Public Record
St John's Lutheran Home
From CMS
Facility profile
- CMS overall rating
- 4 / 5
- Certified beds
- 186
- Avg. residents per day
- 75.6
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 59
- Inspections on file
- 7
- Last inspection
- 2025-07-17
*CMS
*CMS
*CMS
Citations
59 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0585Generalpotential for harm
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.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0906Generalpotential for harm
Ensure gas cylinders are properly stored.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 0225Generalpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0745Generalpotential for harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0732Generalpotential for harm
Post nurse staffing information every day.
- 0758Generalpotential for harm
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.
- 0800Generalpotential for harm
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
- 0802Generalpotential for harm
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- 0803Generalpotential for harm
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.
- 0806Generalpotential for harm
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0300Generalpotential for harm
Meet other general requirements that are deficient.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0911Generalpotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0561Generalpotential for harm
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0921Generalpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222Generalpotential for harm
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.
- 0223Generalpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0225Generalpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0271Generalpotential for harm
Have exits that are accessible at all times.
- 0300Generalpotential for harm
Meet other general requirements that are deficient.
- 0342Generalpotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0758Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
FAQ
Questions and answers
- What is St John's Lutheran Home?
- St John's Lutheran Home is a Medicare- and Medicaid-certified nursing home in Billings, MT, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 275024.
- What is the CMS rating for St John's Lutheran Home?
- St John's Lutheran Home has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does St John's Lutheran Home have?
- St John's Lutheran Home is certified for 186 beds. It serves an average of 75.6 residents per day.
- How many citations does St John's Lutheran Home have?
- St John's Lutheran Home has 59 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was St John's Lutheran Home last inspected?
- St John's Lutheran Home was last inspected on July 17, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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