Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Winona Manor during CMS and state inspections, most recent first.
Failure to reassess a resident’s elopement risk and update the care plan after an elopement episode. The resident had severe cognitive impairment, dementia, anxiety, and a long history of wandering and attempts to leave the building, with interventions such as a WanderGuard, visual checks, and a door alarm already in place. After the resident was found in a vehicle in the parking lot, the event report was incomplete, no post-incident assessment was documented, and the care plan was not revised.
Incomplete Full-Time DON Coverage: The facility failed to maintain and clearly define a full-time DON. Records showed the interim DON worked only part-time, while interviews confirmed the administrator was absent, the nurse manager was not serving as interim DON, and the DON role was being covered by multiple leaders instead of a clearly designated full-time DON. The facility also did not provide education or documentation for the nurse manager to cover the interim DON role.
A facility failed to provide meal assistance and cueing to two residents seated at a designated assistance table. One resident had severe dementia and was dependent on staff for eating, and the other had dementia, depression, anxiety, CKD, and a care plan directing staff to cut up food and supervise meals. During lunch, both residents were left without needed help while staff passed by or were only briefly present, and interviews confirmed staff knew the residents required assistance but did not consistently provide it.
A resident who was cognitively intact kept Voltaren Gel on a tray table and said he used it on both knees for pain throughout the day, but the medication had no provider order and no SAM assessment was completed. Staff observed the gel in the room during medication administration, and interviews confirmed the LPN, NM, and DON all identified that the medication should have been ordered and assessed before the resident retained or used it.
Outdated Resident Rights posters were observed in the facility, including one near the entrance and another by the elevator, both displaying older dates. The administrator stated she was unaware of the newly released poster effective 1/1/26 that was meant to replace prior versions. The facility policy required residents to be informed of their rights and for the Resident Rights to be posted in a conspicuous location.
Survey results were not fully posted in an accessible location for residents, staff, and visitors. A review of the survey binder near the elevator found the prior recertification survey present, but the LSC 2567 was missing. The administrator stated she was unaware the survey results were not in the binder, and no policy for posting survey results was available.
A resident with multiple sclerosis and complete dependence on staff for mobility was injured when a single nursing assistant attempted to reposition her in bed without the required two-person assist, as specified in her care plan. The resident slid off the bed and sustained fractures to both legs. Staff interviews confirmed that the care plan required two-person assistance due to the resident's lack of motor control, but this protocol was not followed, resulting in actual harm.
The facility failed to ensure proper food safety practices, with food service workers not securing hair, neglecting hand hygiene, and improperly sanitizing thermometers. These actions, observed during a survey, had the potential to affect all residents receiving meals from the dining rooms.
The facility failed to consistently implement enhanced barrier precautions (EBP) and proper PPE use for residents with wounds. Observations showed PPE carts and doffing receptacles were placed outside rooms, causing confusion among staff about where to doff PPE. Some residents with open wounds lacked EBP signage and PPE, and wound care was performed without gowns. The infection preventionist and administrator confirmed these lapses, which contradicted the facility's infection control policy.
A resident with severe dementia and a left heel ulcer did not receive consistent wound assessments and documentation as required by the facility's policy. Despite having a care plan for weekly skin assessments, the facility failed to perform comprehensive evaluations, leading to inadequate monitoring of the resident's pressure ulcer. Nursing staff were unsure of assessment frequency, and documentation was inconsistent, resulting in a deficiency in care.
A resident with moderate cognitive impairment and a diagnosis of diarrhea did not have a bowel management program, despite having a predictable bowel pattern. The resident expressed discomfort from sitting in soiled incontinence products and was not offered periodic restroom visits to prevent incontinence. Staff acknowledged the need for a bowel care plan, but none was in place, leading to frequent episodes of stool incontinence.
The facility failed to assess and document the use of assist bars for three residents, leading to a deficiency. Residents with conditions such as cerebral palsy, Parkinson's disease, and dementia had assist bars installed without proper safety assessments, informed consent, or discussion of risks and benefits. The assist bars were also installed incorrectly, contrary to manufacturer instructions, affecting 48 residents using them for mobility.
Failure to Reassess Elopement Risk and Update Care Plan After Elopement
Penalty
Summary
The facility failed to reassess a resident’s elopement risk and revise the comprehensive person-centered care plan after an elopement episode. The resident had severe cognitive impairment with a BIMS score of 3, a history of wandering, and diagnoses including heart failure, non-Alzheimer’s dementia, and anxiety disorder. Her documented behaviors included hitting, pinching, running her wheelchair into staff, repeatedly trying to leave through the elevator, opening doors and setting off alarms, resisting redirection, and verbalizing a desire to leave. Interventions already in place included a WanderGuard bracelet, half-hour visual checks, a motion alarm above her door, and other redirection measures. An event report documented that the resident eloped and was found in someone’s vehicle in the parking lot with no injuries. The event report lacked documentation under sections for measures taken, outcomes of interventions, notification guidelines, vital signs, and orders. Records reviewed did not show an assessment completed after the elopement episode, and the care plan was not updated with new interventions following the incident. During interviews, the nurse manager was unsure whether a new assessment or care plan update had been completed, while the assistant administrator and administrator stated the care plan did not need updating because the resident was not injured and had not left the campus property.
Incomplete Full-Time DON Coverage
Penalty
Summary
The facility failed to maintain and clearly define a full-time Director of Nursing (DON). The facility’s Change of Director of Nursing form dated 5/1/26 identified the administrator, who was also an RN, as the previous DON and designated RN-B as the new interim DON. However, the interim DON’s time card for 7/10/26 through 7/19/26 showed the interim DON worked eight hours on Monday, Wednesday, and Thursday for a total of 24 hours in one week. During interviews, RN-A stated the administrator was not present at the facility that week and that the interim DON worked part-time; RN-A also stated she was the nurse manager and was not filling in as an interim DON. The assistant administrator stated the interim DON was on a leave of absence and had started working part-time on 7/13/26 on Mondays, Wednesdays, and Thursdays, while RN-A was available for clinical questions. In email correspondence, the assistant administrator stated the interim DON’s leave began on 5/18/26 and that the full-time DON role was covered by the full-time nurse manager, part-time interim DON, herself as a full-time LNHA assistant administrator, and the full-time RN/LNHA administrator. The administrator acknowledged the interim DON worked a few days a week. The facility did not provide education or documentation for RN-A to cover the interim DON role.
Failure to Assist Residents With Meals as Care Planned
Penalty
Summary
The facility failed to provide assistance and cueing with ADLs, specifically eating, for two residents who were seated at a table designated for residents needing staff help with meals. One resident had severe cognitive impairment, dementia, delusions, and was dependent on staff for eating; the care plan directed staff to supervise, cue, and assist with meals. The other resident was admitted with dementia with behavioral disturbance, depression, anxiety, chronic kidney disease, and other diagnoses; the care plan directed staff to cut up food, supervise the resident in the dining room, and cue and give a spoon as needed. During lunch observation, both residents sat in wheelchairs at the assistance table with their meals in front of them and were not eating. Two kitchen staff were present in the room, and a TMA was intermittently present near the dining room, but no staff sat with the residents to assist them. One resident eventually began eating some of the meal, while the other continued to stare and did not eat. Staff walked through or briefly entered the dining room, but did not provide meal assistance to either resident. One resident’s water spilled across the table and near the other resident’s shoes before a nurse aide was notified and removed the resident from the dining room. Interviews confirmed staff knew the residents required meal assistance and that the table was designated for residents needing help, but staff described being busy and lacking time to assist. One nurse aide stated the resident was new and he was unsure what assistance was needed, while another acknowledged the resident’s chicken legs were not cut up as directed. Other staff stated residents at that table should have been assisted, with one nurse manager and the administrator both stating staff were expected to sit with residents and provide feeding assistance, supervision, or hand-over-hand help as needed. The facility feeding procedure also directed staff to sit with residents who needed more help than simply serving the tray.
Missing Order and Self-Administration Assessment for In-Room Pain Gel
Penalty
Summary
The facility failed to ensure a self-administration of medication assessment was completed for one resident who was cognitively intact, independent with eating and basic personal hygiene, and dependent on staff for mobility and transfers. The resident’s record did not contain an assessment to self-administer medications, even though the resident stated he used Voltaren Gel on both knees for pain throughout the day and was unsure how many times per day he used it. During observation, a tube of Voltaren Gel was seen sitting in a basket on the resident’s tray table, and the resident stated he used it when his knees hurt. The resident lacked an order for Voltaren Gel, yet the medication remained in the room during multiple observations. An LPN later administered the resident’s morning medications and left the room with the Voltaren Gel still present. Staff interviews confirmed there was no provider order for the gel and no self-administration assessment had been completed, and the facility policy stated a resident may not retain or administer medication in the room unless ordered by the provider and an appropriate assessment is completed.
Outdated Resident Rights Posters
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident Rights poster was provided to each resident and displayed for residents, visitors, and staff to review. During observation, the Resident Rights poster near the entrance was dated 1/2019, and a second Combined Resident Rights poster next to the elevator to the second floor was dated 1/2016. During interview, the administrator stated she was unaware of the newly released Resident Rights poster effective 1/1/26, which was to replace previous posters. The facility policy titled Resident Rights, effective 8/1/21, stated residents had the right to be informed of rights granted within the Resident Rights and the recourse available if rights were violated, and that the Resident Rights were to be posted in a conspicuous location within the facility.
Survey Results Not Posted in Accessible Location
Penalty
Summary
The facility failed to ensure survey results were posted in an accessible location for residents, staff, and visitors. During observation on 3/3/26 at 11:45 a.m., the survey results binder located near the elevator was reviewed and the previous recertification survey dated 12/5/24 was present, but the Life Safety Code (LSC) 2567 completed 12/4/25 was not found in the binder. During interview on 3/3/26 at 1:12 p.m., the administrator stated she was unaware the LSC 2567 survey results were missing from the binder and stated it was important for survey results to be available for review by residents, staff, and visitors. A request was made for the facility policy on posting survey results, but no policy was available.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan requiring the assistance of two staff members for turning and repositioning. The resident, who had multiple sclerosis resulting in significant immobility and dependence on staff for all activities of daily living, was being cared for by a single nursing assistant during a bed mobility task. Despite the care plan specifying two-person assistance for mobility and repositioning, the nursing assistant proceeded alone, resulting in the resident sliding and rolling out of bed. The resident's medical history included multiple sclerosis, bilateral upper and lower extremity impairments, and complete dependence on staff for mobility and toileting. At the time of the incident, the resident was unable to control or move her legs and had no trunk control, making her highly vulnerable during transfers and repositioning. During the incident, the nursing assistant attempted to reposition the resident, but her legs slipped off the bed. The assistant tried to prevent injury by catching the resident's upper body, but was unable to prevent her from falling to the floor. As a result, the resident sustained a right tibia and fibula fracture and a distal end fracture of the left femur. Interviews with staff revealed that other nursing assistants were aware that the resident required two-person assistance for turning and repositioning due to her lack of motor control. The care plan had clearly indicated this requirement, and staff acknowledged that it would not be safe or appropriate for one person to perform these tasks alone. The incident occurred because the care plan was not followed, leading to actual harm to the resident.
Food Safety and Hygiene Deficiencies in Dining Services
Penalty
Summary
The facility failed to ensure proper food safety practices, as observed during a survey. Food service workers (FSW-A and FSW-B) were seen not having their hair fully secured in hairnets, which is a requirement to prevent hair from falling into food or onto food equipment. FSW-A was observed with long, curly hair not fully contained within the hairnet, and despite being asked to secure it, returned with hair still not fully covered. This lack of adherence to hair restraint protocols was noted by the Director of Environment & Risk Management (DERM)-B, who confirmed the expectation for hair to be fully covered. Additionally, there were significant lapses in hand hygiene and glove use. FSW-A was observed touching his face, handling various items, and then directly handling food with contaminated gloves without changing them or washing his hands. This was contrary to the facility's expectations, as stated by DERM-B, that gloves should be changed and hands washed between tasks. FSW-B, who was new to the role, also failed to follow proper glove use and hand hygiene protocols, as he was seen handling various items and food without changing gloves or washing hands. The facility also failed to ensure proper use and sanitation of food thermometers. FSW-A was observed using a thermometer with visible food debris and not properly sanitizing it between uses. FSW-B was seen using a thermometer without following the correct sanitization process, including wiping it on his pants. DERM-B confirmed that the correct procedure was to use an alcohol wipe to clean the thermometer probe between uses, which was not followed. These deficiencies in food safety practices had the potential to affect all residents receiving meals from the dining rooms observed.
Inconsistent Implementation of Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and proper donning and doffing of personal protective equipment (PPE) for residents with wounds. Observations revealed that PPE carts and doffing receptacles were inconsistently placed outside resident rooms, leading to confusion among staff about where to doff PPE. Nursing assistant (NA)-A was observed doffing PPE outside the room of a resident with a chronic foot ulcer, contrary to the facility's infection control policy, which requires doffing inside the room. The infection preventionist was unaware of the improper placement of disposal hampers and confirmed that doffing should occur inside the room. Additionally, the facility did not consistently apply EBP for residents with open wounds. A resident with a stage 3 pressure ulcer on the heel did not have an EBP sign or PPE present outside the room, and the wound care was performed without a gown. Another resident with unstageable pressure ulcers also lacked EBP signage and PPE, and wound care was conducted with gloves only. The infection preventionist acknowledged that these residents should have been on EBP due to their open wounds. The facility's infection control policy mandates that a sign indicating the type of precautions required be placed outside each infectious room, and that PPE be donned upon entry and doffed before exiting. However, observations and interviews revealed that staff were not consistently following these guidelines, leading to potential lapses in infection control. The administrator confirmed that PPE should be doffed before exiting the room and that residents with open wounds should be on EBP precautions.
Inadequate Wound Care and Documentation for Resident
Penalty
Summary
The facility failed to comprehensively assess and document the wound care for a resident identified as R24, who was at risk for pressure ulcers. R24, diagnosed with severe dementia and other conditions, was noted to have a left heel ulcer. Despite having a care plan that included weekly skin assessments and specific wound care orders, the facility did not consistently perform or document comprehensive wound assessments, including measurements and descriptions of the wound bed, drainage, and edges. Observations and interviews revealed that the resident's wound care was not adequately managed. The resident's family member reported that the heel ulcer had been present for months, and the resident was observed without the recommended heel protection. Nursing staff were unsure of the frequency of required wound assessments, and documentation showed inconsistencies in the recording of wound measurements and descriptions. The facility's policy required weekly assessments, but these were not consistently completed or documented. The facility's failure to adhere to its own skin care policy and procedures resulted in inadequate monitoring and documentation of the resident's pressure ulcer. Interviews with nursing staff and the administrator confirmed that comprehensive wound assessments were not performed weekly as required, leading to a deficiency in the care provided to the resident.
Failure to Implement Bowel Management Program for Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident with moderate cognitive impairment and a diagnosis of diarrhea, who required extensive assistance for mobility, transfers, and toileting. The resident did not have an active bowel program to manage bowel continence, and the care plan did not include bowel care interventions or a bowel management regimen. The resident expressed discomfort and frustration due to sitting in soiled incontinence products and indicated a preference for using the toilet to avoid soiling. Despite having a predictable bowel pattern, particularly after meals, the resident was not offered periodic restroom visits to prevent stool incontinence. Interviews with staff revealed that the resident was checked every two hours for catheter and brief changes, but not offered restroom visits to prevent incontinence. The registered nurse acknowledged the need for a bowel care plan, given the resident's predictable bowel pattern, but stated that no such plan was in place. The facility's administrator confirmed that the resident did not have an active or previous bowel care plan, despite the facility's policy to assess and manage fecal incontinence. The lack of a bowel management program led to the resident experiencing frequent episodes of stool incontinence, which could have been mitigated with a proper care plan.
Failure to Assess and Document Use of Assist Bars
Penalty
Summary
The facility failed to ensure that side rails, specifically assist bars, were comprehensively assessed for safety and appropriateness before use. This deficiency was observed in three residents who had assist bars raised on their beds without proper assessment, documentation of informed consent, or discussion of risks and benefits. The lack of these assessments and documentation had the potential to affect all 48 residents utilizing assist bars for mobility. Resident 1, diagnosed with spastic cerebral palsy and osteoarthritis, was observed with two cane-shaped assist bars in the elevated position on their bed. Despite being dependent on staff for activities of daily living and having a moderate fall risk, there was no side rail assessment or documentation of informed consent in their electronic medical record. Similarly, Resident 27, with repeated falls and Parkinson's disease, and Resident 38, with dementia and a high fall risk, also had assist bars without proper assessments or documentation. The facility's policy required side rail assessments, informed consent, and discussion of risks and benefits before use, but these were not conducted for residents using assist bars. The assist bars were installed incorrectly, with the C shape facing the head of the bed instead of the foot, contrary to manufacturer instructions. The facility did not consider grab bars as side rails, leading to a lack of safety assessments and documentation, which was acknowledged by the nurse manager and administrator.
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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 Winona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sainte Anne Extended Healthcare | 2.9 mi | ★★★★★ | 14 | 0 |
| Sauer Health Care | 3.3 mi | ★★★★★ | 15 | 0 |
| Marinuka Manor | 14.5 mi | ★★★★★ | 2 | 0 |
| Good Shepherd Lutheran Home | 17.6 mi | ★★★★★ | 2 | 0 |
| Valley View Healthcare & Rehab | 18.9 mi | ★★★★★ | 0 | 0 |
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