Cycle 1
Health 2024-12-05 · Fire 2024-12-05
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Winona, MN
Lake Winona Manor
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
865 Mankato Avenue, Winona, MN
(507) 457-4366
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
80
Certified beds
Average residents
63
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-02-01
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
0.70
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.36
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.05
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.66
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 42% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 2.56% · Lower 95% interval 6% |
| Discharge to community | 58.35% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 59.46% · Lower 95% interval 47.92% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 36 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 16 · Denominator 32 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 16 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 37 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 10.57% |
8.2%
2.4 pts better
|
Numerator 24 · Denominator 227 |
| Staff flu vaccination coverage | 79.03% |
42%
37 pts better
|
Numerator 196 · Denominator 248 |
| Discharge function score | 59.38% |
56.45%
2.9 pts better
|
Numerator 19 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 18 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 62.5% |
25.2%
37.3 pts better
|
Numerator 15 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.3 |
2.0
3.3 pts worse
|
1.8
3.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.3 · Observed 5.1 · Expected 1.6 · 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 | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.9%
1.3 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.8% · Q3 3.8% · Q4 1.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
4.3%
3.5 pts worse
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.5% · Q3 2.1% · Q4 12.0% · 4Q avg 7.8% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
4.1%
0.9 pts worse
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 6.1% · Q3 2.0% · Q4 5.7% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.4% |
12.4%
About the same
|
19.6%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.0% · Q3 10.2% · Q4 11.3% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.6% |
17.5%
5.1 pts worse
|
16.7%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 21.1% · Q3 23.1% · Q4 29.3% · 4Q avg 22.6% · 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 | 16.4% |
22.5%
6.1 pts better
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 29.8% · Q3 4.3% · Q4 6.7% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
18.6%
0.4 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 29.2% · Q3 20.5% · Q4 8.2% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
2.3%
1.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.8% · Q3 1.5% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.6%
0.2 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.0% · Q3 1.9% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
24.8%
About the same
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 28.0% · Q3 20.5% · Q4 25.6% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
5.4%
4.3 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 8.9% · Q3 10.3% · Q4 12.5% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
88.6%
8.6 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 97.8% · Q3 96.7% · Q4 98.4% · 4Q avg 97.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 32.8% |
14.0%
18.8 pts worse
|
12.0%
20.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.8% · Observed 30.8% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.9%
0.9 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.7%
17.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.5% |
23.1%
13.6 pts better
|
23.9%
14.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 7.7% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
15 health deficiencies
Top issue: Infection Control (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-04-14 · Fire 2022-04-14
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-12-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-03
F · Potential for more than minimal harm
2024-12-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-09
E · Potential for more than minimal harm
2024-12-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-02
F · Potential for more than minimal harm
2023-10-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-23
D · Potential for more than minimal harm
2023-10-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-21
F · Potential for more than minimal harm
2022-04-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-05-16
F · Potential for more than minimal harm
2022-04-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-05-16
F · Potential for more than minimal harm
2022-04-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-05-16
F · Potential for more than minimal harm
2022-04-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-05-16
F · Potential for more than minimal harm
2022-04-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-16
E · Potential for more than minimal harm
2022-04-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-16
E · Potential for more than minimal harm
2022-04-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-14
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2022-05-16
C · Minimal harm
2022-04-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-05-16
C · Minimal harm
2022-04-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-16
Inspection history
Recent health citations
G · Actual harm
2025-12-18
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 2025-11-13
E · Potential for more than minimal harm
2024-12-05
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 2025-01-09
E · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-12-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-12-05
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-06
F · Potential for more than minimal harm
2023-10-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-10-26
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-10-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
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 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
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 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-26
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 2023-12-01
D · Potential for more than minimal harm
2023-10-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-01
C · Minimal harm
2023-10-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-01
B · Minimal harm
2023-10-26
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2023-10-27
E · Potential for more than minimal harm
2022-04-14
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 2022-05-16
E · Potential for more than minimal harm
2022-04-14
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 2022-05-16
D · Potential for more than minimal harm
2022-04-14
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-16
Penalties and ownership
What sits behind the stars
Ownership
Winona Health Services
5% Or Greater Direct Ownership Interest · Organization
Atkinson, Linda
W-2 Managing Employee · Individual
Baker, Rodney
Corporate Director · Individual
Blue, Steven
Corporate Director · Individual
Broghammer, Matthew
Corporate Director · Individual
Brosnahan, Jan
Operational/Managerial Control · Individual
Brosnahan, Jan
Corporate Director · Individual
Burke, Sandra
Corporate Director · Individual
Ceplecha, Audrey
Operational/Managerial Control · Individual
Ceplecha, Audrey
W-2 Managing Employee · Individual
Decker, Vicky
Corporate Director · Individual
Evans, Greg
Corporate Director · Individual
Gilmer, David
Corporate Director · Individual
Hammel, Katrina
Corporate Director · Individual
Heising-Schultz, Rachelle
Operational/Managerial Control · Individual
Heising-Schultz, Rachelle
Corporate Director · Individual
Hoeg, Robin
Operational/Managerial Control · Individual
Miller, Hugh
Corporate Director · Individual
Modjeski, Nicholas
Corporate Director · Individual
Mogren, Kenneth
Corporate Director · Individual
Paulson, Todd
Corporate Director · Individual
Said, Fatima
Corporate Director · Individual
Semling, Brian
Corporate Director · Individual
Wagner, Mark
Corporate Director · Individual
Whyte, Brett
Corporate Director · Individual
Williams, Robert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Saint Anne Extended Healthcare
Winona, MN
3-star overall rating with 3-star inspections with $28,593 in total fines with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Sauer Health Care
Winona, MN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Marinuka Manor
Galesville, WI
5-star overall rating with 4-star inspections with 8 fire-safety deficiencies in the latest cycle
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