Cycle 1
Health 2025-02-13 · Fire 2025-02-13
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Winona, MN
Saint Anne Extended Healthcare
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
1347 West Broadway Street, Winona, MN
(507) 205-6208
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
84
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Benedictine Health System
Operator or chain grouping
Approved since
1983-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.83
Registered nurse staffing
LPN hours / resident day
0.70
Licensed practical nurse staffing
Aide hours / resident day
2.26
Nurse aide staffing
Weekend hours
3.26
Weekend nurse staffing
RN turnover
52%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
2.0
1.3 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
97.3%
0.3 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
96.1%
3.9 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.9%
0.2 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 12.5% |
4.3%
8.2 pts worse
|
11.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.5% |
4.1%
1.6 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.7% |
12.4%
2.7 pts better
|
19.6%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.3% |
17.5%
0.2 pts better
|
16.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.0% |
22.5%
8.5 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
18.6%
1.8 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
2.3%
1.3 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.6%
0.6 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.5% |
24.8%
1.7 pts worse
|
19.8%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
5.4%
3.6 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.2% |
88.6%
1.4 pts worse
|
81.7%
5.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.2% |
14.0%
5.2 pts worse
|
12.0%
7.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.9%
0.5 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.4% |
82.7%
6.3 pts worse
|
79.7%
3.3 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.5% |
23.1%
9.6 pts better
|
23.9%
10.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
10 health deficiencies
Top issue: Infection Control (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-05-26 · Fire 2022-05-26
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-13
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Not marked corrected
F · Potential for more than minimal harm
2025-02-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-13
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 2025-03-19
F · Potential for more than minimal harm
2025-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-02-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-19
F · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Not marked corrected
F · Potential for more than minimal harm
2023-12-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-14
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Not marked corrected
F · Potential for more than minimal harm
2023-12-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-12-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-17
F · Potential for more than minimal harm
2022-05-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-07
F · Potential for more than minimal harm
2022-05-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-07
F · Potential for more than minimal harm
2022-05-26
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-07-07
E · Potential for more than minimal harm
2022-05-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-07
E · Potential for more than minimal harm
2022-05-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-07
D · Potential for more than minimal harm
2022-05-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-07
C · Minimal harm
2022-05-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-19
E · Potential for more than minimal harm
2025-02-13
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 2025-03-19
D · Potential for more than minimal harm
2025-02-13
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-13
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 2025-03-19
D · Potential for more than minimal harm
2025-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-19
G · Actual harm
2024-11-04
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 2024-08-15
D · Potential for more than minimal harm
2024-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-30
G · Actual harm
2023-12-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-12-14
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 2024-01-17
E · Potential for more than minimal harm
2023-12-14
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 2024-01-17
E · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-17
E · Potential for more than minimal harm
2023-12-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-10-31
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 2023-11-30
D · Potential for more than minimal harm
2023-10-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-04-18
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 2023-04-28
Penalties and ownership
What sits behind the stars
$16,675
2024-11-04
Fine
Fine · fine $16,675
Fine
$11,918
2023-12-14
Fine
Fine · fine $11,918
Fine
Ownership
Benedictine Health System
5% Or Greater Direct Ownership Interest · Organization
Benedictine Health System
Operational/Managerial Control · Organization
Bergien, Tricia
Corporate Officer · Individual
Carley, Gerald
Operational/Managerial Control · Individual
Coalwell, Lucas
Corporate Director · Individual
Ehlinger, Carol
Operational/Managerial Control · Individual
Erwin, James
Corporate Director · Individual
Glenzinski, Christina
Corporate Director · Individual
Kilkus, Paul
Corporate Director · Individual
Marek, Patrick
Corporate Director · Individual
Myers, Bonnie
Corporate Director · Individual
Rymanowski, Kevin
Corporate Officer · Individual
Stelman, Joan
Corporate Director · Individual
Vrchota, James
Corporate Director · Individual
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