Cycle 1
Health 2025-07-17 · Fire 2025-07-17
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Billings, MT
St John's Lutheran Home
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
3940 Rimrock Rd, Billings, MT
(406) 655-5600
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
186
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.40
Registered nurse staffing
LPN hours / resident day
0.61
Licensed practical nurse staffing
Aide hours / resident day
2.91
Nurse aide staffing
Weekend hours
4.22
Weekend nurse staffing
RN turnover
41%
Annual RN turnover
Total nurse turnover
45%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
94.4%
0.8 pts worse
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.7%
6.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
4.7%
1.8 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 12.1% |
5.9%
6.2 pts worse
|
5.4%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
17.4%
1.8 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
20.6%
0.1 pts worse
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.2% |
19.7%
3.5 pts worse
|
16.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.6% |
19.8%
0.8 pts worse
|
14.9%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.6%
2.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
2.9%
0.4 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.9% |
25.4%
8.5 pts worse
|
19.8%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
78.7%
19.7 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.2% |
15.0%
3.2 pts worse
|
12.0%
6.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.6%
0.7 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
73.8%
8.3 pts better
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
19.4%
3.8 pts worse
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
19 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-08-03 · Fire 2023-08-03
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
14 fire-safety deficiencies
Top issue: Egress (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-04
F · Potential for more than minimal harm
2025-07-17
K906 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas cylinders are properly stored.
Corrected 2025-09-04
E · Potential for more than minimal harm
2025-07-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-07-17
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-07-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-07-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-04
F · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-08-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-08-15
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-08-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-03
F · Potential for more than minimal harm
2023-08-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-08-03
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 2023-09-21
F · Potential for more than minimal harm
2023-08-03
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-08-03
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-08-03
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-08-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-08-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-08-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-08-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-08-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-08-03
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-08-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-08-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-03
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 2023-09-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-17
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 2025-08-30
F · Potential for more than minimal harm
2025-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-07-17
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 2025-08-30
D · Potential for more than minimal harm
2025-07-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-30
D · Potential for more than minimal harm
2025-07-17
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 2025-08-30
D · Potential for more than minimal harm
2025-07-17
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 2025-08-30
D · Potential for more than minimal harm
2025-07-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-30
F · Potential for more than minimal harm
2024-08-15
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-15
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 2024-09-16
E · Potential for more than minimal harm
2024-08-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-15
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-15
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-15
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 2024-09-16
E · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-15
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 2024-09-16
D · Potential for more than minimal harm
2024-08-15
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 2024-09-16
D · Potential for more than minimal harm
2024-08-15
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 2024-09-16
D · Potential for more than minimal harm
2024-08-15
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 2024-09-16
D · Potential for more than minimal harm
2024-08-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-04-23
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 2024-04-19
F · Potential for more than minimal harm
2023-08-03
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 2023-09-15
D · Potential for more than minimal harm
2023-08-03
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-03
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 2023-09-15
D · Potential for more than minimal harm
2023-08-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-03
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 2023-09-15
D · Potential for more than minimal harm
2023-08-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-15
Penalties and ownership
What sits behind the stars
Ownership
Davies, William
Corporate Director · Individual
Herberg, Connie
Corporate Director · Individual
Macdonald, Margaret
Corporate Director · Individual
Morse, Mina
Corporate Director · Individual
Morse, Mina
Corporate Officer · Individual
Pearsall, Gerald
Operational/Managerial Control · Individual
Pearsall, Gerald
Corporate Officer · Individual
Pearsall, Gerald
W-2 Managing Employee · Individual
Rhodes, Karna
Operational/Managerial Control · Individual
Rhodes, Karna
Corporate Officer · Individual
Rhodes, Karna
W-2 Managing Employee · Individual
Ronneberg, John
Corporate Director · Individual
Thompson, Tim
Corporate Director · Individual
Trost, David
Operational/Managerial Control · Individual
Trost, David
Corporate Officer · Individual
Trost, David
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Aspen Meadows Health And Rehabilitation Center
Billings, MT
2-star overall rating with 3-star inspections with $92,840 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Skyline Heights Nursing And Rehabilitation
Billings, MT
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $460,513 in total fines with 28 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#3
Yellowstone River Nursing And Rehabilitation
Billings, MT
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
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