Cycle 1
Health 2025-08-20 · Fire 2025-08-20
4 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Montevideo, MN
Luther Haven
2-star overall rating with 1-star inspections with $143,108 in total fines with 4 recent health deficiencies
1109 East Highway 7, Montevideo, MN
(320) 269-6517
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
46
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.83
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
5.45
CMS adjusted total nurse staffing hours
Case-mix index
1.06
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,424
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Performance 7.89% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.03
Baseline 41.79% · Performance 51.28% · Measure score 3.03 · Achievement 3.03 · Improvement 0
Adjusted total nurse staffing
5.90
Baseline 4.48 hours · Performance 4.76 hours · Measure score 5.90 · Achievement 5.90 · Improvement 1.61
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.21% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 6.25% · Lower 95% interval 6.73% |
| Discharge to community | 41.44% |
50.57%
9.1 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 34.78% · Lower 95% interval 31% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 55.56% |
95.27%
39.7 pts worse
|
Numerator 20 · Denominator 36 |
| Falls with major injury | 2.78% |
0.77%
2 pts worse
|
Numerator 1 · Denominator 36 |
| Discharge self-care score | 32.35% |
53.69%
21.3 pts worse
|
Numerator 11 · Denominator 34 |
| Discharge mobility score | 41.18% |
50.94%
9.8 pts worse
|
Numerator 14 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.89% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 10% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 7.5% |
8.2%
0.7 pts worse
|
Numerator 9 · Denominator 120 |
| Staff flu vaccination coverage | 36.07% |
42%
5.9 pts worse
|
Numerator 44 · Denominator 122 |
| Discharge function score | 55.88% |
56.45%
0.6 pts worse
|
Numerator 19 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 91.3% |
96.28%
5 pts worse
|
Numerator 21 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.2 |
2.0
3.2 pts worse
|
1.8
3.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.2 · Observed 5.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
96.1%
1.8 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.9%
1.2 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.7% · Q3 4.7% · Q4 4.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.3%
4.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
4.1%
6.5 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 19.0% · Q3 7.9% · Q4 2.6% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
12.4%
0.6 pts worse
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 14.3% · Q3 10.3% · Q4 12.8% · 4Q avg 13.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
17.5%
5.4 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 16.1% · Q3 25.0% · Q4 29.0% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.6% |
22.5%
1.9 pts better
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 29.7% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
18.6%
9 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.0% · Q3 15.8% · Q4 7.9% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.7% |
2.3%
2.4 pts worse
|
1.0%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.5% · Q3 4.7% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.2% |
2.6%
6.6 pts worse
|
1.7%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.9% · Q3 11.9% · Q4 7.3% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.1% |
24.8%
18.7 pts better
|
19.8%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.7% · Q3 6.8% · Q4 8.5% · 4Q avg 6.1% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.4%
3 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 5.9% · Q4 2.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
88.6%
5.2 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 95.6% · Q3 90.5% · Q4 92.3% · 4Q avg 93.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 31.1% |
14.0%
17.1 pts worse
|
12.0%
19.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.1% · Observed 26.1% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.9%
1.2 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.7% · Q3 4.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
82.7%
13 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.9% |
23.1%
11.2 pts better
|
23.9%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 8.7% · Expected 17.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2024-09-12
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-09-20 · Fire 2023-09-20
15 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-12
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-11
C · Minimal harm
2023-09-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-08-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-09-09
G · Actual harm
2025-06-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
J · Immediate jeopardy
2025-01-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-28
J · Immediate jeopardy
2024-09-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-12
F585 · Resident Rights Deficiencies
Health
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 2024-10-11
F · Potential for more than minimal harm
2024-09-12
F726 · Nursing and Physician Services Deficiencies
Health
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 2024-10-11
F · Potential for more than minimal harm
2024-09-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-09-12
F838 · Administration Deficiencies
Health
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 2024-10-11
F · Potential for more than minimal harm
2024-09-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-09-12
F761 · Pharmacy Service Deficiencies
Health
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 2024-10-28
D · Potential for more than minimal harm
2024-09-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-09-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-02-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-02-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-28
F · Potential for more than minimal harm
2023-09-20
F761 · Pharmacy Service Deficiencies
Health
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 2023-11-20
F · Potential for more than minimal harm
2023-09-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-09-20
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-09-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-20
F758 · Pharmacy Service Deficiencies
Health
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 2023-11-20
D · Potential for more than minimal harm
2023-09-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-20
F849 · Administration Deficiencies
Health
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 2023-11-20
D · Potential for more than minimal harm
2023-09-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-09-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-04-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-17
Penalties and ownership
What sits behind the stars
$119,545
2025-01-13
Fine
Fine · fine $119,545
Fine
$23,563
2024-09-12
Fine
Fine · fine $23,563
Fine
$0
2024-09-12
Payment Denial
Payment Denial · denial start 2024-10-10 · 18 days
18 day denial
Ownership
All Temporaries Midwest, Inc.
Operational/Managerial Control · Organization
Bednar, Shelly
Corporate Director · Individual
Dezeeuw, Paul
Corporate Director · Individual
Dynamic Staffing Solutions
Operational/Managerial Control · Organization
Eckberg, Marie
Corporate Director · Individual
Grape Tree Medical Staffing LLC
Operational/Managerial Control · Organization
Hughes, Justin
Operational/Managerial Control · Individual
Hughes, Justin
Corporate Officer · Individual
Krueger, Nicholas
Operational/Managerial Control · Individual
Kurtzbien, Jason
Corporate Director · Individual
Kvam, Kim
Corporate Director · Individual
Landmark, Diane
Corporate Director · Individual
Nordstrom, Ann
Operational/Managerial Control · Individual
Sachariason, Diane
Corporate Director · Individual
Snell, Kelly
Corporate Director · Individual
Tammen, Kathy
Corporate Director · Individual
Winter, Sue
Corporate Director · Individual
Wipfli Llp
Operational/Managerial Control · Organization
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#3
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