Federal inspection record · CMS data as of October 1, 2026
St John's Lutheran Home
3940 Rimrock Rd, Billings, MT · (406) 655-5600
- Certified beds
- 186
- Residents per day
- 80
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- January 1, 1967
1
How this home got 4 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Montana.
-
Staffing
★★★★★+1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★4 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Montana homes
St John's Lutheran Home carries 55 inspection points. That is fewer than 59% of Montana's 59 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Montana: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–31.5 pts
- 4★ 31.5–49.25 pts
- 3★ 49.25–84.75 pts
- 2★ 84.75–135.38 pts
- 1★ over 135.38 pts
Bars show every rated home in Montana by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
37 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Nutrition and Dietary7F
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning7E
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure each resident receives an accurate assessment.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Rights5D
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Keep residents' personal and medical records private and confidential.
- D
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.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Freedom from Abuse, Neglect, and Exploitation5D
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Pharmacy Service5D
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Infection Control3F
- F
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Quality of Life and Care3D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Nursing and Physician Services2E
- D
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.
- E
Post nurse staffing information every day.
Inspection history
2026-07-30
11 health deficiencies · 4 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2025-07-17
7 health deficiencies · 8 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2024-08-15
19 health deficiencies · 4 fire-safety deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 37 min of nursing staff time a day, 1 h of it from a registered nurse.
This home
4 h 37 min
Montana average
4 h 1 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 47% of nursing staff and 36% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.9 pts worse | 2.3 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1 pts better | 1.1 | 2.1 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.3 pts worse | 96.4% | 96.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine6 pts better | 100.0% | 94.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.8 pts better | 3.6% | 4.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms3.4 pts better | 2.9% | 6.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight4 pts worse | 10.4% | 6.4% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.8 pts worse | 16.2% | 15.4% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication5.2 pts better | 15.5% | 20.7% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.6 pts better | 0.0% | 0.6% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened9.9 pts worse | 26.0% | 16.1% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased0.2 pts worse | 18.7% | 18.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder2 pts better | 0.0% | 2.0% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 2.2% | 3.0% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4.2 pts worse | 26.3% | 22.1% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.2 pts better | 5.0% | 6.2% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine13.6 pts better | 97.7% | 84.1% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit2.4 pts worse | 15.5% | 13.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medicationAbout the same | 1.2% | 1.2% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine14.8 pts better | 91.5% | 76.7% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission3.7 pts worse | 23.9% | 20.2% | 23.4% |
·
Who owns and runs it
16 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Davies, William | Corporate Director · Individual | 0% | 1 facilities |
| Herberg, Connie | Corporate Director · Individual | 0% | 1 facilities |
| Macdonald, Margaret | Corporate Director · Individual | 0% | 1 facilities |
| Morse, Mina | Corporate Director · Individual | 0% | 1 facilities |
| Morse, Mina | Corporate Officer · Individual | 0% | 1 facilities |
| Pearsall, Gerald | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Pearsall, Gerald | Corporate Officer · Individual | 0% | 1 facilities |
| Pearsall, Gerald | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Rhodes, Karna | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Rhodes, Karna | Corporate Officer · Individual | 0% | 1 facilities |
| Rhodes, Karna | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Ronneberg, John | Corporate Director · Individual | 0% | 1 facilities |
| Thompson, Tim | Corporate Director · Individual | 0% | 1 facilities |
| Trost, David | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Trost, David | Corporate Officer · Individual | 0% | 1 facilities |
| Trost, David | Operational/Managerial Control · Individual | 0% | 1 facilities |
·
Fire safety
16 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Egress6E
- E
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.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- D
Have properly located and lighted "Exit" signs.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Meet other general requirements that are deficient.
Smoke5F
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems4F
- F
Meet requirements for the installation and maintenance of electrical systems.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure gas cylinders are properly stored.
- D
Meet requirements for the installation and maintenance of electrical systems.
Miscellaneous1F
- F
Have simulated fire drills held at unexpected times.
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Other homes nearby
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Aspen Meadows Health And Rehabilitation Center
Billings, MT · Evergreen Healthcare Group
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 45 min
- Fines
- $91,549
-
Skyline Heights Nursing And Rehabilitation
Billings, MT · Eduro Healthcare · Special Focus
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 3 min
- Fines
- $481,582
-
Yellowstone River Nursing And Rehabilitation
Billings, MT · Eduro Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 19 min
- Fines
- $127,566