| Luther Haven | |
| 1109 East Highway 7, Montevideo, Minnesota 56265 | |
| (320) 269-6517 | |
| Name | Luther Haven |
|---|---|
| Location | 1109 East Highway 7, Montevideo, Minnesota |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 55 |
| Occupancy Rate | 91.27% |
| Medicare ID (CCN) | 245259 |
| Legal Business Name | Luther Haven |
| Ownership Type | Non Profit - Church Related |
| NPI Number | 1184629925 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Luther Haven |
| Address | 1109 E Highway 7, Montevideo, MN 56265 |
| Phone Number | 320-269-6517 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 4.22 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.73 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.78 | 0.86 |
| Nurse aide hours per resident per day | 2.71 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.79 | 3.42 |
| RN hours per resident per day on the weekend | 0.4 | 0.48 |
| Physical therapist hours per resident per day | 0.03 | 0.07 |
| Total nursing staff turnover | 51.6% | 45.8% |
| Registered nurse turnover | 46.2% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 2 |
| Total Amount of Fines in Dollars | $101,268 |
| Number of Payment Denials | 1 |
| Total Number of Penalties | 3 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Aug 20, 2025 | Ensure each resident receives an accurate assessment. F0641, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Sep 9, 2025 |
| Aug 20, 2025 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. F0921, Environmental, Standard inspection | Potential for harm, isolated | Corrected by Sep 9, 2025 |
| Jun 5, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Actual harm, isolated | Plan of correction |
| Mar 19, 2025 | Provide and implement an infection prevention and control program. F0880, Infection Control, Complaint inspection | Potential for harm, isolated | Corrected by Apr 11, 2025 |
| Jan 13, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Immediate jeopardy, isolated | Corrected by Jan 28, 2025 |
| Sep 12, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection, Complaint inspection | Immediate jeopardy, isolated | Corrected by Oct 11, 2024 |
| Sep 12, 2024 | 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. F0585, Resident Rights, Standard inspection, Complaint inspection | Potential for harm, widespread | Corrected by Oct 11, 2024 |
| Sep 12, 2024 | 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. F0726, Nursing and Physician Services, Standard inspection, Complaint inspection | Potential for harm, widespread | Corrected by Oct 11, 2024 |
| Sep 12, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Oct 11, 2024 |
| Sep 12, 2024 | 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. F0838, Administration, Standard inspection, Complaint inspection | Potential for harm, widespread | Corrected by Oct 11, 2024 |
| Sep 12, 2024 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. F0867, Administration, Standard inspection | Potential for harm, widespread | Corrected by Oct 15, 2024 |
| Sep 12, 2024 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677, Quality of Life and Care, Standard inspection, Complaint inspection | Potential for harm, pattern | Corrected by Oct 11, 2024 |
| Sep 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, pattern | Corrected by Oct 28, 2024 |
| Sep 12, 2024 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Oct 11, 2024 |
| Sep 12, 2024 | Respond appropriately to all alleged violations. F0610, Freedom from Abuse, Neglect, and Exploitation, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Oct 11, 2024 |
| Feb 7, 2024 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. F0607, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Potential for harm, isolated | Corrected by Feb 28, 2024 |
| Feb 7, 2024 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Potential for harm, isolated | Corrected by Feb 28, 2024 |
| Sep 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. F0761, Pharmacy Service, Standard inspection | Potential for harm, widespread | Corrected by Nov 20, 2023 |
| Sep 20, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Nov 20, 2023 |
| Sep 20, 2023 | Have a plan that describes the process for conducting QAPI and QAA activities. F0865, Administration, Standard inspection | Potential for harm, widespread | Corrected by Nov 20, 2023 |
| Sep 20, 2023 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Standard inspection | Potential for harm, pattern | Corrected by Nov 20, 2023 |
| Sep 20, 2023 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, pattern | Corrected by Nov 20, 2023 |
| Sep 20, 2023 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Nov 20, 2023 |
| Sep 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. F0756, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 20, 2023 |
| Sep 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. F0758, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 20, 2023 |
| Sep 20, 2023 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 20, 2023 |
| Sep 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. F0849, Administration, Standard inspection | Potential for harm, isolated | Corrected by Nov 20, 2023 |
| Sep 20, 2023 | Develop and implement policies and procedures for flu and pneumonia vaccinations. F0883, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Nov 20, 2023 |
| Sep 20, 2023 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. F0921, Environmental, Standard inspection | Potential for harm, isolated | Corrected by Nov 20, 2023 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.94 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 7.1 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.95 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 7.32 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 0 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.39 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.83 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.98 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.16 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.29 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.87 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.65 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 5.38 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.56 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 27.59 | 15.38 |