Luther Haven
1109 East Highway 7 · Montevideo, MN · 56265 · 3202696517
55 certified beds Non profit - Church related
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $101,268 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
$101,268 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.97 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.69 | 0.55–0.75 |
| Weekend hours / resident-day | 3.59 | ≈ weekday level |
| Nursing turnover / year | 52% | median 45% |
| Fines (3-yr window) | 2 · $101,268 |
Inspection citations (29 in the current record)
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Potential for harm · D August 20, 2025
Ensure each resident receives an accurate assessment.
Corrected September 9, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 20, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected September 9, 2025 · Environmental
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Actual harm · G June 5, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 7, 2025 · Quality of Life and Care
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Potential for harm · D March 19, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected April 11, 2025 · Infection Control
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Immediate jeopardy · J January 13, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 28, 2025 · Quality of Life and Care
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Immediate jeopardy · J September 12, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 11, 2024 · Quality of Life and Care
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Potential for harm · E September 12, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected October 28, 2024 · Pharmacy Service
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Potential for harm · F September 12, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 11, 2024 · Nutrition and Dietary
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Potential for harm · F September 12, 2024
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected October 15, 2024 · Administration
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Potential for harm · F September 12, 2024 · found via complaint
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 October 11, 2024 · Resident Rights
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Potential for harm · D September 12, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected October 11, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 12, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected October 11, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E September 12, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 11, 2024 · Quality of Life and Care
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Potential for harm · F September 12, 2024 · found via complaint
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected October 11, 2024 · Nursing and Physician Services
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Potential for harm · F September 12, 2024 · found via complaint
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected October 11, 2024 · Administration
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Potential for harm · D February 7, 2024 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected February 28, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 7, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 28, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E September 20, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 20, 2023 · Resident Assessment and Care Planning
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Potential for harm · D September 20, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 20, 2023 · Quality of Life and Care
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Potential for harm · D September 20, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected November 20, 2023 · Pharmacy Service
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Potential for harm · D September 20, 2023
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 November 20, 2023 · Pharmacy Service
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Potential for harm · D September 20, 2023
Ensure medication error rates are not 5 percent or greater.
Corrected November 20, 2023 · Pharmacy Service
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Potential for harm · F September 20, 2023
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected November 20, 2023 · Pharmacy Service
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Potential for harm · F September 20, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 20, 2023 · Nutrition and Dietary
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Potential for harm · D September 20, 2023
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected November 20, 2023 · Administration
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 13, 2025 | Fine | $77,705 |
| September 12, 2024 | Fine | $23,563 |
| September 12, 2024 | Payment Denial | 18 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 245259 · certified since January 1, 1975. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.