D-
44/100YELLOWSTONE RIVER NURSING AND REHABILITATION Inspection Report, Violations & Safety Grade (BILLINGS, Montana)
2115 CENTRAL AVE, BILLINGS, Montana 59102
Phone: 4066566500
CMS Overall:1/5
Overview & Bed Count
Certified Beds
160
Avg Residents/Day
114.2
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
County
Yellowstone
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing3/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Montana Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.68 | 0.92 | -0.24 |
| Total Nurse Hours per Resident per Day | 3.32 | 4.02 | -0.70 |
| CMS Staffing Rating | 3/5 | 3.5/5 | - |
| Nursing Staff Turnover | 62.6% | 54.6% | - |
Health Citation History
60 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-27 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2026-07-30 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D – Moderate Harm Potential |
| 2026-05-06 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2026-05-06 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | G – Actual Harm |
| 2026-05-06 | Resident Assessment and Care Planning Deficiencies | Assess the resident when there is a significant change in condition | D – Moderate Harm Potential |
| 2026-05-06 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | D – Moderate Harm Potential |
| 2026-05-06 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2026-05-06 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-12-31 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-11-19 | Administration Deficiencies | Hire a qualified full-time social worker in a facility with more than 120 beds. | E – Moderate Harm Potential |
| 2025-11-19 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-11-19 | Nursing and Physician Services Deficiencies | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | D – Moderate Harm Potential |
| 2025-11-19 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D – Moderate Harm Potential |
| 2025-11-19 | Quality of Life and Care Deficiencies | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D – Moderate Harm Potential |
| 2025-08-28 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2025-08-28 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | G – Actual Harm |
| 2025-08-28 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2025-08-28 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2025-08-28 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-08-28 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-08-28 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-06-05 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2025-06-05 | Nursing and Physician Services Deficiencies | 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. | E – Moderate Harm Potential |
| 2025-06-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-06-05 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2025-03-27 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2025-03-27 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-03-27 | Resident Rights Deficiencies | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | D – Moderate Harm Potential |
| 2025-03-27 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2025-03-27 | Environmental Deficiencies | Provide a bathroom in or located near each resident’s room. | D – Moderate Harm Potential |
| 2025-03-27 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | D – Moderate Harm Potential |
| 2024-12-17 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-07-18 | Nutrition and Dietary Deficiencies | 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. | F – Moderate Harm Potential |
| 2024-07-18 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-07-18 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F – Moderate Harm Potential |
| 2024-07-18 | Environmental Deficiencies | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F – Moderate Harm Potential |
| 2024-07-18 | Resident Rights Deficiencies | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | E – Moderate Harm Potential |
| 2024-07-18 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-07-18 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2024-07-18 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2024-07-18 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2024-07-18 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2024-07-18 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D – Moderate Harm Potential |
| 2024-07-18 | Quality of Life and Care Deficiencies | Provide appropriate foot care. | D – Moderate Harm Potential |
| 2024-07-18 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-07-18 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | D – Moderate Harm Potential |
| 2024-07-18 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-07-18 | Environmental Deficiencies | Keep all essential equipment working safely. | D – Moderate Harm Potential |
| 2023-10-26 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2023-10-26 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
Showing 50 of 60 citations.
Fire Safety Citation History
26 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-08-28 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-08-28 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-08-28 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | F – Moderate Harm Potential |
| 2025-08-28 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-08-28 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-08-28 | Egress Deficiencies | 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. | E – Moderate Harm Potential |
| 2025-08-28 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-08-28 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2025-08-28 | Egress Deficiencies | Meet other general requirements that are deficient. | D – Moderate Harm Potential |
| 2024-07-18 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | F – Moderate Harm Potential |
| 2024-07-18 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-07-18 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-07-18 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2024-07-18 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2024-07-18 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2024-07-18 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | D – Moderate Harm Potential |
| 2024-07-18 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2024-07-18 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2024-07-18 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2024-07-18 | Smoke Deficiencies | Install properly constructed windows in hallway walls or doors. | D – Moderate Harm Potential |
| 2023-06-22 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2023-06-22 | Egress Deficiencies | 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. | E – Moderate Harm Potential |
| 2023-06-22 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | E – Moderate Harm Potential |
| 2023-06-22 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D – Moderate Harm Potential |
| 2023-06-22 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | D – Moderate Harm Potential |
| 2023-06-22 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | D – Moderate Harm Potential |
Total Penalties & Fines
$127,566
Total Fine Amount (CMS)
4
Number of Fines
5
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-05-06 | Fine | $12,763 | - |
| 2026-05-06 | Fine | $15,340 | - |
| 2025-08-28 | Fine | $87,019 | - |
| 2025-08-28 | Payment Denial | - | 47 days starting 2025-10-02 |
| 2025-06-04 | Fine | $12,444 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the BILLINGS area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.