St John's Lutheran Home
3940 Rimrock Rd, Billings, MT 59102 · Yellowstone County · 186 certified beds · avg 77 residents/day · certified since Jan 1, 1967
3/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
5.71
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
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.
All citations in the current public record (40)
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 |
|---|---|---|
| Jul 1, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jul 1, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jul 1, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jul 1, 2026 | D · Potential for 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 |
| Jul 1, 2026 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jul 1, 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 |
| Jul 1, 2026 | D · Potential for harm, one-off | 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 |
| Jul 17, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 17, 2025 | F · Potential for harm, facility-wide | 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. |
| Jul 17, 2025 | 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. |
| Jul 17, 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. |
| Jul 17, 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. |
| Jul 17, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jul 17, 2025 | 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 |
| Aug 15, 2024 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Aug 15, 2024 | E · Potential for harm, repeated | 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. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 15, 2024 | E · Potential for harm, repeated | 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. |
| Aug 15, 2024 | 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. |
| Aug 15, 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 |
| Aug 15, 2024 | 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. |
| Aug 15, 2024 | 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. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. |
| Aug 15, 2024 | D · Potential for harm, one-off | 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 |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Apr 23, 2024 | D · Potential for harm, one-off | 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 |
| Aug 3, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Aug 3, 2023 | 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. |
| Aug 3, 2023 | D · Potential for 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. |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 3, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Aug 3, 2023 | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (18 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 0 | F |
| 2024 | 19 | 0 | F |
| 2025 | 7 | 0 | F |
| 2026 | 7 | 0 | E |
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)
No fines or payment denials in the published 3-year window.
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) | 5.71 | 4.82 | 3.95 | top 24% in Montana; top 6% in the U.S. |
| Registered Nurse hours | 1.37 | 1.17 | 0.69 | top 28% in Montana; top 6% in the U.S. |
| Weekend total nurse staffing | 5.26 | 4.26 | 3.50 | top 17% in Montana; top 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.07 | 0.71 | 0.48 | top 10% in Montana; top 5% in the U.S. |
| Total nursing staff turnover (%) | 44.6 | 54.8 | 45.8 | top 23% in Montana; top 49% in the U.S. |
| RN turnover (%) | 28.0 | 48.3 | 42.9 | top 14% in Montana; top 26% 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 5.40, RN 1.30, weekend 4.97. Staffing rating: 5/5.
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: 4/5 · long-stay residents: 2/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Davies, William | Individual | Corporate Director | NOT APPLICABLE | 05/01/2021 |
| Herberg, Connie | Individual | Corporate Director | NOT APPLICABLE | 05/01/2018 |
| Macdonald, Margaret | Individual | Corporate Director | NOT APPLICABLE | 05/01/2018 |
| Morse, Mina | Individual | Corporate Director | NOT APPLICABLE | 05/01/2018 |
| Morse, Mina | Individual | Corporate Officer | NOT APPLICABLE | 05/01/2021 |
| Pearsall, Gerald | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/11/2012 |
| Pearsall, Gerald | Individual | Corporate Officer | NOT APPLICABLE | 01/11/2012 |
| Pearsall, Gerald | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/11/2012 |
| Rhodes, Karna | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/01/2007 |
| Rhodes, Karna | Individual | Corporate Officer | NOT APPLICABLE | 09/16/2013 |
| Rhodes, Karna | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2007 |
| Ronneberg, John | Individual | Corporate Director | NOT APPLICABLE | 05/01/2018 |
| Thompson, Tim | Individual | Corporate Director | NOT APPLICABLE | 05/01/2016 |
| Trost, David | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/02/2001 |
| Trost, David | Individual | Corporate Officer | NOT APPLICABLE | 05/02/2016 |
| Trost, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/1995 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "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 |
|---|---|---|---|---|---|
| Aspen Meadows Health and Rehabilitation Center | 1.7 mi | Billings, MT | ★★☆☆☆ | 3/5 | |
| Skyline Heights Nursing and Rehabilitation | 2.0 mi | Billings, MT | ★☆☆☆☆ | 1/5 | SFF |
| Yellowstone River Nursing and Rehabilitation | 3.1 mi | Billings, MT | ★☆☆☆☆ | 1/5 | |
| Billings Rehabilitation and Nursing LLC | 6.0 mi | Billings, MT | ★★☆☆☆ | 2/5 | |
| River Ridge Rehabilitation and Nursing LLC | 8.3 mi | Billings, MT | ★★☆☆☆ | 2/5 | |
| Laurel Health & Rehabilitation Center | 11.1 mi | Laurel, MT | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 275024.