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.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
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)
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
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.