Yellowstone River Nursing and Rehabilitation
2115 Central Ave · Billings, MT · 59102 · 4066566500
160 certified beds For profit - Individual Chain: Eduro Healthcare
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $99,463 in fines in the last 24 months.
- 4 citations involved actual harm to residents.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$99,463 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
72% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.18 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.69 | 0.55–0.75 |
| Weekend hours / resident-day | 2.75 | ≈ weekday level |
| Nursing turnover / year | 72% | median 45% |
| Fines (3-yr window) | 3 · $138,359 |
Inspection citations (54 in the current record)
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Potential for harm · D December 31, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 9, 2025 · Quality of Life and Care
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Potential for harm · D November 19, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 14, 2025 · Resident Assessment and Care Planning
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Potential for harm · D November 19, 2025 · found via complaint
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected December 14, 2025 · Nursing and Physician Services
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Potential for harm · D November 19, 2025 · found via complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected December 14, 2025 · Quality of Life and Care
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Potential for harm · D November 19, 2025 · found via complaint
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected December 14, 2025 · Quality of Life and Care
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Potential for harm · E November 19, 2025 · found via complaint
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected December 14, 2025 · Administration
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Actual harm · G August 28, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected September 19, 2025 · Quality of Life and Care
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Actual harm · G August 28, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected September 19, 2025 · Quality of Life and Care
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Potential for harm · D August 28, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 19, 2025 · Resident Rights
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Potential for harm · E August 28, 2025
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.
Corrected September 19, 2025 · Resident Rights
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Potential for harm · D August 28, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 19, 2025 · Quality of Life and Care
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Potential for harm · D August 28, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected September 19, 2025 · Quality of Life and Care
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Potential for harm · E August 28, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 19, 2025 · Nutrition and Dietary
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Immediate jeopardy · J June 5, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 20, 2025 · Quality of Life and Care
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Potential for harm · D June 5, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected June 20, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 5, 2025 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected June 20, 2025 · Resident Assessment and Care Planning
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Potential for harm · E June 5, 2025 · found via complaint
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.
Corrected June 20, 2025 · Nursing and Physician Services
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Potential for harm · D March 27, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected April 18, 2025 · Resident Rights
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Potential for harm · D March 27, 2025 · found via complaint
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected April 18, 2025 · Resident Rights
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Potential for harm · D March 27, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected April 18, 2025 · Resident Rights
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Potential for harm · E March 27, 2025 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected April 18, 2025 · Nutrition and Dietary
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Potential for harm · D March 27, 2025 · found via complaint
Provide a bathroom in or located near each resident’s room.
Corrected April 18, 2025 · Environmental
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Potential for harm · D March 27, 2025 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected April 18, 2025 · Environmental
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Potential for harm · D December 17, 2024 · found via complaint
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.
Corrected January 15, 2025 · Pharmacy Service
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Potential for harm · E July 18, 2024
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected September 5, 2024 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| August 28, 2025 | Fine | $87,019 |
| August 28, 2025 | Payment Denial | 47 days |
| June 4, 2025 | Fine | $12,444 |
| June 22, 2023 | Fine | $38,896 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 275029 · certified since October 1, 1969. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.