Billings Rehabilitation and Nursing LLC

In the surveyor’s words

From the most serious findings on record at Billings Rehabilitation and Nursing LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF880Feb 16, 2023

  Based on observation, interview, and record review, the facility failed to implement measures to mitigate the spread of COVID-19 within the facility. The facility had 38 out of 73 residents contract COVID-19, and 4 (#s 1, 4, 5, and 7) of 17 sampled residents were sent to the hospital, and after evaluation were diagnosed with COVID-19 related illnesses. Staff were observed going in/out of at least 12 resident rooms without following proper infection control prevention measures. […]

• Immediate jeopardy, patternF600Nov 21, 2022

  Based on observation, interview, and record review, the facility neglected to ensure sufficient staff were available and working on the secure unit to supervise, protect, prevent, or intervene in resident to resident physical, sexual, and psychosocial abuse involving 9 (#s 14, 16, 17, 32, 35, 48, 50, 53, and 58) of 15 sampled residents, as evidenced by ongoing resident to resident abuse incidents, and these events caused physical injury, residents had fear of others, or were targeted by other residents, and some continued to be at risk for ongoing abuse; and, 4 (#s 30, 31, 34, and 55) residents were identified to need more than supervisory assistance of the facility staff when it was not provided sufficiently by the facility. […]

• Immediate jeopardy, isolatedF600Jun 6, 2024

  Based on observation, interview, and record review, the facility failed to prevent Immediate Jeopardy level neglect by refusing to allow a resident re-entry to the facility after transferring to the hospital, then he went AMA, and attempted to return to the facility, which resulted in the resident sitting outside of the facility for several hours in inclement weather, and placing the resident at high risk of a serious adverse outcome, for 1 (#1) of 3 residents sampled for discharge. On 6/6/24 at 1:06 p.m., the facility Administrator and administrative staff were notified of an Immediate Jeopardy involving resident #1, pertaining to F600 - Freedom from Abuse and Neglect. […]

• Actual harm, widespreadF741Nov 21, 2022

  Based on observation, interview, and record review, the facility failed to ensure there were sufficient staff members present on the secure care unit to assist with resident care and supervision of residents, to include those with behavioral needs, for 11 (#s 14, 16, 17, 30, 31, 34, 48, 50, 53, 55, and 58) of 14 sampled residents. This failure led to repeated incidents of resident-to-resident abuse, and one incident of staff to resident abuse. Findings include: During an observation on 11/19/22 at 1:28 p.m., resident #53 was walking in and out of other resident rooms and closing the doors behind him. Staff were not around to be able to intervene or redirect resident #53's behavior. […]

• Actual harm, patternF610Nov 21, 2022

  Based on observation, interview, and record review, the facility failed to prevent and protect residents from ongoing sexual, physical, or emotional abuse for 6 residents residing on the secure care unit (#s 8, 16, 32, 35, 53, and 58) of 29 sampled residents. This deficient practice allowed residents to continue to be at risk for further abuse, and resident #53 had multiple injuries, to include stitches, female residents exhibited fear, and were risk for sexually inappropriate touching. Findings include: 1. Review of a facility reported incident, dated 11/23/21, showed, [Resident #53] had his hand in [resident #32's] shirt. Appeared that he (resident #53) was attempting to put his other hand down her (resident #32's) pants when they were separated. […]