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
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
275020 12/31/2025
Skyline Heights Nursing and Rehabilitation 1807 24th St W Billings, MT 59102
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.
275020 12/31/2025
Skyline Heights Nursing and Rehabilitation 1807 24th St W Billings, MT 59102
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.