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Home / Montana / Billings

Yellowstone River Nursing and Rehabilitation

2115 Central Ave, Billings, MT 59102 · Yellowstone County · (406) 656-6500

160 certified beds, about 116 residents a day · For profit - Individual · Medicare and Medicaid since 1969

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
2 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 275029 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on August 28, 2025, inspectors cited 7 health deficiencies (the Montana average is 11.2, the national average 9.2).

Of 59 health citations since June 2023, 6 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).

CMS lists 4 fines totaling $142,698 in the last three years; the largest was $87,019, and the latest is dated May 6, 2026.

Nurses and nurse aides worked 3.15 hours per resident per day, against 4.05 across Montana and 3.86 nationally. Registered nurses accounted for 0.68 of those hours.

71.8% of nursing staff left within the year CMS measured (Montana average 54.8%).

CMS links it to Eduro Healthcare, an affiliated group of 34 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 59 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
5G
0H
0I
Potential for more than minimal harm
36D
13E
4F
Potential for minimal harm
0A
0B
0C
July 30, 2026Complaint inspection · 1 citation
  1. D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 18, 2026
    Inspectors wroteBased on interviews and record review, the facility failed to notify the resident's representative, in writing, of the reason for the transfer and the required bed-hold information for 1 (#9), of 10 sampled residents.
May 6, 2026Complaint inspection · 6 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review, the facility failed to ensure a staff member provided safe transportation of a resident being transferred to the facility for admission for 1 (#10) of 10 sampled residents. The deficient practice caused resident #10 injury, resulting in a left ankle fracture, requiring hospitalization and surgery, which prolonged the resident's stay at the facility. The facility identified that the resident was not transported safely and immediately addressed and corrected the deficient practice before the survey, resulting in the findings of past non-compliance.
  2. G
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2026 · disputed by the home (informal dispute resolution)
    Inspectors wroteBased on interview and record review, the facility failed to ensure medications were transcribed into a resident's electronic medical record accurately, and failed to identify a high-risk medication ordered for a resident with end-stage renal disease for 1 (#6) of 4 residents sampled for dialysis. This deficient practice resulted in resident #6's altered mental status, requiring hospitalization and treatment.
  3. D
    Assess the resident when there is a significant change in condition
    F637 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Significant Change MDS (Minimum Data Set) assessment for a resident's change in condition, for 1 (#9) of 10 sampled residents. This deficient practice increased the risk of resident #9 not receiving services for his care to prevent further decline.
  4. D
    PASARR screening for Mental disorders or Intellectual Disabilities
    F645 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2026 · disputed by the home (informal dispute resolution)
    Inspectors wroteBased on observation, interview, and record review, the facility failed to complete and maintain resident documentation for PASARR (Preadmission Screening and Resident Review) assessment prior to admission for 1 (#9) of 3 residents sampled for PASARRs. The deficient practice increased the risk of resident #9 not receiving services for mental disorder or intellectual disability.
  5. D
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2026
    Inspectors wroteBased on interview and record review, facility staff failed to ensure a resident at risk for nutritional deficits was provided a therapeutic diet and had fluids limited as ordered by a provider for 1 (#6) of 4 residents sampled for dialysis. This deficient practice increased resident #6's risk of experiencing hyperkalemia and fluid imbalance as related to end-stage renal (kidney) disease, when she required treatment for hyperkalemia (high level of potassium) and altered mental status resulting in hospitalization.
  6. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2026
    Inspectors wroteBased on interview and record review, facility staff failed to complete an assessment of a resident's health status prior to and after returning from the dialysis center for 2 (#s 2 and 6) of 4 sampled residents receiving dialysis treatments. This deficient practice increased the risk of residents #2 and #6 to experience adverse outcomes related to complications from end-stage renal disease.
December 31, 2025Complaint inspection · 1 citation
  1. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on the interview and record review, the facility failed to ensure staff responded to resident needs timely for a resident requiring assistance with activities of daily living for 1 (#4) of 7 sampled residents. The deficient practice increased the risk for adverse psychosocial outcomes and skin integrity issues. The facility identified the failure of staff to respond timely, addressed and corrected the deficient practice before the survey, resulting in the findings of past non-compliance.
November 19, 2025Complaint inspection · 5 citations
  1. E
    Hire a qualified full-time social worker in a facility with more than 120 beds.
    F850 · Administration · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 14, 2025
    Inspectors wroteBased on interview and record review, the facility failed to hire and employ a full-time social worker who met the regulatory requirements and to meet the mood, behavioral, emotional, and psychosocial needs of residents. The facility was licensed for 160 beds.
  2. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 14, 2025
    Inspectors wroteBased on interview and record review, the facility failed to include person-centered information in the resident comprehensive care plan to include measurable objectives and timeframes to meet medical, nursing, and psychosocial needs for 2 (#s 1 and 4) of 8 sampled residents. This deficient practice increased the risk of resident #4 not having psychosocial needs met, and for staff assisting with resident #1's care to not follow enhanced barrier precautions to prevent infection.
  3. D
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    F711 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 14, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure a provider reviewed a resident's total program of care during a single visit with the resident, when the resident fired the physician who left not finalizing the visit, but then no other physicians attempted to finish the assessment, for 1 (#4) of 8 sampled residents. This deficient practice caused resident #4 to be at risk of not receiving medications, treatments, and services for maintaining physical, mental, and psychosocial well-being.
  4. D
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    F740 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 14, 2025
    Inspectors wroteBased on interview and record review, the facility failed to assist a resident who requested mental health counseling to receive behavioral health services; when the resident had consistent documentation of emotional behaviors and concerns with her care staff that occurred since the date of admission, for 1 (#4) of 8 sampled residents.
  5. D
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    F745 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 14, 2025
    Inspectors wroteBased on interview and record review, the facility failed to provide individualized medically related social services, and accurately and thoroughly assess a resident, for her mood, behavior, and psychosocial status, and the resident displayed mood symptoms and took an antidepressant, displayed anxiety, paranoia, would often refused care, and act out toward others; and the facility failed to ensure her care plan included individualized interventions for care staff to use when the resident did display symptoms or concerns of the mood, behavior, or psychosocial concerns; and she was not referred for mental health services, although this was identified as necessary, for 1 (#4) of 8 sampled residents.
August 28, 2025Standard inspection · 7 citations
  1. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) September 19, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer to the coccyx for 1 (#5) of 26 sampled residents. The resident's medical record failed to include consistent and accurate documentation to reflect if the wound was avoidable, although the resident was at risk for malnutrition and had a severe weight loss over recent months; and the facility implemented some interventions for prevention, but failed to thoroughly and consistently assess the wound and document the status of the pressure ulcer, such as the size, measurements, severity, characteristics and detail, and at one point, the wound was documented as a Stage IV with no defining characteristics as to why this was determined.
  2. G
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) September 19, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to follow interventions related to resident assistance, evaluate current abilities, and implement additional interventions and monitoring for a severe weight loss of 7.65% in one month, and the resident had a new diagnosis of Severe Protein Calorie Malnutrition, for 1 (#94) of 26 sampled residents.
  3. E
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 19, 2025
    Inspectors wroteBased on observation and interview, the facility failed to provide a wheelchair-accessible grievance box, so residents could submit a grievance independently or anonymously, and the box was not within reach for all the facility residents who used wheelchairs for mobility; and this failure affected 1 (#112) of 26 sampled residents.
  4. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 19, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident meal trays were served to the residents' rooms in a timely manner and according to the posted mealtimes for 3 (#s 19, 42, and 97) of 26 sampled residents, and it was reported the meals could be lukewarm and residents felt hungry due to having to wait so long for the room trays to be served.
  5. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to respect a resident's personal items. The staff cleaned the resident's room, disposing of personal resident items without the resident being present or aware of what was disposed. The lack of respect for the resident's belongings and environment caused the resident frustration, for 1 (#53) of 26 sampled residents.
  6. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the doctor's orders for edema treatment for 2 (#s 12 and 80) of 26 sampled residents. This deficient practice increased the risk for serious complications related to the edema, especially due to their mobility issues.
  7. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 19, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to follow doctor's orders for oxygen treatment related to CPAP administration for 1 (#80) and nasal canula administration for 1 (#12); and failed to post an oxygen sign on the door or have full oxygen tanks for 1 (#12) of 26 sampled residents.
June 5, 2025Complaint inspection · 4 citations
  1. J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 20, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent Immediate Jeopardy level accidents and hazards resulting in a resident with a traumatic brain injury eloping from the facility through unsecured doors, accessing a public road and leaving the facility property, without staff supervision, for 1 (#1) of 9 sampled residents. This failure placed other residents at risk for elopement if they successfully exited out the unsecured doors not equipped with a wander guard alarm system, for 5 (#s 10, 11, 12, 13, and 14) of 9 sampled residents. The facility's failure increased the risk of serious bodily harm, injury, impairment, or death, due to the facility's failure to sufficiently address the doors the resident eloped from. [...]
  2. E
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) June 20, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure staff had the necessary education to monitor the functionality of the facility's wander guard alarm system for 6 (#s 1, 10, 11, 12, 13, and 14) of 6 residents sampled for wandering and elopement risk. This failure increased the risk for the resident's attempting to elope.
  3. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 20, 2025
    Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation involving a resident who had access to, and went out of, a door which was not alarmed with a wander guard alarm system. The resident left the facility property, accessing a public road, traveling 0.2 miles on foot without staff supervision. The facility failed to identify exit doors not equipped with a wander guard alarm system which would alert staff to redirect a resident prior to exiting an emergency egress door as a hazard for 1 (#1) of 9 sampled residents for wandering and elopement risk. The facility's failure to address these concerns placed this resident, and any others at risk of eloping, at continued risk of imminent harm.
  4. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 20, 2025
    Inspectors wroteBased on interview and record review, the facility failed to update a resident care plan with a new fall intervention identified by the IDT, for 1 (#7) of 9 sampled residents. The failure placed the resident at risk for recurrent falls and injuries.
March 27, 2025Complaint inspection · 6 citations
  1. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 18, 2025
    Inspectors wroteBased on interview and record review the facility failed to ensure meals were served at an appetizing temperature to ensure resident satisfaction for 4 (#s 15, 16, 17 and 18) of 4 sampled residents for food satisfaction.
  2. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 18, 2025
    Inspectors wroteBased on observation and interview, the facility failed to provide equal access to quality care for 1 (#7) of 18 sampled residents. The resident was placed in a room without a sink, bathroom, or call light. The resident slept on a mattress placed on the floor.
  3. D
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    F559 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 18, 2025
    Inspectors wroteBased on interview and record review, the facility failed to provide written notice for a room change, including the reason for the change, for 2 (#s 7 and 8) of 3 residents sampled for room changes.
  4. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 18, 2025
    Inspectors wroteBased on interview and record review, the facility failed to notify a resident's representative when a change in condition necessitating a transfer to a higher level of care for 1 (#1) of 4 residents sampled for appropriate transfer. Findings Include: During an interview on 3/25/25 at 11:05 a.m., NF5 stated she was not notified when resident #1 was admitted to an acute care hospital on 2/16/25. NF5 stated she was notified when resident #1 attempted to elope and became very agitated. But was not notified when the decision was made to transfer resident #1 to the hospital for a psychiatric evaluation. NF5 stated she did not know about the transfer or the admission until another family member arrived at the facility to visit and was told he was in the hospital. Review of resident #1's documents received from the acute care hospital, dated between 2/16/25 and 2/24/25, showed the following: [...]
  5. D
    Provide a bathroom in or located near each resident’s room.
    F918 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 18, 2025
    Inspectors wroteBased on observation and interview, the facility failed to ensure each resident room was equipped with a sink and toilet for 1 (#7) of 18 sampled residents.
  6. D
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    F919 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 18, 2025
    Inspectors wroteBased on observation and interview, the facility failed to ensure each resident's sleeping area had functioning call light for 1 (#7) of 18 sampled residents.
December 17, 2024Complaint inspection · 1 citation
  1. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 15, 2025
    Inspectors wroteBased on record review and interview, the facility failed to ensure PRN (as needed) anti-anxiety medication was limited to 14 days for 1 (#49) of one sampled resident and failed to ensure an adequate indication of use for an antipsychotic for 1 (#99) of 1 sampled resident.
July 18, 2024Standard inspection, Complaint inspection · 16 citations
  1. F
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    F801 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation and interviews, the facility failed to employ a Certified Dietary Manager, to carry out the functions of the food and nutrition services, for the facility. This failure increased the risk of negative outcomes for all residents residing at the facility and receive nutritional services.
  2. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen, and the dietary storage areas. The facility failed to ensure kitchen staff wore beard coverings while serving food, failed to label and date food items in the walk-in cooler, failed to maintain a clean (dietary/kitchen) environment, and failed to have appropriate pest control. This deficient practice had the potential to cause foodborne illness to all who received food from the kitchen.
  3. F
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    F867 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, correct, and monitor quality-deficient practices effectively related to the kitchen cleanliness and pest control using the QAPI program. This failure increased the risk of negative outcomes for any resident who received food and or services from the dietary department.
  4. F
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    F925 · Environmental · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to assure pest control in the kitchen, 200 and 300 halls, and a resident room for 1 (#65) of 43 sampled residents. This deficient practice had the potential to affect all residents served food from the kitchen, and all residents residing on the 200 and 300 halls.
  5. E
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    F553 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on interviews and record review, the facility failed to invite residents to care plan meetings for 4 (#s 21, 63, 89, and 91) of 43 sampled residents.
  6. E
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and sanitary environment for 3 (#s 32, 63, and 89); and failed to consistently clean the 300 hallway and resident rooms for 2 (#s 39 and 65) of 43 sampled residents.
  7. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued medications were properly disposed of or destroyed for 2 (#s 6 and 318) of 43 sampled residents.
  8. E
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent, for 2 (#s 37 and 309) of 43 sampled residents. The medication error rate calculated to 11.54 percent, and there were multiple errors made for each resident, increasing the risk of a negative outcome.
  9. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to enable the residents to maintain their highest practicable level of functioning for 1 (#16) of 43 sampled residents.
  10. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse by a staff member, for 2 (#s 304 and 305) of 43 sampled residents.
  11. D
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    F604 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a concave mattress as a potential restraint and did not complete a risk assessment, consent, or monitoring for 1 (#88) of 2 residents sampled for restraints.
  12. D
    Provide appropriate foot care.
    F687 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure there was an effective process for providing foot care to diabetic residents for 1 (#91) of 43 sampled residents.
  13. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation and interview, the facility failed to identify the risk of a trip hazard by using a twin-size scoop mattress as a bedside fall mat for 1 (#91); and failed to protect a resident from hazardous materials for 1 (#89) of 43 sampled residents.
  14. D
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    F835 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observations, interviews, and record review, it was found facility administration failed to hire and employ a Dietary Manager with appropriate competencies and skills sets to carry out the necessary functions of the food and nutritional services; and the facility dietitian did not schedule regular consultations and go onsite to work with the dietary manager and assist with oversight of nutritional services. This failure resulted in numerous concerns being identified in the dietary department (Refer fo F825.
  15. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were followed when performing wound care and medication administration through a feeding tube, for 1 (#86) of 1 sampled resident; and failed to repair a worn recliner, resulting in an uncleanable surface, for 1 (#65) of 43 sampled residents. This deficient practice had the potential to increase the transmission of infectious agents for the residents.
  16. D
    Keep all essential equipment working safely.
    F908 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) September 5, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and proper operation of the kitchen equipment (the oven, dessert refrigerator, cooks' refrigerator, and ice machine). This deficient practice had the potential to affect any resident receiving food from the kitchen when the equipment is used for the preparation or storage of food.
October 26, 2023Complaint inspection · 6 citations
  1. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 21, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control practices for transmission-based precautions during a COVID-19 outbreak for 1 (#11) of 15 sampled residents. This deficient practice had the increased potential to spread COVID -19 in the facility.
  2. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 21, 2023
    Inspectors wroteBased on observation, interview, and record review, nursing staff failed to respect a resident's dignity by drawing a smiley face on a resident's buttocks when providing care for 1 (#10) of 15 sampled residents; failed to speak to a resident with respect while assisting with care for 1 (#12) of 15 sampled residents.
  3. D
    Ensure that residents are fully informed and understand their health status, care and treatments.
    F552 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 21, 2023
    Inspectors wroteBased on interview and record review, the facility failed to obtain verbal or written consent, or complete an explanation of risks versus benefits with a resident's POA prior to giving an anti-psychotic medication, for 1 (#12) of 15 sampled residents.
  4. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 21, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had her call light with in reach for 1 (#10) of 15 sampled resident. This deficient practice caused the resident to yell out for help instead of using the call light.
  5. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 21, 2023
    Inspectors wroteBased on interview and record review, the facility failed to investigate a facility reported incident thoroughly for a resident found, during cares, to have a smiley face on her buttock, and implement protective measures for the resident, for 1 (#10) of 15 sampled residents.
  6. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 21, 2023
    Inspectors wroteBased on interview and record review, the facility failed to limit an as needed anti-psychotic medication order to 14 days for 1 (#12) of 15 sampled residents.
June 22, 2023Standard inspection · 6 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) July 21, 2023
    Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 2 (#s 21 and 32) of 10 sampled residents, resulting in falls with fractures, and the potential for a fall related to the safe and appropriate use, by a staff member, for the sit-to-stand mechanical lift.
  2. E
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 21, 2023
    Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a clean homelike environment, and clean bugs out of light fixtures, for 2 (#s 44 and 85), and the soiled light fixtures were noticed by the two residents; one specifically felt the bugs were creepy.
  3. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 21, 2023
    Inspectors wroteBased on interview and record review, the facility failed to provide adequate staffing to assist with resident care needs, with respect to answering call lights in a timely manner, for 8 (#s 26, 29, 60, 89, 93, 98, 158, and 159) of 20 sampled residents; and, failed to provide showers as scheduled for 10 (#s 6, 25, 26, 29, 44, 45, 60, 89, 93, and 98) of 20 sampled residents.
  4. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 21, 2023
    Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain proper hand hygiene practices for 3 (#s 20, 21 & 70) of 5 sampled residents; clean and disinfect sit-to-stand lifts after use for 2 (# 20 and 21) of 2 sampled residents; failed to maintain a documented infection prevention surveillance program; failed to maintain a water management program to minimize the growth and spread of waterborne pathogens; and, failed to address unsanitary conditions in resident bathrooms, for 3 (#s 35, 45, and 89) of 7 sampled residents.
  5. D
    Assess the resident when there is a significant change in condition
    F637 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 21, 2023
    Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change MDS Assessment, for 1 (#105) of 2 sampled residents, who received hospice services.
  6. D
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 21, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were competent in providing care and services for 1 (#108) of 2 sampled residents to prevent the worsening of facility aquired pressure ulcers; and failed to ensure direct care staff had the education to address cleanliness of resident bathrooms and for necessary cleaning, for 1 (#35) if 2 sampled residents.

Fire safety inspections

26 fire safety citations on file: 9 on August 28, 2025, 11 on July 18, 2024, 6 on June 22, 2023.

Every fire safety citation26 citations
  1. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · August 28, 2025 · Corrected (the home has a date of correction)
  2. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · August 28, 2025 · Corrected (the home has a date of correction)
  3. F
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · August 28, 2025 · Corrected (the home has a date of correction)
  4. F
    Have simulated fire drills held at unexpected times.
    K 712 · August 28, 2025 · Corrected (the home has a date of correction)
  5. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · August 28, 2025 · Corrected (the home has a date of correction)
  6. E
    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
    K 222 · August 28, 2025 · Corrected (the home has a date of correction)
  7. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · August 28, 2025 · Corrected (the home has a date of correction)
  8. E
    Provide properly protected cooking facilities.
    K 324 · August 28, 2025 · Corrected (the home has a date of correction)
  9. D
    Meet other general requirements that are deficient.
    K 300 · August 28, 2025 · Corrected (the home has a date of correction)
  10. F
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · July 18, 2024 · Corrected (the home has a date of correction)
  11. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · July 18, 2024 · Corrected (the home has a date of correction)
  12. F
    Have simulated fire drills held at unexpected times.
    K 712 · July 18, 2024 · Corrected (the home has a date of correction)
  13. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · July 18, 2024 · Corrected (the home has a date of correction)
  14. E
    Install smoke barrier doors that can resist smoke for at least 20 minutes.
    K 374 · July 18, 2024 · Corrected (the home has a date of correction)
  15. D
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · July 18, 2024 · Corrected (the home has a date of correction)
  16. D
    Have properly located and lighted "Exit" signs.
    K 293 · July 18, 2024 · Corrected (the home has a date of correction)
  17. D
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · July 18, 2024 · Corrected (the home has a date of correction)
  18. D
    Provide properly protected cooking facilities.
    K 324 · July 18, 2024 · Corrected (the home has a date of correction)
  19. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · July 18, 2024 · Corrected (the home has a date of correction)
  20. D
    Install properly constructed windows in hallway walls or doors.
    K 364 · July 18, 2024 · Corrected (the home has a date of correction)
  21. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · June 22, 2023 · Corrected (the home has a date of correction)
  22. E
    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
    K 222 · June 22, 2023 · Corrected (the home has a date of correction)
  23. E
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · June 22, 2023 · Corrected (the home has a date of correction)
  24. D
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · June 22, 2023 · Corrected (the home has a date of correction)
  25. D
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · June 22, 2023 · Corrected (the home has a date of correction)
  26. D
    Meet requirements for the installation and maintenance of electrical systems.
    K 911 · June 22, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
May 6, 2026Fine $19,635
May 6, 2026Fine $23,600
August 28, 2025Fine $87,019
August 28, 2025Payment Denial 47 days from October 2, 2025
June 4, 2025Fine $12,444

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeMontanaUnited States
All nursing staff (RN, LPN and aides)3.154.053.86
Registered nurses0.680.980.69
All nursing staff on weekends2.803.593.42
Nurse aides1.80
Licensed practical nurses0.67
Nursing staff turnover (share who left in a year)71.8%54.8%45.8%
Registered nurse turnover75.8%48.3%42.9%
Administrators who left2

CMS expects 3.41 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.29 on weekdays and 2.80 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 15.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.31 in April to June 2025 to 3.15 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.150.683.292.80 15.4%0 of 90116
Oct to Dec 20253.180.693.352.75 16.4%0 of 92112
Jul to Sep 20253.350.723.512.95 17.6%0 of 92112
Apr to Jun 20253.310.743.433.01 33.1%0 of 91105
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Montana, Jan to Mar 20263.910.894.103.4611.6%0.4% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Montana

JobMedianMiddle halfEmployed
Montana, all employers
CNAs (nursing assistants)$19.67$18.29 to $22.864,390
LPNs and LVNs$29.91$27.95 to $32.141,620
Registered nurses$41.00$38.56 to $48.4610,950
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeMontanaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
24.418.713.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.32.10.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
2.02.91.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
1.74.43.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
2.01.31.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
26.117.214.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
5.76.34.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
29.520.415.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
27.319.223.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
18.314.512.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.51.41.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.42.21.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Yellowstone River Nursing and Rehabilitation's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (60.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

60.6% this home

Better than the national rate

US median of homes 51.5% · Montana: 7 better, 2 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 285 eligible stays.

Potentially preventable readmissions

9.1% this home

No different from the national rate

US median of homes 10.7% · Montana: 0 better, 0 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 304 eligible stays.

Infections that led to a hospital stay

5.5% this home

No different from the national rate

US median of homes 7.1% · Montana: 0 better, 0 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 153 eligible stays.

Self-care and mobility at discharge

52.0% this home

Median of homes: Montana58.5% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 98 residents counted.

Falls with major injury

0.7% this home

Median of homes: Montana0.3% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 136 residents counted.

New or worsened pressure ulcers

3.1% this home

Median of homes: Montana2.8% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 136 residents counted.

Medication list given at discharge

96.4% this home

Median of homes: Montana97.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 56 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: YELLOWSTONE NURSING AND REHAB CENTER LLC. CMS links this home to Eduro Healthcare, a group of 34 nursing homes averaging 2.5 stars overall.

NameRoleTypeShareSince
Caldwell, SarahW-2 managing employeeIndividual06/01/2023
Bewsey, MichaelCorporate officerIndividual06/01/2023
Monroe, DustinCorporate officerIndividual06/01/2023

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 14 problems in this area, most recently on May 6, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 13 problems in this area, most recently on July 30, 2026: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 5 problems in this area, most recently on May 6, 2026: "Ensure that residents are free from significant medication errors."
  4. When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on May 6, 2026: "Assess the resident when there is a significant change in condition"
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.80 hours per resident per day, below the Montana average of 3.59.
  6. How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.

Other nursing homes nearby

Montana contacts for a concern about a nursing home

These are the official offices in Montana. NursingHomeClear cannot take or act on complaints.

Common questions

What is Yellowstone River Nursing and Rehabilitation's Medicare star rating?
CMS rates Yellowstone River Nursing and Rehabilitation 1 out of 5 stars overall, with 1 for health inspections, 2 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Yellowstone River Nursing and Rehabilitation get at its last inspection?
7 health deficiencies at the standard inspection on August 28, 2025. The Montana average is 11.2.
Has Yellowstone River Nursing and Rehabilitation been fined?
Yes. CMS lists 4 fines totaling $142,698 in the last three years.
Does Yellowstone River Nursing and Rehabilitation accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Yellowstone River Nursing and Rehabilitation?
CMS lists 3 owners and managers, and links the home to Eduro Healthcare. Legal business name: YELLOWSTONE NURSING AND REHAB CENTER LLC.

Sources

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