Inspection Reports for Yellowstone River Nursing and Rehabilitation

MT, 59102

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 19.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

240% worse than Montana average
Montana average: 5.8 deficiencies/year

Deficiencies per year

16 12 8 4 0
2023
2024
2025

Census

Latest occupancy rate 100% occupied

Based on a December 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Census over time

0 50 100 150 200 Nov 2025 Dec 2025

Inspection Report

Complaint Investigation
Census: 2 Capacity: 2 Deficiencies: 1 Date: Dec 31, 2025

Visit Reason
The inspection was conducted following a complaint regarding delayed staff response to a resident's call light for assistance with activities of daily living.

Complaint Details
The complaint involved resident #4 who had to wait over four hours for staff assistance after activating the call light. The family contacted the police due to lack of facility response. The facility's investigation confirmed delayed response but no psychosocial harm or skin breakdown. Staff involved were disciplined and re-educated.
Findings
The facility failed to ensure timely staff response to a resident's needs, resulting in a delay of over four hours in assisting a resident with personal care. The facility identified the issue, disciplined involved staff, and provided re-education on call light policies and nursing rounds.

Deficiencies (1)
Failure to provide timely assistance to a resident requiring help with activities of daily living.
Report Facts
Call light response time: 281 Sampled residents: 7 Residents affected: 1

Inspection Report

Annual Inspection
Census: 115 Capacity: 160 Deficiencies: 5 Date: Nov 19, 2025

Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Yellowstone River Nursing and Rehabilitation.

Findings
The facility was found deficient in several areas including failure to develop and implement comprehensive person-centered care plans with measurable objectives, failure to ensure provider review of residents' total program of care, failure to provide necessary behavioral health care and services, failure to provide individualized medically-related social services, and failure to employ a qualified full-time social worker as required for the facility size.

Deficiencies (5)
Failed to include person-centered information in resident care plans with measurable objectives and timeframes for medical, nursing, and psychosocial needs for 2 of 8 sampled residents.
Failed to ensure a provider reviewed a resident's total program of care during a single visit, resulting in incomplete assessments and risk of inadequate care.
Failed to ensure each resident received necessary behavioral health care and services, including failure to assist a resident requesting mental health counseling.
Failed to provide individualized medically-related social services and accurately assess a resident's mood, behavior, and psychosocial status, with inadequate care plan interventions and lack of referrals for mental health services.
Failed to hire and employ a qualified full-time social worker meeting regulatory requirements for a facility with more than 120 beds.
Report Facts
Residents sampled: 8 Facility licensed capacity: 160 Facility census: 115 Deficiencies cited: 5

Employees mentioned
NameTitleContext
Staff member F Social Services Director Named in relation to failure to provide behavioral health services and social work qualifications
Staff member A Provided information about social services staffing and facility census
Staff member B Part of interdisciplinary team adding information to care plans
Staff member C Part of interdisciplinary team reviewing care plans and grievances
Staff member D Provider Provider who saw resident #4 for one visit and was fired by resident

Inspection Report

Routine
Deficiencies: 7 Date: Aug 28, 2025

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, treatment, and facility operations at Yellowstone River Nursing and Rehabilitation.

Findings
The facility was found deficient in multiple areas including failure to respect resident personal belongings, lack of wheelchair-accessible grievance box, failure to follow doctor's orders for edema treatment and oxygen therapy, inadequate pressure ulcer care, failure to prevent pressure ulcer development, failure to provide adequate nutrition and assistance, and delays in timely meal delivery to residents' rooms.

Deficiencies (7)
Failed to respect a resident's personal items by cleaning the room and disposing of items without resident presence or awareness.
Failed to provide a wheelchair-accessible grievance box for residents to submit grievances independently or anonymously.
Failed to follow doctor's orders for edema treatment for two residents, including lack of use of compression stockings and leg elevation.
Failed to prevent development and properly document a pressure ulcer for one resident, including inconsistent wound staging and inadequate assessment.
Failed to provide adequate nutritional assistance and monitoring for a resident with severe weight loss and new diagnosis of Severe Protein Calorie Malnutrition.
Failed to follow doctor's orders for oxygen treatment related to CPAP and nasal cannula administration, including lack of oxygen signage and empty oxygen tanks.
Failed to ensure resident meal trays were served timely and at appropriate temperatures, causing residents to experience hunger and receive lukewarm food.
Report Facts
Residents sampled: 26 Weight loss percentage: 7.65 CPAP application rate: 58 CPAP application rate: 90 CPAP application rate: 65 CPAP application rate: 68 Pressure ulcer measurement: 3 Pressure ulcer measurement: 4.4 Pressure ulcer measurement: 0.4

Employees mentioned
NameTitleContext
Staff member B Mentioned in relation to cleaning resident #53's room and oxygen therapy issues
Staff member Q Mentioned regarding conversation about resident #53's room cleaning permissions
Staff member A Mentioned regarding lack of policy on hoarding and room cleaning
Staff member L Mentioned regarding edema treatment for resident #12
Staff member K Mentioned regarding edema treatment and charting
Staff member J Mentioned regarding nurse responsibilities for ace wraps
Staff member M Mentioned regarding application and removal of ace wraps for resident #80
Staff member T Authored skin check progress note for resident #80
Staff member P Mentioned regarding resident #5's weight loss and wound care
Staff member U Mentioned regarding concerns about resident repositioning and pressure ulcers
Staff member V LPN Mentioned regarding wound care and assessment for resident #5
Staff member S Mentioned regarding resident #94's drowsiness and meal intake
Staff member R Mentioned regarding resident #94's therapy and recovery
Staff member O Mentioned regarding oxygen tank status for resident #12
Staff member C Mentioned regarding meal tray delivery issues
Staff member D Mentioned regarding meal tray delivery and facility goals
Staff member E Mentioned regarding meal tray delivery timing
Staff member F Mentioned regarding resident complaints about cold food and meal service process

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: Jun 5, 2025

Visit Reason
The inspection was conducted due to a complaint investigation involving a resident who eloped from the facility through unsecured doors not equipped with a wander guard alarm system, placing residents at risk of elopement and harm.

Complaint Details
The complaint investigation was triggered by an incident on 3/28/25 where resident #1 eloped from the facility through unsecured doors not equipped with wander guard alarms, leaving the facility property and traveling 0.2 miles unsupervised. The facility was found to have failed to identify and secure all exit doors and failed to properly monitor the wander guard alarm system, placing residents at risk of elopement and harm.
Findings
The facility failed to prevent elopement of a resident with traumatic brain injury who exited through unsecured doors without staff supervision, failed to identify and secure all exit doors with wander guard alarms, and failed to ensure staff properly monitored the functionality of the wander guard alarm system. The facility also failed to update a resident's care plan with new fall interventions and ensure staff competency in monitoring wander guard devices.

Deficiencies (4)
Failed to complete a thorough investigation and address unsecured exit doors not equipped with wander guard alarm system, allowing resident elopement.
Failed to update a resident care plan with a new fall intervention identified by the interdisciplinary team.
Failed to prevent Immediate Jeopardy level accidents and hazards resulting in resident elopement through unsecured doors without staff supervision.
Failed to ensure nurses and nurse aides had the necessary education to monitor the functionality of the wander guard alarm system for residents at risk of wandering and elopement.
Report Facts
Residents sampled for wandering and elopement risk: 9 Residents affected by Immediate Jeopardy level hazard: 5 Residents with wander guard alarm devices: 6 Distance resident eloped: 0.2 Time resident #1 was missing: 45 Date of resident #1 elopement incident: Mar 28, 2025 Date of survey completion: Jun 5, 2025

Employees mentioned
NameTitleContext
Staff member C Interviewed regarding resident #1's elopement, IDT review, and wander guard alarm system usage
Staff member B Interviewed regarding resident #7's fall and care plan update
Staff member E Observed unsecured doors and discussed resident #1's elopement
Staff member D Reported observations during resident #1's elopement and return
Staff member I Interviewed about wander guard alarm system checks and functionality
Staff member L Interviewed about wander guard alarm system policy and usage
Staff member J Interviewed about orientation and wander guard alarm system checks
Staff member H Maintenance department staff interviewed about door alarm checks

Inspection Report

Complaint Investigation
Deficiencies: 6 Date: Mar 27, 2025

Visit Reason
The inspection was conducted based on complaints regarding resident care, room changes without proper notification, failure to notify family of resident transfers, food temperature issues, and inadequate resident room facilities including lack of bathroom, sink, and call light.

Complaint Details
The visit was complaint-related, triggered by concerns about resident #7's placement in an inadequate room, lack of notification for room changes for residents #7 and #8, failure to notify family of resident #1's hospital transfer, and food temperature complaints.
Findings
The facility failed to provide equal access to quality care for resident #7 by placing him in a room without a sink, bathroom, or call light, and sleeping on a mattress on the floor. The facility also failed to provide written notice for room changes for residents #7 and #8, failed to notify a resident's representative of a transfer to a higher level of care, served meals at cold temperatures causing dissatisfaction, and did not ensure each resident room was equipped with a sink, toilet, or functioning call light.

Deficiencies (6)
Failed to provide equal access to quality care for resident #7 by placing him in a room without a sink, bathroom, or call light, and sleeping on a mattress on the floor.
Failed to provide written notice for room changes for residents #7 and #8, including the reason for the change.
Failed to notify resident #1's representative of a change in condition necessitating transfer to a higher level of care.
Failed to ensure meals were served at an appetizing temperature, resulting in resident dissatisfaction.
Failed to ensure each resident room was equipped with a sink and toilet for resident #7.
Failed to ensure each resident's sleeping area had a functioning call light for resident #7.
Report Facts
Residents sampled: 18 Residents affected: 1 Residents affected: 2 Residents affected: 1 Residents affected: 4

Employees mentioned
NameTitleContext
NF3 Interviewed regarding resident #7's placement in the Country Store without proper facilities
Staff member C Interviewed about room changes and attempts to place resident #7
Staff member G Interviewed about resident #7's placement and care in the Country Store
Staff member B Interviewed about resident #7's sleeping arrangements
Staff member A Interviewed about resident #7's placement and awareness of mattress placement
NF1 Interviewed about lack of notification for room changes for resident #7
NF4 Interviewed about lack of notification for room changes for resident #8
NF5 Interviewed about lack of notification for resident #1's transfer to hospital
Staff member I Interviewed about complaints regarding cold food

Inspection Report

Annual Inspection
Deficiencies: 2 Date: Dec 17, 2024

Visit Reason
The inspection was conducted to assess compliance with regulations regarding the use of psychotropic medications, including gradual dose reductions and appropriate documentation, at Yellowstone River Nursing and Rehabilitation.

Findings
The facility failed to ensure PRN anti-anxiety medication was limited to 14 days for one resident and failed to provide adequate indication for antipsychotic use for another resident. Documentation of behaviors and side effects related to psychotropic medications was inadequate, and interventions to prevent side effects were lacking.

Deficiencies (2)
Failure to limit PRN anti-anxiety medication to 14 days for resident #49 and failure to provide adequate indication for antipsychotic use for resident #99.
Inadequate documentation of behaviors and side effects related to psychotropic medications and lack of interventions to prevent side effects.
Report Facts
Side effects occurrences: 14 Medication monitoring instances: 6 Medication dose change date: Oct 30, 2024 Medication start date: Nov 4, 2024

Employees mentioned
NameTitleContext
Staff member B Interviewed on 12/17/24 regarding documentation and interdisciplinary team practices related to psychotropic medication.
Physician assistant Documented increased agitation and physical altercations, ordered medication changes for resident #99.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Jul 18, 2024

Visit Reason
The inspection was conducted due to allegations of abuse by a staff member towards two residents, #304 and #305, during care and transfers.

Complaint Details
The abuse allegation was substantiated on 3/27/24 following investigation of complaints from residents #304 and #305. NF4 was suspended immediately and refused to provide a statement or return to work. Abuse training was provided to all staff and the incident was discussed in QAPI.
Findings
The facility failed to ensure residents were free from abuse by a staff member, NF4, who was reported to be rough during care and used degrading language. The abuse allegations were substantiated, NF4 was suspended and did not return to work, and the facility provided abuse training to all staff.

Deficiencies (1)
Failed to protect residents from abuse by a staff member, including rough handling and degrading language.
Report Facts
Residents sampled: 43 Residents affected: 2

Inspection Report

Routine
Deficiencies: 15 Date: Jul 18, 2024

Visit Reason
The inspection was conducted as a routine regulatory survey of Yellowstone River Nursing and Rehabilitation to assess compliance with healthcare facility regulations and standards.

Findings
The facility was found deficient in multiple areas including failure to invite residents to care plan meetings, inadequate accommodation of resident needs, unsanitary environment with pest issues, abuse by a staff member, improper use of restraints, ineffective foot care, trip hazards, improper medication disposal, medication errors, lack of qualified dietary management, poor kitchen sanitation and pest control, malfunctioning kitchen equipment, and ineffective infection control practices.

Deficiencies (15)
Failed to invite residents to care plan meetings for 4 of 43 sampled residents.
Failed to provide services to enable residents to maintain their highest practicable level of functioning for 1 of 43 sampled residents.
Failed to provide a clean and sanitary environment for 3 residents and failed to consistently clean hallway and resident rooms for 2 residents.
Failed to ensure residents were free from abuse by a staff member for 2 of 43 sampled residents.
Failed to identify a concave mattress as a potential restraint and did not complete risk assessment, consent, or monitoring for 1 of 2 residents sampled for restraints.
Failed to ensure effective foot care for diabetic resident with long, curling toenails.
Failed to identify trip hazard from twin-size scoop mattress and failed to protect resident from hazardous bug spray stored openly.
Failed to ensure discontinued medications were properly disposed of or destroyed for 2 of 43 sampled residents.
Medication error rate was 11.54%, exceeding 5% threshold, with multiple errors for 2 of 43 sampled residents.
Failed to employ a Certified Dietary Manager and lacked regular dietitian oversight, resulting in multiple dietary service deficiencies.
Failed to maintain sanitary kitchen and dietary storage areas, including lack of beard coverings, unlabeled and undated food items, pest infestation, and unclean equipment.
Failed to identify, correct, and monitor quality deficiencies related to kitchen cleanliness and pest control through QAPI program.
Failed to ensure safe and proper operation of kitchen equipment including ovens, dessert refrigerator, cooks' refrigerator, and ice machine.
Failed to maintain an effective pest control program; mouse droppings and ants observed in kitchen and resident areas.
Failed to ensure enhanced barrier precautions during wound care and medication administration through feeding tube; failed to repair worn recliner creating uncleanable surface.
Report Facts
Sampled residents: 43 Medication error rate: 11.54 Discontinued insulin pens found: 19 Days storeroom cleaned: 15 Pest control visits: 11

Employees mentioned
NameTitleContext
NF4 Nursing staff Named in abuse findings for rough care and suspension
Staff member G Medication administration staff Admitted to medication administration errors
Staff member A Facility staff Discussed abuse training, QAPI, and pest control awareness
Staff member E Dietary staff Discussed kitchen conditions, pest control, and lack of beard coverings
Staff member S Dietary staff Observed not wearing beard covering while preparing food
Staff member B Staff Reported on care plan meetings and infection control practices
Staff member Q Staff Discussed medication disposal and infection control practices
Staff member C Staff Interviewed residents during abuse investigation
Staff member F Dietitian Discussed dietitian visits and oversight
Staff member N Staff Commented on damaged recliner needing disposal
Staff member U Staff Discussed use of concave mattress and trip hazard
Staff member H Nursing staff Observed not wearing gown during wound care and feeding tube medication administration
Staff member K Staff Reported observing ants in facility
Staff member L Staff Reported bugs flying through windows and unknown resolution
Staff member J Staff Acknowledged bug problem and cleaning responsibilities
Staff member V Maintenance staff Discussed equipment repair notifications
Staff member T Dietary staff Observed serving food without beard covering

Inspection Report

Complaint Investigation
Deficiencies: 6 Date: Oct 26, 2023

Visit Reason
The inspection was conducted due to complaints and concerns regarding resident dignity, consent for medication, call light accessibility, investigation of alleged violations, psychotropic medication use, and infection control practices during a COVID-19 outbreak.

Complaint Details
The complaint investigation involved incidents including disrespectful staff behavior, failure to obtain medication consent, call light accessibility issues, inadequate investigation of a resident dignity violation, improper psychotropic medication orders, and infection control lapses during a COVID-19 outbreak. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in respecting resident dignity, obtaining consent for antipsychotic medication, ensuring call light accessibility, thoroughly investigating alleged violations, limiting PRN antipsychotic medication orders to 14 days, and adhering to infection control practices during a COVID-19 outbreak.

Deficiencies (6)
Nursing staff failed to respect a resident's dignity by drawing a smiley face on a resident's buttocks and speaking disrespectfully to another resident.
Facility failed to obtain verbal or written consent or explain risks versus benefits with a resident's POA prior to giving an anti-psychotic medication.
Facility failed to ensure a resident had her call light within reach, causing the resident to yell out for help instead of using the call light.
Facility failed to investigate a facility reported incident thoroughly for a resident found with a smiley face on her buttock and implement protective measures.
Facility failed to limit an as needed anti-psychotic medication order to 14 days.
Facility failed to adhere to infection control practices for transmission-based precautions during a COVID-19 outbreak.
Report Facts
Residents sampled: 15 Residents affected: 1 Date of survey completed: Oct 26, 2023 Medication administration time: 1.37 Staff interviewed: 3 Staff working night shift: 11 Staff working day shift: 14

Employees mentioned
NameTitleContext
Staff member N Interviewed regarding resident #10's care and investigation of smiley face incident
Staff member O Assisted with resident #10's care and reported smiley face incident
Staff member B Wrote IDT progress note on root cause of smiley face incident and interviewed about medication consent and investigation
Staff member Q Wrote nursing note documenting smiley face on resident #10
Staff member M Interviewed about dementia care training
Staff member L Interviewed about care of resident #12 and handling agitation
Staff member A Involved in staff education and infection control
Staff member C Provided infection control education and audits
Staff member D Conducted investigation of smiley face incident
Staff member I Observed with mask down during COVID-19 outbreak
Staff member J Observed not using PPE properly during COVID-19 outbreak
Staff member K Observed with mask improperly worn during COVID-19 outbreak

Inspection Report

Complaint Investigation
Deficiencies: 6 Date: Jun 22, 2023

Visit Reason
The inspection was conducted based on complaints and observations regarding inadequate care, cleanliness, and safety issues at Yellowstone River Nursing and Rehabilitation.

Complaint Details
The visit was complaint-related, triggered by allegations of neglect, inadequate care, and unsafe conditions leading to resident harm and distress. Substantiation status is not explicitly stated.
Findings
The facility failed to maintain a clean environment, provide adequate assistance with activities of daily living, prevent pressure ulcers, ensure resident safety, maintain adequate staffing, and ensure staff competency. Multiple residents experienced neglect, pain, emotional distress, pressure ulcers, falls, and inadequate hygiene care.

Deficiencies (6)
Facility staff failed to provide a clean homelike environment, with dead insects in light fixtures noticed by residents.
Facility staff failed to provide necessary ADL care and services to residents, leading to pain and emotional distress.
Facility failed to implement appropriate measures to prevent skin breakdown and timely identify pressure ulcers, resulting in multiple pressure ulcers and infections for a resident.
Facility staff failed to ensure adequate supervision and use of assistive devices to prevent accidents, resulting in falls with fractures and unsafe use of mechanical lifts.
Facility failed to provide adequate staffing to meet resident care needs, including timely response to call lights and scheduled showers.
Facility failed to ensure staff competency in providing care to prevent worsening of pressure ulcers and maintain cleanliness of resident bathrooms.
Report Facts
Residents sampled: 20 Residents affected: 8 Residents affected: 10 Residents affected: 2 Residents affected: 1 Residents affected: 2 Pressure ulcers developed: 7 Deep Tissue Injuries: 4 Hours of no incontinence care: 36

Employees mentioned
NameTitleContext
Staff member H Responsible for pressure ulcer care for resident #108; suspended due to incompetency
Staff member A Reported suspension of staff member H and inability to discuss resident #108's decline
Staff member W Failed to use knee straps during sit-to-stand lift transfers for resident #21
Staff member I Involved in care of resident #122 during neglect incident
Staff member K Involved in care of resident #122 during neglect incident
Staff member S Reported assessment of resident #122 and found pressure ulcer on resident #108's left ear
Staff member M Involved in care of resident #122 and commented on staff education
Staff member J Commented on lack of orientation and competency checklist review
Staff member O Bath aide mentioned by resident #60 regarding shower availability
Staff member P Reported belief that night shift staffing was cut and CNAs need more help
Staff member U Reported resident #32 did not have or use a fall mat
Staff member C Commented on cleaning schedule for lighting fixtures
Staff member G Responsible for cleaning lighting fixtures
Staff member R Named by resident #28 as staff who failed to assist

Inspection Report

Routine
Deficiencies: 6 Date: Jun 22, 2023

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, staffing, infection control, and facility environment at Yellowstone River Nursing and Rehabilitation.

Findings
The facility was found deficient in multiple areas including failure to maintain a clean and homelike environment, incomplete significant change assessments, inadequate supervision and use of assistive devices leading to falls, insufficient staffing impacting resident care and timely response, lack of staff competency in wound care and cleanliness, poor infection prevention practices including hand hygiene and cleaning of equipment, and unsanitary conditions in shared resident bathrooms.

Deficiencies (6)
Facility staff failed to provide a clean homelike environment, including cleaning bugs out of light fixtures in the Sapphire unit hallway.
Facility failed to complete a Significant Change MDS Assessment for a resident receiving hospice services.
Facility staff failed to ensure adequate supervision and safe use of assistive devices, resulting in falls with fractures and increased fall risk.
Facility failed to provide adequate staffing to meet resident care needs, including timely response to call lights and scheduled showers.
Facility failed to ensure staff competency in wound care and cleanliness of resident bathrooms.
Facility staff failed to maintain proper hand hygiene, clean and disinfect sit-to-stand lifts after use, maintain infection prevention surveillance and water management programs, and address unsanitary conditions in resident bathrooms.
Report Facts
Residents sampled: 20 Residents affected: 8 Residents affected: 10 Residents affected: 2 Residents affected: 3 Residents affected: 3 Pressure ulcers developed: 7

Employees mentioned
NameTitleContext
Staff member W Named in findings related to failure to use sit-to-stand lift safely and failure to maintain hand hygiene
Staff member X Named in findings related to improper wound care and glove use
Staff member H Named in findings related to wound care competency and suspension
Staff member B Named in findings related to infection control education and bathroom cleanliness
Staff member I Named in findings related to failure to maintain hand hygiene and proper care during resident transfer
Staff member J Named in findings related to failure to maintain hand hygiene and lack of competency training
Staff member C Named in findings related to water management program and infection control
Staff member P Named in findings related to staffing levels
Staff member U Named in findings related to fall prevention and use of fall mats
Staff member V Named in findings related to response to resident call light
Staff member T Named in findings related to housekeeping and bathroom cleaning
Staff member A Named in findings related to suspension of staff member H and wound care competency

Inspection Report

Annual Inspection
Deficiencies: 0 Date: Mar 9, 2023

Visit Reason
The inspection was conducted as an annual survey of Yellowstone River Nursing and Rehabilitation to assess compliance with health and safety regulations.

Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected are unknown.

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