Luther Haven
1109 East Highway 7, Montevideo, MN 56265 · Chippewa County · 55 certified beds · avg 50 residents/day · certified since Jan 1, 1975
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
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.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jan 13, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 28, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 12, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 11, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 5, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 7, 2025 (Deficient, Provider has plan of correction)
All citations in the current public record (29)
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 |
|---|---|---|
| Aug 20, 2025 | 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 20, 2025 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jun 5, 2025 | ▲ G · Actual 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. · from a complaint |
| Mar 19, 2025 | D · Potential for harm, one-off | 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. · from a complaint |
| Jan 13, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 12, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 12, 2024 | F · Potential for harm, facility-wide | 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. · from a complaint |
| Sep 12, 2024 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Sep 12, 2024 | 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. |
| Sep 12, 2024 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint |
| Sep 12, 2024 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Sep 12, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 12, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 12, 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 |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Feb 7, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Feb 7, 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 |
| Sep 20, 2023 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 20, 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. |
| Sep 20, 2023 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Sep 20, 2023 | E · Potential for harm, repeated | 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. |
| Sep 20, 2023 | 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. |
| Sep 20, 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. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Sep 20, 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. |
| Sep 20, 2023 | 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. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Sep 20, 2023 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (10 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 12 | 0 | F |
| 2024 | 12 | 1 | J ▲ |
| 2025 | 5 | 2 | J ▲ |
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)
2 fines totaling $101,268, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jan 13, 2025 | Fine | $77,705 |
| Sep 12, 2024 | Fine | $23,563 |
| Sep 12, 2024 | Payment Denial | 18 days from Oct 10, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.19 | 4.83 | 3.95 | top 31% in Minnesota; top 11% in the U.S. |
| Registered Nurse hours | 0.90 | 1.22 | 0.69 | bottom 23% in Minnesota; top 21% in the U.S. |
| Weekend total nurse staffing | 4.66 | 4.27 | 3.50 | top 27% in Minnesota; top 10% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.40 | 0.69 | 0.48 | bottom 19% in Minnesota; top 49% in the U.S. |
| Total nursing staff turnover (%) | 51.6 | 42.2 | 45.8 | bottom 24% in Minnesota; bottom 33% in the U.S. |
| RN turnover (%) | 46.2 | 38.6 | 42.9 | bottom 35% in Minnesota; bottom 42% 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 4.22, RN 0.73, weekend 3.79. Staffing rating: 4/5.
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: 3/5 · long-stay residents: 1/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| All Temporaries Midwest, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/09/2025 |
| All Temporaries Midwest, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 01/24/2025 |
| Bednar, Shelly | Individual | Corporate Director | NOT APPLICABLE | 05/01/2019 |
| Dezeeuw, Paul | Individual | Corporate Director | NOT APPLICABLE | 05/01/2024 |
| Dynamic Staffing Solutions | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/09/2025 |
| Dynamic Staffing Solutions | Organization | ADP of the SNF | NOT APPLICABLE | 01/24/2025 |
| Eckberg, Marie | Individual | Corporate Director | NOT APPLICABLE | 05/01/2024 |
| Grape Tree Medical Staffing LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/20/2025 |
| Grape Tree Medical Staffing LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/24/2025 |
| Hughes, Justin | Individual | Corporate Officer | NOT APPLICABLE | 03/19/2024 |
| Hughes, Justin | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/09/2025 |
| Hughes, Justin | Individual | ADP of the SNF | NOT APPLICABLE | 01/24/2025 |
| Krueger, Nicholas | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/09/2025 |
| Krueger, Nicholas | Individual | ADP of the SNF | NOT APPLICABLE | 01/24/2025 |
| Kurtzbien, Jason | Individual | Corporate Director | NOT APPLICABLE | 05/01/2022 |
| Kvam, Kim | Individual | Corporate Director | NOT APPLICABLE | 05/01/2021 |
| Landmark, Diane | Individual | Corporate Director | NOT APPLICABLE | 05/01/2023 |
| Nordstrom, Ann | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/09/2025 |
| Sachariason, Diane | Individual | Corporate Director | NOT APPLICABLE | 05/01/2022 |
| Snell, Kelly | Individual | Corporate Director | NOT APPLICABLE | 05/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you decide you have enough staff and resources for your resident population, including nights and weekends?"
- "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 |
|---|---|---|---|---|---|
| Clarkfield Care Center | 12.0 mi | Clarkfield, MN | ★★★★☆ | 4/5 | |
| Parkview Home | 12.6 mi | Belview, MN | ★★★☆☆ | 2/5 | |
| Avera Granite Falls Care Center | 13.3 mi | Granite Falls, MN | ★★★☆☆ | 2/5 | |
| Clara City Care Center | 16.7 mi | Clara City, MN | ★☆☆☆☆ | 1/5 | |
| Johnson Memorial Hospital & Home | 17.3 mi | Dawson, MN | ★★★☆☆ | 4/5 |
Compare this facility with the 3 closest →
All facilities in Montevideo →
Facility data as of CMS processing date 2026-08-01. CCN 245259.