Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ST JOHN'S LUTHERAN HOME
BILLINGS, MT · 186 certified beds · Last Life Safety survey July 17, 2025
CMS Certification Number 275024 · first certified January 1967
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MT
26 citations — more than 83% of the 61 certified nursing homes in MT. Compared within MT rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (July 2026 to August 2026), and past the point by which nine in ten MT facilities have been surveyed. This facility’s last Life Safety survey was July 2025. Facilities in MT are typically surveyed 12–13 months after the last one (median 12), measured over 104 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 26 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MT, and nationally. Surveyors differ markedly between states, so the MT figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 26 |
| Median facility in MT | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 3, 2023 | 14 |
| August 15, 2024 | 4 |
| July 17, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-07-17 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 3 | 2025-07-17 |
| K-0300 | Meet other general requirements that are deficient. | 2 | 2024-08-15 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-07-17 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 2 | 2025-07-17 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-07-17 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2025-07-17 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2023-08-03 |
What the citations cover
- Egress Deficiencies 11
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 3
| Category | Citations |
|---|---|
| Egress Deficiencies | 11 |
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 17, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 4, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (September 4, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 4, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 5, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 4, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 4, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 4, 2025) |
| K-0906 | Ensure gas cylinders are properly stored. | Deficient, Provider has date of correction (September 4, 2025) |
August 15, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 3, 2024) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (October 3, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 3, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (October 3, 2024) |
August 3, 2023 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (September 21, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (September 21, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.