was made on 12/31/25 at 7:56 a.m. for documentation confirming education provided to residents about the new liners and skin breakdown.
The facility did not provide documentation of education provided to residents about new incontinence products by the end of the survey period.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/31/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Skyline Heights Nursing and Rehabilitation
1807 24th St W Billings, MT 59102
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review, the facility failed to submit the findings of a Facility Reported Incident to the State Survey Agency prior to the five-day deadline for 1 (#5) of 8 sampled residents.
Findings include:Review of a Facility Reported Incident submitted to the State Survey Agency on 11/29/25, involving resident #5, which showed: a facility resident had suffered an unwitnessed fall with injury.
The findings of this incident should have been submitted to the State Survey Agency no later than 12/5/25.
The findings were submitted to the State Survey Agency on 12/7/25, which was two days late.
During an interview on 12/30/25 at 12:27 p.m., staff member A stated, I was out of state when the incident (with resident #5) happened. I had staff member C filling in for me, and she was the one who submitted the findings to the State Survey Agency.
She alerted me that it was late.
During an interview on 12/30/25 at 1:49 p.m., staff member C stated she did realize the findings were submitted late for the event for resident #5.
Staff member C said she missed it and submitted it as soon as she realized it needed to be submitted.During an interview on 12/31/25 at 8:09 a.m., staff member A stated no education had been provided for staff member C on reporting requirements related to the event for resident #5.
Review of a facility document titled, Abuse, Neglect and Exploitation with an implementation date of 6/23/25, showed: .B.
The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/31/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Skyline Heights Nursing and Rehabilitation
1807 24th St W Billings, MT 59102
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review, the facility failed to update a resident's comprehensive care plan with new interventions for incontinence care for 2 (#s 4 and 7) of 8 sampled residents.
Findings include:During an interview on 12/30/25 at 9:11 a.m., resident #4 stated, The staff told me I cannot wear a liner and a brief anymore (for incontinent episodes).
They make us use reusable liners, and they are very small.
They don't last as long, and I have more accidents. I have talked to the staff about how much I don't like them. I want to go back to the disposable big liners I had before. Resident #4 stated, I used to participate in care planning, but I don't anymore.
During an interview on 12/30/25 at 12:27 p.m., staff member A said the care plans should reflect all the incontinence products tried for the resident or any changes related to incontinence care.
During an interview on 12/30/25 at 1:56 p.m., resident #7 stated, I am having too many accidents (with incontinence), and the little reusable pads just aren't working for me.Review of resident #4's comprehensive care plan, with a revision date of 4/14/25, showed: .Focus: ADL's with bowel and bladder.Goal: Interventions with brief with insert.Interventions: I have reviewed and signed a risk vs. benefit form addressing the pros and cons with materials close to body that may cause increased infection and UTI.
Date initiated: 12/27/23. [sic]Resident #4's comprehensive care plan failed to show the updated interventions for incontinence products, education provided to the resident on the risks vs benefits of the new products, and the facility's change in the incontinence product which the resident felt was not working.
Review of resident #7's comprehensive care plan with a revision date of 10/2/25 showed: .Focus: ADL's with bowel and bladder,Goal: Interventions with brief insert,Interventions: I have reviewed and signed a risk vs. benefit form addressing the pros and cons with materials close to body that may cause increased infection and UTI.
Date Initiated: 12/27/2023.Resident #7's comprehensive care plan failed to show the updated interventions for incontinence products, education provided to the resident on the risks vs benefits of the new products, and the facility's change in the incontinence product, which the resident felt was not working.
Facility ID: