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Nursing HomeMedicaid Investigative

Luther Haven

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1109 East Highway 7, Montevideo, MN 5626555 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.1/5

based on 24 Google reviews

5
4
3
2
1
Luther Haven Nursing Home in Montevideo, MN — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • High staff turnover (56%)

Below average in MN · Meets national RN staffing standard · Above recommended total nurse staffing · $143,108 in fines

Source: Medicare data

What this means for your family

While some visitors find the staff friendly, the reports of severe neglect regarding basic patient needs are deeply concerning. We strongly recommend that families conduct unannounced visits and speak directly with current residents' families to verify the quality of daily care before making a decision.

Google Reviews

Google Reviews

24 reviews on Google
Luther Haven receives highly polarized feedback, with some visitors describing it as a nice environment while others report severe neglect and management failures. Families should be aware of serious allegations regarding patient care and dissatisfaction with administrative leadership.

Quality Themes

Tap a score for details
FoodN/AStaff4.0CleanN/AActivitiesN/AMedsN/AMemoryN/AComms1.0ValueN/A

Strengths

  • Friendly staff members
  • Generally pleasant facility environment

Concerns

  • Neglect and delayed assistance with basic hygiene needs (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'17(2)'19(7)'22(3)'24(1)'26(1)

Distribution · 25 analyzed

5
13
4
7
3
1
2
0
1
4

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given that staffing levels are a high point here, how do you ensure that this translates into consistent, timely support for residents who need help with daily hygiene and personal care?
  • 2We understand that communication is a top priority; what specific systems do you have in place to keep families updated on their loved one's health status and daily well-being?
  • 3With a capacity of 55 residents, how do you foster a sense of community and ensure that every resident receives personalized attention throughout the day?
  • 4What steps is the leadership team currently taking to address the recent health inspection findings and improve the overall care quality metrics?
  • 5Since many families appreciate the friendly atmosphere here, how do you support your staff to ensure that same warmth is maintained during busy or high-pressure shifts?
  • 6Could you walk us through your protocol for medical emergencies and how you coordinate care with outside specialists or hospitals when a resident’s needs change?

Personalized based on this facility's data


Key Review Excerpts

They left my cousin on the toilet for 2 1/2 hours. This happened more than once.

Family member · 2019☆☆☆☆

The management at this facility should do everyone in the community a favor! Resign, replace themselve's, and go home!

Community member · 2023☆☆☆☆

Friendly staff

Visitor · 2023★★★★
Source: 24 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.69hrs
91%
Registered nurses for medical care
Total Nursing
3.97hrs
97%
All nurses + aides combined
Staff Turnover
52%
Lower is better (< 30% = good)
RN Turnover
46%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

9

measures

Worse Than Avg

5

measures

Mixed Results

3

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility7.8%
Better than Avg
Here
7.8%
US
19.4%
MN
24.5%
Chippewa
24.1%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility26.4%
Worse than Avg
Here
26.4%
US
15.5%
MN
17.0%
Chippewa
10.7%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
MN
4.3%
Chippewa
3.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility13.0%
Mixed vs Avgs
Here
13.0%
US
19.5%
MN
12.5%
Chippewa
21.0%
🦠

Residents who got a urinary tract infection

↓ Lower is better
This Facility8.8%
Worse than Avg
Here
8.8%
US
1.6%
MN
2.5%
Chippewa
2.4%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
MN
97.3%
Chippewa
96.2%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility95.7%
Better than Avg
Here
95.7%
US
79.8%
MN
82.7%
Chippewa
84.4%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility94.1%
Better than Avg
Here
94.1%
US
81.8%
MN
88.3%
Chippewa
88.6%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.0%
Worse than Avg
Here
2.0%
US
1.6%
MN
1.8%
Chippewa
0.8%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

3deficiencies
3penalties
Well below state avg (8.0)
12 complaint-triggered
$143,108 in fines

Luther Haven has faced multiple family complaints that triggered inspections, highlighting concerning patterns in accident prevention, medication management, and abuse/neglect reporting. The facility shows recurring safety issues, with accident hazards appearing across three recent surveys (2024-2025), suggesting persistent supervision problems. While all deficiencies have correction dates, the repeated nature of safety violations and multiple complaint-driven investigations indicate ongoing care quality challenges families should carefully consider.

Aug 20, 2025Routine
2
0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0921Potential for harm · IsolatedCorrected

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Jun 5, 2025Complaint
1
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Mar 19, 2025Complaint
1
0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Jan 13, 2025Complaint
1
0689Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Sep 12, 2024Routine
6
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0867Potential for harm · WidespreadCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0926Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Sep 12, 2024Complaint
7
0689Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0585Potential for harm · WidespreadCorrected

Resident Rights Deficiencies

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.

0726Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

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.

0838Potential for harm · WidespreadCorrected

Administration Deficiencies

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.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Federal Penalties

Fine

Jan 13, 2025

$77,705

Fine

Sep 12, 2024

$23,563

Payment Denial

Sep 12, 2024

18-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Luther Haven

Organization Type

nonprofit

Ownership & Management

Key personnel

Bednar, ShellyOfficer / DirectorDezeeuw, PaulOfficer / DirectorEckberg, MarieOfficer / DirectorKurtzbien, JasonOfficer / DirectorKvam, KimOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 4 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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