Aspen Meadows Health and Rehabilitation Center
3155 Ave C, Billings, MT 59102 · Yellowstone County · 90 certified beds · avg 66 residents/day · certified since Oct 27, 1992
Part of chain: EVERGREEN HEALTHCARE GROUP (44 facilities, chain avg rating 2.5★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 26, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 2, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 26, 2026 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 2, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 26, 2026 · F-0760
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 2, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 21, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 24, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (36)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 26, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 26, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Mar 26, 2026 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Sep 10, 2025 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Sep 10, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 16, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 16, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jan 16, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Jan 16, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Jan 16, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Oct 21, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 11, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 11, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (7 → 16).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 6 | 1 | G ▲ |
| 2025 | 14 | 0 | E |
| 2026 | 16 | 3 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $115,183.
| Date | Type | Amount / length |
|---|---|---|
| Mar 26, 2026 | Fine | $67,525 |
| Oct 21, 2024 | Fine | $47,658 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Montana avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.04 | 4.82 | 3.95 | bottom 40% in Montana; top 38% in the U.S. |
| Registered Nurse hours | 0.45 | 1.17 | 0.69 | bottom 1% in Montana; bottom 30% in the U.S. |
| Weekend total nurse staffing | 3.59 | 4.26 | 3.50 | bottom 38% in Montana; top 38% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.51 | 0.71 | 0.48 | bottom 33% in Montana; top 32% in the U.S. |
| Total nursing staff turnover (%) | 76.2 | 54.8 | 45.8 | bottom 9% in Montana; bottom 3% in the U.S. |
| RN turnover (%) | 83.3 | 48.3 | 42.9 | bottom 2% in Montana; bottom 4% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.63, RN 0.40, weekend 3.22. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Aspen Meadows SNF Operations, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 08/31/2023 |
| CH Pacific Northwest Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/31/2023 |
| Herzka, Yisroel | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/31/2023 |
| Pacific Northwest SNF Operations Holdings (mt) LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 08/31/2023 |
| Pacific Northwest SNF Operations Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/31/2023 |
| Witzcorp Global LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 08/31/2023 |
| Yenowitz, Yitzchok | Individual | Indirect Ownership Interest | NOT APPLICABLE | 08/31/2023 |
| Aspen Meadows SNF Operations, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Aspen Meadows SNF Operations, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/20/2025 |
| CH Pacific Northwest Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Couve Financial Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Couve Financial Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/20/2025 |
| Couve Healthcare Consulting LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Couve Healthcare Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/20/2025 |
| Herzka, Yisroel | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Jensen, Sheldon | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Jensen, Sheldon | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
| Johnson, Rebecca | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/31/2023 |
| Johnson, Rebecca | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/31/2023 |
| Johnson, Rebecca | Individual | ADP of the SNF | NOT APPLICABLE | 08/31/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What are your visiting policies — can family visit any time the resident wants?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Skyline Heights Nursing and Rehabilitation | 0.5 mi | Billings, MT | ★☆☆☆☆ | 1/5 | SFF |
| Yellowstone River Nursing and Rehabilitation | 1.5 mi | Billings, MT | ★☆☆☆☆ | 1/5 | |
| St John's Lutheran Home | 1.7 mi | Billings, MT | ★★★★☆ | 3/5 | |
| Billings Rehabilitation and Nursing LLC | 4.4 mi | Billings, MT | ★★☆☆☆ | 2/5 | |
| River Ridge Rehabilitation and Nursing LLC | 7.1 mi | Billings, MT | ★★☆☆☆ | 2/5 | |
| Laurel Health & Rehabilitation Center | 11.5 mi | Laurel, MT | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 275140.