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
Chain footprint
22 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
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
0.70
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
4.52
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,897
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.11
Baseline 19.60% · Performance 20.92% · Measure score 1.11 · Achievement 1.11 · Improvement 0
Healthcare-associated infections
4.46
Baseline 5.78% · Performance 6.50% · Measure score 4.46 · Achievement 4.46 · Improvement 0
Total nurse turnover
3.11
Baseline 51.46% · Performance 50.96% · Measure score 3.11 · Achievement 3.11 · Improvement 0
Adjusted total nurse staffing
3.89
Baseline 3.73 hours · Performance 4.18 hours · Measure score 3.89 · Achievement 3.89 · Improvement 1.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.97% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 6.56% · Lower 95% interval 6.27% |
| Discharge to community | 57.56% |
50.57%
7 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 54.76% · Lower 95% interval 44.85% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 37 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 56.25% |
53.69%
2.6 pts better
|
Numerator 18 · Denominator 32 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 16 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 2.55% |
| Healthcare-associated infections requiring hospitalization | 6.5% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 2.86% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 7.74% |
8.2%
0.5 pts worse
|
Numerator 12 · Denominator 155 |
| Staff flu vaccination coverage | 38.85% |
42%
3.1 pts worse
|
Numerator 61 · Denominator 157 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 20 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 44% |
25.2%
18.8 pts better
|
Numerator 11 · Denominator 25 |
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 · Adjusted 1.7 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| 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 · Adjusted 3.3 · Observed 2.4 · Expected 1.2 · Used in QM five-star |
| 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 · Q1 95.9% · Q2 97.2% · Q3 98.6% · Q4 98.7% · 4Q avg 97.6% |
| 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 · 4Q avg 92.2% |
| 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 · Q1 4.1% · Q2 2.8% · Q3 2.7% · Q4 6.4% · 4Q avg 4.1% · Used in QM five-star |
| 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 · Q1 17.9% · Q2 10.9% · Q3 12.9% · Q4 8.6% · 4Q avg 12.5% |
| 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 · Q1 1.8% · Q2 3.4% · Q3 3.2% · Q4 1.5% · 4Q avg 2.5% |
| 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 · Q1 10.3% · Q2 11.7% · Q3 12.7% · Q4 4.5% · 4Q avg 9.7% |
| 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 · Q1 17.4% · Q2 18.4% · Q3 18.4% · Q4 15.4% · 4Q avg 17.3% · 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 | 31.0% |
22.5%
8.5 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 35.6% · Q3 31.1% · Q4 22.8% · 4Q avg 31.0% · Used in QM five-star |
| 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 · Q1 14.8% · Q2 20.7% · Q3 23.7% · Q4 21.9% · 4Q avg 20.4% · Used in QM five-star |
| 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 · Q1 1.3% · Q2 1.4% · Q3 0.0% · Q4 1.3% · 4Q avg 1.0% · Used in QM five-star |
| 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 · Q1 5.6% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| 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 · Q1 22.9% · Q2 20.0% · Q3 30.5% · Q4 31.5% · 4Q avg 26.5% |
| 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 · Q1 2.3% · Q2 1.3% · Q3 2.4% · Q4 1.3% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 85.4% · Q2 79.5% · Q3 88.2% · Q4 96.7% · 4Q avg 87.2% |
| 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 · Adjusted 19.2% · Observed 18.4% · Expected 10.7% · Used in QM five-star |
| 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 · Q1 8.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| 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 · 4Q avg 76.4% |
| 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 · Adjusted 13.5% · Observed 10.5% · Expected 18.5% · Used in QM five-star |
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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#2
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4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
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