Map showing the location of YELLOWSTONE RIVER NURSING AND REHABILITATION in BILLINGS, Montana
2115 CENTRAL AVE, BILLINGS, MT, 59102

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • MontanaLowest tier among peers59 rated homes · average 2.9★
  • Yellowstone CountyLowest tier among peers6 rated homes · average 2.0★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs MT avg
  • StaffingCan add or remove a star2★−1.5 vs MT avg
  • Quality measuresCan add or remove a star2★−1.0 vs MT avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersMT avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 10% of peersMT avg3.5★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 10% of peersMT avg3.0★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.35hrsAbove only 42% of peersMT avg3.97Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.72hrsAbove only 35% of peersMT avg0.94Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better70%Above only 20% of peersMT avg56%RN turnover69%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$188,360Above only 3% of peersMT avg$55,122Fines · denials4 · 1
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
54citations
9inspection dates
4actual harm (G–I)
1immediate jeopardy (J–L)
Dec 31, 2025most recent

Citations by monthJun 2023 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 31, 20251 citationCycle 1worst D · no actual harm
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrection pending
Nov 19, 20255 citationsCycle 1worst E · no actual harm
  1. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected Dec 14, 2025
  2. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Dec 14, 2025
  3. F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Nursing and Physician ServicesD · isolatedCorrected Dec 14, 2025
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Dec 14, 2025
  5. F850Hire a qualified full-time social worker in a facility with more than 120 beds.AdministrationE · patternCorrected Dec 14, 2025
Aug 28, 20257 citationsCycle 1worst G · actual harm$133,875, payment denial
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 19, 2025
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Sep 19, 2025
  3. F585Honor 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.Resident RightsE · patternCorrected Sep 19, 2025
  4. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Sep 19, 2025
  5. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Sep 19, 2025
  6. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Sep 19, 2025
  7. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Sep 19, 2025
Jun 5, 20254 citationsCycle 1worst J · immediate jeopardy$12,444
  1. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected Jun 20, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Jun 20, 2025
  3. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jun 20, 2025
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 20, 2025
Mar 27, 20256 citationsCycle 1worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Apr 18, 2025
  2. Provide a bathroom in or located near each resident’s room.EnvironmentalD · isolatedCorrected Apr 18, 2025
  3. F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Resident RightsD · isolatedCorrected Apr 18, 2025
  4. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Apr 18, 2025
  5. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Apr 18, 2025
  6. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Apr 18, 2025
Dec 17, 20241 citationCycle 2worst D · no actual harm
  1. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Jan 15, 2025
Jul 18, 202416 citationsCycle 2worst F · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Sep 5, 2024
  2. F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsE · patternCorrected Sep 5, 2024
  3. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Sep 5, 2024
  4. F584Honor 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.Resident RightsE · patternCorrected Sep 5, 2024
  5. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 5, 2024
  6. F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Sep 5, 2024
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 5, 2024
  8. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Sep 5, 2024
  9. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Sep 5, 2024
  10. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Sep 5, 2024
  11. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationD · isolatedCorrected Sep 5, 2024
  12. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Sep 5, 2024
  13. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 5, 2024
  14. F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Sep 5, 2024
  15. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Sep 5, 2024
  16. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 1, 2024
Oct 26, 20236 citationsCycle 3worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Nov 21, 2023
  2. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Nov 21, 2023
  3. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Nov 21, 2023
  4. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 21, 2023
  5. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Nov 21, 2023
  6. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 21, 2023
Jun 22, 20238 citationsCycle 3worst G · actual harm$38,896, $3,145
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 21, 2023
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Jul 21, 2023
  3. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Jul 21, 2023
  4. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 21, 2023
  5. F584Honor 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.Resident RightsE · patternCorrected Jul 21, 2023
  6. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jul 21, 2023
  7. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Jul 21, 2023
  8. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Jul 21, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.35hrsAbove only 42% of peers−0.62 vs MT avg
  • Registered nursesRN hours only0.72hrsAbove only 35% of peers−0.22 vs MT avg
  • Licensed practical nursesLPN hours0.62hrs
  • Nurse aidesCNA hours2.02hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.95hrs
  • Montana average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better70%Above only 20% of peersMT avg 56%
  • RN turnoverRegistered nurses only69%Not ranked by CMS
  • Administrators who leftIn the past year2Leadership changed
  • Occupancy160 certified beds · ~112 residents a day70%Above 54% of peersMT avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $188,360In fines
  • 4Fines
  • 1Payment denial
  • $55,122MT avg in fines
Above only 3% of peersFewer fines than 3% of rated homes in Montana

Actions on record

  1. Aug 28, 2025Civil money penalty$133,875
  2. Aug 28, 2025Denial of payment for new admissionsfrom Oct 2, 2025
  3. Jun 4, 2025Civil money penalty$12,444
  4. Jun 22, 2023Civil money penalty$38,896
  5. Jun 12, 2023Civil money penalty$3,145

Ownership

As filed with CMS

Structure

Ownership type
For profit - Individual
Chain
Eduro Healthcare37 facilities in the chain2.3★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Eduro Healthcare LLC
Indirect owners (5%+)
  • Michael Bewsey
Corporate officers
  • Michael Bewsey
  • Dustin Monroe
Managing employees
  • Sarah Caldwell

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 275029 · 2115 CENTRAL AVE, BILLINGS, MT, 59102.
  • Percentiles compare this facility with every rated nursing home in Montana and Yellowstone County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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