Cycle 1
Health 2025-08-28 · Fire 2025-08-28
23 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Billings, MT
Yellowstone River Nursing And Rehabilitation
1-star overall rating with 1-star inspections with $141,504 in total fines with 22 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
2115 Central Ave, Billings, MT
(406) 656-6500
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eduro Healthcare
Operator or chain grouping
Approved since
1969-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.94 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.97 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.69 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,069
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9944
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8
Baseline 20.35% · Performance 17.73% · Measure score 8 · Achievement 8 · Improvement 7.40
Healthcare-associated infections
7.79
Baseline 6.17% · Performance 5.51% · Measure score 7.79 · Achievement 7.79 · Improvement 5.16
Total nurse turnover
0.79
Baseline 64.71% · Performance 60.44% · Measure score 0.79 · Achievement 0.79 · Improvement 0.57
Adjusted total nurse staffing
0
Baseline 3.87 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.12% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 304 · Observed rate 7.89% · Lower 95% interval 6.96% |
| Discharge to community | 60.63% |
50.57%
10.1 pts better
|
Better than the National Rate · Eligible stays 285 · Observed rate 55.79% · Lower 95% interval 54.26% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.15% |
95.27%
1.1 pts worse
|
Numerator 161 · Denominator 171 |
| Falls with major injury | 1.75% |
0.77%
1 pts worse
|
Numerator 3 · Denominator 171 |
| Discharge self-care score | 49.22% |
53.69%
4.5 pts worse
|
Numerator 63 · Denominator 128 |
| Discharge mobility score | 40.63% |
50.94%
10.3 pts worse
|
Numerator 52 · Denominator 128 |
| Pressure ulcers or injuries, new or worsened | 2.92% |
2.29%
0.6 pts worse
|
Numerator 5 · Denominator 171 · Adjusted rate 3.64% |
| Healthcare-associated infections requiring hospitalization | 5.51% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 3.27% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 7.96% |
8.2%
0.2 pts worse
|
Numerator 9 · Denominator 113 |
| Staff flu vaccination coverage | 18.3% |
42%
23.7 pts worse
|
Numerator 28 · Denominator 153 |
| Discharge function score | 43.75% |
56.45%
12.7 pts worse
|
Numerator 56 · Denominator 128 |
| Transfer of health information to provider | 98.72% |
95.95%
2.8 pts better
|
Numerator 77 · Denominator 78 |
| Transfer of health information to patient | 89.55% |
96.28%
6.7 pts worse
|
Numerator 60 · Denominator 67 |
| Resident COVID-19 vaccinations up to date | 28.24% |
25.2%
3 pts better
|
Numerator 24 · Denominator 85 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.4%
5.3 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
93.7%
5.2 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
4.2%
1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.4% · Q3 4.6% · Q4 1.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
4.7%
2.3 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.2% · Q3 3.6% · Q4 1.2% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.9%
0.5 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.7% · Q3 6.4% · Q4 4.9% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.7% |
17.4%
20.3 pts worse
|
19.6%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.9% · Q2 50.6% · Q3 17.1% · Q4 16.9% · 4Q avg 37.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.1% |
20.6%
14.5 pts worse
|
16.7%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.6% · Q2 38.8% · Q3 31.9% · Q4 31.4% · 4Q avg 35.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.2% |
19.7%
5.5 pts worse
|
16.3%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 21.0% · Q3 9.5% · Q4 44.6% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.9% |
19.8%
4.1 pts worse
|
14.9%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.9% · Q3 23.1% · Q4 35.0% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
2.6%
About the same
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.0% · Q3 1.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.9%
1.7 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
25.4%
3.3 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 19.9% · Q3 26.0% · Q4 34.9% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
6.4%
2 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 7.1% · Q4 5.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
78.7%
13.7 pts better
|
81.7%
10.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 93.3% · Q3 93.4% · Q4 83.9% · 4Q avg 92.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.8% |
15.0%
4.8 pts worse
|
12.0%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 20.2% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.6%
0.8 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.1% · Q3 1.1% · Q4 1.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.8% |
73.8%
19 pts better
|
79.7%
13.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.2% |
19.4%
8.8 pts worse
|
23.9%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.2% · Observed 28.7% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-18 · Fire 2024-07-18
17 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-06-22 · Fire 2023-06-22
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-28
F · Potential for more than minimal harm
2025-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-28
F · Potential for more than minimal harm
2025-08-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-28
F · Potential for more than minimal harm
2025-08-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-28
F · Potential for more than minimal harm
2025-08-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-28
E · Potential for more than minimal harm
2025-08-28
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-09-28
E · Potential for more than minimal harm
2025-08-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-09-28
E · Potential for more than minimal harm
2025-08-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-08-28
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-11-18
F · Potential for more than minimal harm
2024-07-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-07-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-07-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-07-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-07-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-18
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-09-01
F · Potential for more than minimal harm
2023-06-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-06-22
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-06-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-06-22
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-06-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-06-22
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-08-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
E · Potential for more than minimal harm
2025-11-19
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-12-14
D · Potential for more than minimal harm
2025-11-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-14
D · Potential for more than minimal harm
2025-11-19
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-12-14
D · Potential for more than minimal harm
2025-11-19
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-12-14
D · Potential for more than minimal harm
2025-11-19
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-12-14
G · Actual harm
2025-08-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-19
G · Actual harm
2025-08-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-08-28
F585 · Resident Rights Deficiencies
Health
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 2025-09-19
E · Potential for more than minimal harm
2025-08-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-19
J · Immediate jeopardy
2025-06-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-06-05
F726 · Nursing and Physician Services Deficiencies
Health
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 2025-06-20
D · Potential for more than minimal harm
2025-06-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-03-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F559 · Resident Rights Deficiencies
Health
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 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F918 · Environmental Deficiencies
Health
Provide a bathroom in or located near each resident’s room.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-27
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-04-18
D · Potential for more than minimal harm
2024-12-17
F758 · Pharmacy Service Deficiencies
Health
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 2025-01-15
F · Potential for more than minimal harm
2024-07-18
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-07-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-07-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-07-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-07-18
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-07-18
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-07-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-07-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-07-18
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-18
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-09-05
E · Potential for more than minimal harm
2023-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-10-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-10-26
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-10-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-10-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-10-26
F758 · Pharmacy Service Deficiencies
Health
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 2023-11-21
G · Actual harm
2023-06-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-21
G · Actual harm
2023-06-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-22
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-22
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-22
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-22
F726 · Nursing and Physician Services Deficiencies
Health
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 2023-07-21
Penalties and ownership
What sits behind the stars
$87,019
2025-08-28
Fine
Fine · fine $87,019
Fine
$0
2025-08-28
Payment Denial
Payment Denial · denial start 2025-10-02 · 47 days
47 day denial
$12,444
2025-06-04
Fine
Fine · fine $12,444
Fine
$38,896
2023-06-22
Fine
Fine · fine $38,896
Fine
$3,145
2023-06-12
Fine
Fine · fine $3,145
Fine
Ownership
Bewsey, Michael
5% Or Greater Indirect Ownership Interest · Individual
Eduro Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Bewsey, Michael
Corporate Officer · Individual
Caldwell, Sarah
W-2 Managing Employee · Individual
Monroe, Dustin
Corporate Officer · Individual
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