Nursing Care Index

Luther Haven

Montevideo, Chippewa County, Minnesota · CCN 245259 · Non-profit (Church related) · not part of a chain

CMS rates Luther Haven 1 of 5 overall as of August 2026. 55 certified beds, 50 residents a day on average. 29 citations on record from the current inspection cycles, 2 at immediate jeopardy; 2 fines totalling $101,268 and 1 payment denial.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★★★☆ 4 of 5
Quality measures★★★☆☆ 3 of 5
Quality: long-stay / short-stay1 / 4 of 5

Staffing

Total nurse staffing4.21995 hours per resident per day
Registered nurses0.73294 hours per resident per day
Weekend total3.78808 hours per resident per day
Nursing staff turnover51.6% (registered nurses 46.2%)
Administrators who left0

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2025-08-20 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · tag F0641
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-08-20 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-09-09
2025-06-05
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has plan of correction
2025-07-07
2025-03-19
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-11
2025-01-13
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2025-01-28
2024-09-12
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2024-10-11
2024-09-12
complaint survey
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.
Resident Rights Deficiencies · tag F0585
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-10-11
2024-09-12
complaint survey
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.
Nursing and Physician Services Deficiencies · tag F0726
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-10-11
2024-09-12 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-10-11
2024-09-12
complaint survey
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.
Administration Deficiencies · tag F0838
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-10-11
2024-09-12 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2024-10-15
2024-09-12
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-10-11
2024-09-12 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-10-28
2024-09-12
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-11
2024-09-12
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-10-11
2024-02-07
complaint survey
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-28
2024-02-07
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-02-28
2023-09-20 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.
Pharmacy Service Deficiencies · tag F0761
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-11-20
2023-09-20 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-11-20
2023-09-20 Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · tag F0865
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-11-20
2023-09-20 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-11-20
2023-09-20 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-11-20
2023-09-20 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20
2023-09-20 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · tag F0756
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20
2023-09-20 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.
Pharmacy Service Deficiencies · tag F0758
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20
2023-09-20 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20
2023-09-20 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.
Administration Deficiencies · tag F0849
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20
2023-09-20 Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies · tag F0883
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20
2023-09-20 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-20

Fines and payment denials

DatePenaltyAmount
2025-01-13Fine$77,705
2024-09-12Payment denial for 18 days from 2024-10-10
2024-09-12Fine$23,563

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
All Temporaries Midwest, Inc.
Organization
adp of the snf2025-01-24
Dynamic Staffing Solutions
Organization
adp of the snf2025-01-24
Grape Tree Medical Staffing LLC
Organization
adp of the snf2025-01-24
Wipfli LLP
Organization
adp of the snf2025-01-24
All Temporaries Midwest, Inc.
Organization
operational/managerial control2025-01-09
Dynamic Staffing Solutions
Organization
operational/managerial control2025-01-09
Grape Tree Medical Staffing LLC
Organization
operational/managerial control2025-01-20
Wipfli LLP
Organization
operational/managerial control2025-01-20
Hughes, Justin
Individual
adp of the snf2025-01-24
Krueger, Nicholas
Individual
adp of the snf2025-01-24
Bednar, Shelly
Individual
corporate director2019-05-01
Dezeeuw, Paul
Individual
corporate director2024-05-01
Eckberg, Marie
Individual
corporate director2024-05-01
Kurtzbien, Jason
Individual
corporate director2022-05-01
Kvam, Kim
Individual
corporate director2021-05-01
Landmark, Diane
Individual
corporate director2023-05-01
Sachariason, Diane
Individual
corporate director2022-05-01
Snell, Kelly
Individual
corporate director2023-05-01
Tammen, Kathy
Individual
corporate director2022-05-01
Winter, Sue
Individual
corporate director2024-05-01
Hughes, Justin
Individual
corporate officer2024-03-19
Hughes, Justin
Individual
operational/managerial control2025-01-09
Krueger, Nicholas
Individual
operational/managerial control2025-01-09
Nordstrom, Ann
Individual
operational/managerial control2025-01-09

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Chippewa County.