Yellowstone River Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Yellowstone River Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 5, 2025

  Based on observation, interview, and record review, the facility failed to prevent Immediate Jeopardy level accidents and hazards resulting in a resident with a traumatic brain injury eloping from the facility through unsecured doors, accessing a public road and leaving the facility property, without staff supervision, for 1 (#1) of 9 sampled residents. This failure placed other residents at risk for elopement if they successfully exited out the unsecured doors not equipped with a wander guard alarm system, for 5 (#s 10, 11, 12, 13, and 14) of 9 sampled residents. The facility's failure increased the risk of serious bodily harm, injury, impairment, or death, due to the facility's failure to sufficiently address the doors the resident eloped from. […]

• Actual harm, isolatedF689May 6, 2026

  Based on interview and record review, the facility failed to ensure a staff member provided safe transportation of a resident being transferred to the facility for admission for 1 (#10) of 10 sampled residents. The deficient practice caused resident #10 injury, resulting in a left ankle fracture, requiring hospitalization and surgery, which prolonged the resident's stay at the facility. The facility identified that the resident was not transported safely and immediately addressed and corrected the deficient practice before the survey, resulting in the findings of past non-compliance. Findings include:Review of a facility-reported incident, submitted to the State Survey Agency on 3/5/26, showed resident #10 was being transported from a local hospital to the facility for admission. […]

• Actual harm, isolatedF760May 6, 2026

  Based on interview and record review, the facility failed to ensure medications were transcribed into a resident's electronic medical record accurately, and failed to identify a high-risk medication ordered for a resident with end-stage renal disease for 1 (#6) of 4 residents sampled for dialysis. This deficient practice resulted in resident #6's altered mental status, requiring hospitalization and treatment. Findings include:During an interview on 5/6/26 at 3:20 p.m., staff member B stated residents were reviewed by the interdisciplinary team as new admissions, and nursing management would enter admission orders. Staff member B stated there were two staff members to check the admission orders that were entered, so they would not miss something with an order. […]

• Actual harm, isolatedF686Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer to the coccyx for 1 (#5) of 26 sampled residents. The resident's medical record failed to include consistent and accurate documentation to reflect if the wound was avoidable, although the resident was at risk for malnutrition and had a severe weight loss over recent months; and the facility implemented some interventions for prevention, but failed to thoroughly and consistently assess the wound and document the status of the pressure ulcer, such as the size, measurements, severity, characteristics and detail, and at one point, the wound was documented as a Stage IV with no defining characteristics as to why this was determined. […]

• Actual harm, isolatedF692Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to follow interventions related to resident assistance, evaluate current abilities, and implement additional interventions and monitoring for a severe weight loss of 7.65% in one month, and the resident had a new diagnosis of Severe Protein Calorie Malnutrition, for 1 (#94) of 26 sampled residents. Findings include:During an observation on 8/27/25 at 9:13 a.m., resident #94 was asleep in bed with his breakfast tray dropped off on his bedside table, untouched.During an observation on 8/27/25 at 9:35 a.m., resident #94's full breakfast tray was dumped into the cart for dirty dishes. […]