BILLINGS, MT - Federal health inspectors cited Yellowstone River Nursing and Rehabilitation for five deficiencies following a complaint investigation in November 2025, including a failure to provide adequate medically-related social services to help residents achieve the highest possible quality of life.
Complaint Investigation Reveals Multiple Deficiencies
The Centers for Medicare & Medicaid Services (CMS) conducted a complaint investigation at the Billings facility on November 19, 2025, resulting in citations across multiple areas of care. Among the findings, inspectors determined the facility fell short under regulatory tag F0745, which requires nursing homes to provide medically-related social services that support each resident's well-being and quality of life.
The deficiency was classified at Scope/Severity Level D, meaning it was isolated in nature and did not result in documented actual harm. However, inspectors determined there was potential for more than minimal harm to residents — a designation that signals real risk even in the absence of an immediate adverse outcome.
The F0745 citation was one of five total deficiencies identified during the investigation, indicating a pattern of concerns that prompted the federal review.
What Medically-Related Social Services Require
Federal regulations mandate that nursing homes employ or contract qualified social services staff to address the psychosocial and emotional needs of residents. Under 42 CFR § 483.40, facilities with more than 120 beds must employ a full-time qualified social worker, while smaller facilities must still provide appropriate social services.
These services are not optional amenities. They are a core component of resident care that includes adjustment counseling for residents adapting to facility life, assistance with discharge planning, coordination with families and outside agencies, help resolving grievances, and support for residents experiencing depression, anxiety, or social isolation.
When a facility fails to deliver these services, residents may experience declining mental health, increased feelings of isolation, and difficulty navigating important decisions about their own care. For elderly residents who may have limited family involvement or outside support networks, facility-based social services often represent their primary connection to psychosocial support.
The Broader Context of Five Citations
While CMS has not publicly detailed all five deficiencies from this investigation, the fact that a complaint investigation yielded multiple citations suggests the concerns raised in the original complaint had merit. Complaint investigations differ from routine annual surveys in that they are triggered by specific allegations — often filed by residents, family members, or staff — and are typically conducted on an unannounced basis.
A single complaint investigation resulting in five separate deficiency findings indicates inspectors identified problems beyond the scope of the original complaint. This can occur when surveyors, while investigating one concern, observe additional areas of noncompliance during their on-site review.
Nursing homes in Montana are subject to both federal CMS oversight and state-level regulation through the Montana Department of Public Health and Human Services. Facilities that receive deficiency citations must submit a formal plan of correction outlining specific steps to address each finding.
Facility Response and Correction Timeline
Yellowstone River Nursing and Rehabilitation submitted a plan of correction and reported that the identified deficiencies were corrected as of December 14, 2025 — approximately 25 days after the inspection. The facility's status remains listed as deficient with an accepted plan of correction.
A plan of correction does not constitute an admission of the deficiency findings but represents the facility's commitment to implementing changes that bring operations into compliance with federal standards. CMS and state agencies may conduct follow-up visits to verify that corrective measures have been effectively implemented.
What Families Should Know
Families with loved ones residing at Yellowstone River Nursing and Rehabilitation, or those considering placement there, can review the facility's complete inspection history through the CMS Care Compare database. This federal tool provides detailed information about deficiency citations, staffing levels, quality measures, and overall star ratings for every Medicare- and Medicaid-certified nursing home in the country.
Residents and family members who have concerns about care quality at any nursing facility can file complaints with the Montana Long-Term Care Ombudsman Program or directly with the state health department. These reports can be made anonymously and may trigger additional investigation.
The full inspection report, including details on all five deficiencies cited during the November 2025 investigation, is available through federal and state regulatory databases.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Yellowstone River Nursing and Rehabilitation from 2025-11-19 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.