Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Luther Haven during CMS and state inspections, most recent first.
Two residents with documented mental illness were not accurately identified as such in their MDS assessments, despite PASRR findings and diagnoses. Staff interviews confirmed the omission, and facility policy lacked details on ensuring assessment accuracy or staff training.
A resident's personal refrigerator was found without temperature monitoring, a thermometer, or maintenance logs, and contained expired and improperly stored food items. Facility staff confirmed that there was no process in place to ensure food safety in personal refrigerators, despite the vulnerability of residents and the facility's responsibility to provide care.
A resident with Parkinson's disease, dementia, and depression experienced multiple falls resulting in serious injuries due to the facility's failure to analyze fall trends, determine root causes, and consistently implement or document effective interventions. Staff were often unaware of the resident's care plan requirements, and recommendations for medication review and monitoring were not followed, leading to continued falls and harm.
A resident with severe cognitive impairment and diagnosed with RSV was not properly isolated, as staff failed to implement full transmission-based precautions. The resident was observed without a mask in the hallway, and staff did not wear gowns when entering the resident's room. The infection control preventionist identified incorrect signage and missing gowns, indicating a lapse in following CDC guidelines.
A resident with a history of exit-seeking behavior and cognitive impairment eloped from a facility through a window due to the facility's failure to complete a timely comprehensive elopement risk assessment. Despite known risk factors, the resident was not identified as an elopement risk upon admission, and inadequate interventions were in place. The resident was found by police and family an hour later, having been exposed to the elements.
A facility failed to follow care plans for mechanical lift transfers, resulting in falls for two residents. One resident fell from an EZ-Stand due to a nurse aide's lack of awareness of the two-staff requirement, while another passed out during a transfer and was hospitalized for a leg fracture. A third resident was transferred without clear parameters for using a full lift, highlighting inadequate training and care plan adherence.
The facility failed to prevent staff from storing personal food and effects in a kitchen refrigerator meant for resident food, potentially affecting all 54 residents. A refrigerator in the baking area contained staff items like drink cups and Tupperware with personal food, alongside resident food items. The dietary manager acknowledged the issue, noting that staff should use designated areas for personal storage according to policy.
The facility failed to analyze and document data submitted to the QAPI committee, affecting areas such as UTIs, infection control, grievances, and falls. Despite concerns being raised, there was no evidence of data analysis, root cause identification, or action plans. The ongoing performance improvement project for pressure ulcers also lacked analysis and a clear action plan.
The facility failed to implement its grievance policy effectively, impacting all residents. The grievance policy was not posted throughout the facility, and forms for anonymous submissions were unavailable. Documentation of grievances and resolutions was lacking, with several residents reporting long call light wait times without follow-up. Interviews revealed residents' uncertainty about reporting complaints, and staff acknowledged the need for improvement in grievance documentation.
The facility failed to ensure that nursing assistants, RNs, the infection preventionist, and an LPN were competent in using mechanical lifts and following care plans. Interviews and record reviews showed no competency evaluations were conducted upon hire or annually, affecting 54 residents who might use mechanical lifts. The DON acknowledged the need for improved orientation and training processes.
The facility did not implement its facility-wide assessment protocol, leading to a mismatch between listed competency requirements and actual staff training practices. Recent changes to the assessment, mandated by new regulations, were not communicated to all staff, leaving them uninformed. The QAA committee was tasked with approving revisions and communicating operational goals related to person-centered care, staffing, and resources. The assessment tool highlighted the need for staff education, training, certifications, and policies to support resident care and planned for annual resource reviews and evaluations of daily operations, including emergencies.
The facility failed to remove and destroy discontinued medications promptly, leading to their co-mingling with active medications in the carts. Observations revealed that several residents, including those deceased or discharged, still had their medications stored in the carts. Staff confirmed the need for timely removal and destruction, but staffing challenges delayed the process. The DON acknowledged the issue, and the facility's policy requires timely medication destruction.
The facility failed to respond to call lights promptly, affecting four residents who required assistance with ADLs. Residents experienced significant delays, with call light wait times ranging from 41 to 189 minutes. Despite having intact cognition, residents reported long waits for help, impacting their care and safety. Staff interviews revealed awareness of the issue but highlighted challenges in addressing it, including workload documentation and staffing levels.
A resident with dementia and other conditions fell while being transferred by a nursing assistant using the EZ-Stand, resulting in a head laceration. The nursing assistant, new to the facility and from a staffing agency, was unaware that two staff members were required for transfers, as she had not received proper orientation. The incident was not reported to the State Agency, and no thorough investigation or fall analysis was conducted.
A resident with dementia and other health issues fell during a transfer using an EZ-Stand, resulting in a head injury. The nursing assistant, new to the facility and unaware of the care plan requiring two staff for transfers, attempted the transfer alone. The facility failed to conduct a thorough investigation to determine the root cause and adherence to the care plan, as confirmed by the clinical nurse manager and director of nursing.
Failure to Accurately Document Mental Illness in MDS Assessments
Penalty
Summary
The facility failed to ensure that resident status was accurately identified in the Minimum Data Set (MDS) assessments for two sampled residents. For one resident, documentation showed diagnoses of altered mental status, social phobia, depression, hallucinations, and psychotic disorder with delusions. This resident's Level I PASRR indicated a referral for a Level II assessment for mental illness, which was completed and confirmed the presence of mental illness. However, the resident's admission MDS and subsequent MDS assessments did not document the mental illness in Section A, despite the PASRR findings. Interviews with the social worker revealed that the omission occurred because the resident was not eligible for additional services, but the social worker acknowledged that the MDS should have been coded to reflect the mental illness diagnosis. The DON also agreed that the MDS should accurately reflect the resident's condition. Review of the facility's policy showed requirements for timely completion of assessments but did not specify procedures to ensure accuracy, staff training, or oversight for MDS completion.
Failure to Monitor Personal Refrigerators for Food Safety
Penalty
Summary
The facility failed to implement a process for monitoring personal refrigerators located in resident rooms, as evidenced by the lack of temperature monitoring, absence of thermometers, and no documentation of maintenance or food checks. During an observation, a small dorm-style refrigerator in a resident's room was found to contain various food items, including sausage, sliced cheese, bottles of nutritional supplement, soft chocolate candy, and a meat product labeled with a freeze-by date that had already passed. Neither the refrigerator nor the freezer compartment had a thermometer, and there was no log or record indicating that staff were monitoring the appliance or its contents. Interviews with the facility administrator and the infection preventionist confirmed that the facility was not monitoring personal refrigerators and acknowledged that this was a concern due to the potential for food-borne illness. The facility's policy stated that residents or their families were responsible for maintaining the refrigerator and ensuring safe temperatures, but staff recognized that residents in the facility require care and should not be expected to manage this responsibility themselves. The lack of monitoring and maintenance of personal refrigerators led to the deficiency identified during the survey.
Failure to Analyze Fall Trends and Implement Effective Interventions
Penalty
Summary
The facility failed to assess or analyze trends of falls to determine causal factors or root causes and did not implement effective interventions to prevent or reduce the risk of falls with major injury for a resident with a history of multiple falls. The resident, who had diagnoses of Parkinson's disease, dementia, and depression, experienced seven falls over a period of several months, resulting in significant injuries including spinal compression fractures and a rib fracture. Despite being identified as high risk for falls and having a care plan with various interventions, there was no evidence that these interventions were consistently implemented or that their effectiveness was evaluated. Documentation revealed gaps in the recording of ambulation and toileting schedules, with several months showing no documentation of required ambulation or toileting times. Staff interviews indicated a lack of awareness or understanding of the resident's care plan interventions, such as scheduled ambulation and toileting. Additionally, recommendations from the pharmacist regarding medication review and orthostatic blood pressure monitoring were not acted upon, and there was no indication that root cause analyses were performed after each fall event. The facility's quality assurance and performance improvement (QAPI) records showed ongoing concerns with falls and falls with injury, but there was no evidence of systematic analysis or targeted interventions for the resident in question. The facility's fall policy did not specify the need for immediate intervention following a fall, and event reports often lacked root cause analysis. As a result, the resident continued to experience falls with significant injuries, and the facility did not demonstrate adequate supervision or hazard mitigation to prevent accidents.
Inadequate Transmission-Based Precautions for RSV
Penalty
Summary
The facility failed to ensure appropriate transmission-based precautions for a resident diagnosed with Respiratory Syncytial Virus (RSV). The resident, who had severe impaired cognition and dementia, was noted to have symptoms such as a runny nose and wet cough. On the morning of March 14, 2025, a physician confirmed the RSV diagnosis, and the resident was placed on droplet precautions. However, observations on March 18, 2025, revealed that the resident's room door was open, and the resident was seen wheeling himself into the hallway without a mask, indicating a lapse in maintaining droplet precautions. Further observations and interviews on the same day showed that staff members were not fully adhering to the required precautions. Nursing assistants entered the resident's room wearing gloves, masks, and goggles but did not wear gowns, which are part of the necessary protective equipment for RSV. The infection control preventionist confirmed that the precautions sign outside the resident's room was incorrect, and gowns were missing from the isolation cart. The interim director of nursing stated that staff were expected to follow CDC guidelines for infection control, but the facility's policy on isolation precautions was not fully implemented, leading to the deficiency.
Failure to Assess and Prevent Resident Elopement
Penalty
Summary
The facility failed to complete a timely comprehensive elopement risk assessment for a resident with a history of exit-seeking behavior. The resident, who had diagnoses of encephalopathy, hallucinations, tremors, and insomnia, was admitted to the facility with moderate cognitive impairment and a history of wandering. Despite these risk factors, the facility did not identify the resident as an elopement risk upon admission, nor did they complete a comprehensive risk assessment for elopement or wandering. On the night of the incident, the resident was restless and exhibited exit-seeking behavior, which included wandering into other residents' rooms and attempting to open exit doors. The resident had previously removed a wander guard bracelet, and no replacement was available, leading to the implementation of hourly checks. However, the resident managed to elope through a window in her room, which was found open with the screen removed. The resident was located by police and family approximately an hour later, having been exposed to the elements and showing signs of confusion and agitation. Interviews with staff revealed that the facility was aware of the resident's elopement risk but failed to implement adequate interventions to prevent the elopement. The social worker responsible for elopement risk assessments did not complete the assessment on the day of admission, and the facility's elopement policy did not address prevention measures. Additionally, the facility had not considered the risk of elopement through windows, despite previous incidents involving other residents. This oversight contributed to the resident's successful elopement and the subsequent immediate jeopardy situation.
Removal Plan
- Updated the Elopement Risk Assessment tool to include assessment of physical ability to elope from the windows.
- Updated the Facility Elopement policy to include to complete the elopement assessment on admission, readmission, change of condition, or as needed.
- Removed all window cranks in common areas.
- Reassessed all residents at risk for elopement for their physical ability to elope out the windows.
- Reviewed elopement policy and educated staff on recognizing elopement hazards, opportunities, window cranks all interventions.
Failure to Follow Care Plans for Mechanical Lift Transfers
Penalty
Summary
The facility failed to appropriately assess and follow care plans for three residents using sit-to-stand mechanical lifts, resulting in immediate jeopardy for two residents. Resident 11, who had diagnoses including dementia and diabetes, fell from the EZ-Stand when a nurse aide attempted a transfer alone, contrary to the care plan requiring two staff. This resulted in a head laceration and hospital evaluation. The nurse aide was unaware of the care plan requirements due to inadequate orientation and training. Resident 16, with diagnoses including diabetes and hypertension, experienced a fall when a nurse aide attempted a transfer alone using the EZ-Stand, despite the care plan requiring two staff. The resident held her breath during the transfer, passed out, and was lowered to the floor, later requiring hospitalization for a leg fracture. The nurse aide was aware of the two-staff requirement but did not follow it due to the resident's preference for certain staff. Resident 37, with a history of heart failure and falls, was observed being transferred using a sit-to-stand lift by a nurse aide who was unable to identify when a full mechanical lift should be used. The care sheet did not provide clear parameters for when to use a full lift, leading to potential safety risks during transfers. The facility's lack of proper training and adherence to care plans contributed to these deficiencies.
Removal Plan
- Reviewed and updated policies related to care sheets, care plans, and using the EZ Lift/Stand.
- Educated all licensed staff and nursing assistants including agency staff and performed competencies on how to appropriately use the EZ Stand and Care sheets.
- Updated the orientation checklist for agency staff.
- Re-assessed all residents currently using an EZ Stand to determine if they were able to be partial weight bearing per manufacturer's guidelines in order to use the EZ Stand.
- Educated staff on incident reporting to the SA.
Improper Storage of Staff Personal Items in Kitchen
Penalty
Summary
The facility failed to ensure that staff did not co-mingle personal food and effects with resident food, which had the potential to affect all 54 residents who consumed food prepared in the kitchen. During an observation, a reach-in refrigerator in the baking area of the kitchen was found to have two compartments. The top compartment contained staff personal items, including five tumbler-style drink cups with straws and two Tupperware containers with personal food. This compartment also stored resident food items such as butter, frosting, liquid eggs, ice cream topping, and glucerna supplements. The bottom compartment, which was not cooling, contained staff effects like shoes, pretzels, clothing, and bags with unknown items. The dietary manager acknowledged the findings and expressed that staff should have used the staff break room fridge and lockers for their personal items, as per the facility's 2017 Personal Hygiene Training Policy.
Deficiency in QAPI Data Analysis and Action Planning
Penalty
Summary
The facility failed to ensure that data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was properly analyzed and documented. This deficiency was observed in the QAPI meetings from March to July 2024, where various concerns were raised by facility departments, including issues related to urinary tract infections (UTIs), infection control, grievances, and falls. Despite these concerns being brought to the committee's attention, there was no evidence of data analysis, root cause identification, measurable goals, or action plans being developed to address these issues. Specific instances included the lack of analysis and action plans for reducing UTIs, addressing infection control with multiple cases of norovirus and COVID-19, and handling grievances related to rough care and falls. Additionally, the facility's ongoing performance improvement project for pressure ulcers lacked data analysis and a clear action plan, despite having a goal to reduce the rate of pressure ulcers. The administrator acknowledged that the facility had not been working on anything other than the performance improvement project for skin integrity, which had not been analyzed since its inception.
Grievance Policy Implementation Failure
Penalty
Summary
The facility failed to ensure that its grievance policy and procedures were properly implemented, affecting all 54 residents. The grievance policy was not prominently posted throughout the facility, and there were no forms available for residents to submit grievances anonymously. Additionally, the facility did not document all grievances, the actions taken to resolve them, or the summary of their resolutions. This lack of documentation and accessibility to grievance forms was confirmed through interviews with residents, family members, and staff. Several residents and family members reported issues with long call light wait times, which were documented in a word document listing dates and concerns. However, follow-up documentation was only available for one instance, and no actions or resolutions were identified for the other grievances. Interviews with residents revealed that many were unsure of how to report complaints or were hesitant to do so due to fear of reprisal. The social worker and director of nursing acknowledged the lack of formal grievance documentation and the need for improvement in this area. The facility's grievance policy encouraged residents and representatives to communicate grievances verbally or in writing, but it did not specify that grievances should be documented, nor did it mention the availability of anonymous grievance submissions. The policy also lacked instructions for posting it throughout the facility. The administrator and director of nursing were unaware that the grievance forms had not been utilized, and the facility's grievance process was not effectively communicated to residents and their families.
Lack of Staff Competency in Mechanical Lifts and Care Plans
Penalty
Summary
The facility failed to ensure that all nursing assistants, registered nurses, the infection preventionist, and a licensed practical nurse were competent in the operation of mechanical lifts and in following care plans and care sheets. This deficiency was identified through interviews and record reviews, revealing that none of the staff had undergone competency evaluations upon hire, annually, or as needed when concerns about competence were noted. This lack of competency assessment had the potential to affect all 54 residents who required or might require the use of mechanical lifts and adherence to care plans and care sheets. Interviews with staff members, including a nursing assistant who had been working independently for a few weeks, indicated that they had not received training or competency evaluations related to mechanical lifts, care plans, or care sheets. The Director of Nursing confirmed that there were no competency evaluations conducted for these critical areas and acknowledged that the orientation process for all staff, including agency staff, could be improved. The facility's staff development policy required all personnel to participate in initial orientation and regularly scheduled in-service training classes, but this was not adhered to, as evidenced by the lack of training records in employee files.
Failure to Implement Facility-Wide Assessment Protocol
Penalty
Summary
The facility failed to implement its facility-wide assessment protocol, which is crucial for ensuring staff competencies align with their duties. During an interview, the administrator acknowledged that the competency requirements listed in the facility assessment did not match the actual staff training practices on the floor. This discrepancy arose after recent changes were made to the facility assessment, following new regulations mandated for nursing homes in July 2024. However, these changes were not communicated to all staff, leaving them uninformed and unupdated about the new requirements. The Quality Assessment and Assurance (QAA) committee was responsible for approving the assessment revisions and communicating the facility's operational goals related to person-centered care, staffing services, and resources to all staff. The facility's assessment tool identified the need for staff education, training, certifications, testing, and policies to support resident care, as well as processes and oversight to meet residents' needs through regulatory, operational, maintenance, and staff training requirements. Additionally, the facility planned to review resources annually and evaluate daily operations, including emergencies, to ensure residents' care maintained their highest practicable physical, mental, and psychosocial well-being.
Failure to Timely Remove and Destroy Discontinued Medications
Penalty
Summary
The facility failed to adhere to its policy regarding the timely removal and destruction of discontinued medications, resulting in the co-mingling of these medications with active ones in the medication carts. During an observation and interview, it was found that several residents, including those who had passed away or been discharged, still had their medications stored in the facility's medication carts. Specifically, the narcotic count revealed that a deceased resident had four bottles of morphine, another discharged resident had two bottles of morphine, and another deceased resident had two bottles of morphine. Additionally, another resident had discontinued Fentanyl patches and hydrocodone tablets still present in the cart. The staff, including registered nurses and licensed practical nurses, confirmed that the discontinued medications should have been removed and destroyed promptly. However, due to staffing challenges, the destruction of controlled medications, which requires two licensed staff members, had been delayed. The Director of Nursing acknowledged not having reviewed the medication destruction policy but confirmed that discontinued medications should not remain co-mingled with active medications for long. The facility's Medication Destruction/Disposal policy mandates timely destruction and disposal of medications in compliance with federal, state, and Board of Pharmacy guidelines.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure timely response to call lights for four residents, leading to delays in assistance with activities of daily living (ADLs). Interviews and document reviews revealed that residents experienced significant wait times for assistance, with one resident reporting a wait of up to 86 minutes. The facility's call light logs confirmed these delays, showing multiple instances where call lights were not answered promptly, ranging from 41 to 189 minutes. Residents involved in the deficiency had intact cognition and required varying levels of assistance with ADLs. One resident, who was a fall risk, reported having to wait until 9:00 a.m. for assistance despite wanting to get up at 7:30 a.m. Another resident, who experienced frequent pain, reported waiting two hours for help. A third resident expressed concerns about having to get off the toilet by themselves due to delayed assistance, highlighting the potential risk of falls. Staff interviews indicated that the facility was aware of the issue but struggled to address it effectively. The interim administrator had previously managed to reduce call light response times, but this improvement was not sustained. Staff cited challenges such as being occupied with other residents and insufficient documentation of workload, which affected staffing levels. Despite the facility's policy requiring prompt response to call lights, grievances related to long wait times were not consistently resolved or addressed.
Failure to Report Fall and Potential Neglect
Penalty
Summary
The facility failed to report a fall with injury and potential neglect to the State Agency for a resident with dementia, diabetes mellitus, and acute kidney failure. The resident fell in her room while being transferred by a nursing assistant using the EZ-Stand. The resident let go of the bars, fell out of the sling, and was believed to have hit her head, resulting in a laceration. The incident was not reported to the State Agency, and there was no evidence of a thorough investigation or comprehensive fall analysis to determine the root cause. The nursing assistant involved in the incident was from a staffing agency and was new to the facility. She was unaware that the resident required assistance from two staff members during transfers with the EZ-Stand, as she had not received proper orientation or training on the care plan or care sheets. The clinical nurse manager confirmed that the nursing assistant had transferred the resident alone, contrary to the care plan, and was unsure of the orientation provided to the nursing assistant before she worked independently. The physical therapist noted that the resident had a history of being unpredictable in the EZ-Stand and required two staff members for transfers. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such incidents, but the fall was not reported. The administrator expected all staff, including agency staff, to be trained to follow care sheets and care plans, and to report incidents as per facility policy.
Failure to Conduct Thorough Investigation of Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation into a fall incident involving a resident, identified as R11, who had dementia, diabetes mellitus, and acute kidney failure. On the date of the incident, R11 fell in her room while being transferred by a nursing assistant using an EZ-Stand. The resident let go of the bars, fell out of the sling, and sustained a head laceration, which required evaluation at the ER. The facility's records lacked evidence of a comprehensive fall analysis to determine the root cause and whether the care plan was followed. The investigation revealed that the nursing assistant, who was new to the facility and worked for a staffing agency, was unaware that R11 required assistance from two staff members during transfers with the EZ-Stand. This lack of awareness was due to insufficient orientation and training on the care plan and mechanical lifts. The clinical nurse manager confirmed that the nursing assistant had transferred R11 alone, contrary to the care plan, and had only verbally reminded the assistant to follow care sheets after the incident. Interviews with the physical therapist and the director of nursing further confirmed that the care plan was not followed, as the resident required two staff members for transfers due to a history of unpredictability with the EZ-Stand. The director of nursing acknowledged that a thorough investigation, including a root cause analysis, had not been conducted, which was against the facility's policy on neglect and investigation procedures. The administrator also admitted that the investigation was insufficient to determine if neglect occurred.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Montevideo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clarkfield Care Center | 12 mi | ★★★★★ | 5 | 0 |
| Parkview Home | 12.6 mi | ★★★★★ | 8 | 0 |
| Avera Granite Falls Care Center | 13.4 mi | ★★★★★ | 5 | 0 |
| Clara City Care Center | 16.7 mi | ★★★★★ | 9 | 1 |
| Johnson Memorial Hospital & Home | 17.3 mi | ★★★★★ | 2 | 0 |
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