Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Saint Anne Extended Healthcare during CMS and state inspections, most recent first.
Medication storage and labeling were not maintained as required when an opened tuberculin solution bottle in the med refrigerator had no open date and a resident’s Lantus insulin pen on the med cart was also undated. An LPN confirmed both items were not dated, and an RN confirmed the insulin pen should have been dated once opened and discarded after 28 days.
Failure to Provide or Document Routine Dental Services: A resident with dementia and anxiety who needed help with oral hygiene had no EMR evidence of a dental referral, consult, or documented routine dental visit. Staff and leadership stated the facility’s annual dental process was handled inconsistently, with no reliable way to track refusals or the last dental visit, and the resident and guardian were unaware of when dental care last occurred.
Failure to provide or document routine dental services for a resident with severe cognitive impairment and dependence for all cares, including oral hygiene. The resident had multiple broken teeth on dental consult, but the EMR did not show a follow-up dental visit or evidence that routine dental care was offered or provided. Interviews with the resident’s emergency contact and facility staff showed there was no clear process to track dental visits, refusals, or coordination of routine dental services, and the DON confirmed the record lacked documentation of dental care.
Unlabeled and Undated Food Stored in Kitchen Refrigerator: A kitchen refrigerator contained multiple food items that were not properly labeled or dated, including egg salad sandwiches, a taco, [NAME] tot, and portion cups with an unidentified creamy substance. Staff, including an NA, an LPN, and the culinary supervisor, confirmed dietary staff were responsible for monitoring refrigerator contents for proper labeling, dating, and removal of outdated items, and the facility policy required covered food containers with resident name, room number, and dates.
The facility failed to provide a dignified dining experience for residents needing assistance with eating. Nursing staff were observed standing and moving between tables without engaging with residents during meals. The RDON confirmed that staff should sit with residents to assist them, as per facility policy, but this was not practiced, affecting the quality of care.
During a facility-wide remodel, the facility failed to maintain separately locked, permanently affixed compartments for controlled drug storage in four medication storage areas. Refrigerators on multiple floors were locked but not affixed to a permanent surface and were located in temporary nurse's stations accessible through an unlocked half-height door. Medications stored included flu shots, insulin pens, tuberculin, and Ativan. The facility's policy required controlled substances to be stored in a permanently affixed, double-locked compartment, which was not adhered to during the remodel.
A resident with a history of vein disorders and edema did not receive assistance with applying compression stockings as ordered by a physician. Despite the resident's inability to apply the stockings independently, staff failed to consistently assist, as confirmed by observations and interviews. The facility did not provide a policy on compression stockings, indicating a lack of procedural guidance.
A resident with mild cognitive impairment and dependency on staff for personal care was observed with unaddressed facial hair, despite expressing a desire for its removal. Staff interviews revealed a lack of task entry in the task administration record, leading to the oversight. The facility's policy mandates assistance for residents unable to perform ADLs independently, which was not followed in this instance.
The facility failed to maintain and replace oxygen tubing for two residents with severe cognitive impairments and respiratory conditions. One resident had dirty tubing tied in a knot under their wheelchair, while another had tubing lying on the floor and frequently removed their nasal cannula. Staff interviews revealed a lack of awareness and adherence to the facility's policy requiring weekly changes and labeling of oxygen tubing.
The facility failed to clean medical equipment and use barriers during glucose monitoring, affecting all residents receiving such care. Additionally, a resident requiring enhanced barrier precautions due to a g-tube did not receive proper PPE use, as an LPN only used gloves instead of both gloves and a gown. The infection preventionist confirmed the need for proper cleaning and PPE use, as outlined in the facility's policy.
A resident with severe cognitive impairment and a history of falls was not provided with scheduled toileting assistance, leading to an unwitnessed fall and a right fibular fracture. The nursing assistant failed to follow the care plan, which included specific toileting times and the use of a night light. The resident attempted to use the bathroom independently, resulting in a fall and emergency hospital transport.
The facility failed to ensure proper hand hygiene during personal and wound care for a resident with chronic heart failure and dementia. Two LPNs did not follow hand hygiene protocols, including not changing gloves and not using gloves while applying a new dressing, despite being aware of the facility's hand hygiene policy.
Medication Storage and Dating Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to accepted professional principles when an opened bottle of tuberculin solution in the fourth-floor medication refrigerator had no open date. During an observation and interview on 05/18/26, the bottle was noted to be approximately three quarters used and had a label stating it should be discarded 30 days after opening, but there was no date showing when it had been opened. An LPN present during the observation confirmed the bottle was not dated once opened and stated it should not have been in the refrigerator. The facility also failed to ensure that 1 of 1 resident's Lantus insulin pen was dated once opened. During an observation and interview on 05/20/26, the fourth-floor second medication cart contained a Lantus insulin pen being used for R32 with a yellow label stating discard 28 days after opening, but the pen was not dated. The LPN present confirmed the pen was not dated and stated it had last been used on 5/19/26 at 6:00 p.m. An RN later confirmed that the Lantus pen was to be dated once opened and discarded 28 days after opening.
Failure to Provide or Document Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided or offered for one resident with impaired cognition who required assistance with oral hygiene. The resident had diagnoses of dementia and anxiety, and the annual MDS identified the need for help with oral hygiene. Physician orders dated 7/22/25 included dental consults to evaluate and treat as indicated, and the care plan noted the resident needed assistance with dental care due to dementia and that she had an upper partial denture. The resident’s EMR did not contain a progress note, referral, or documentation of a dental consultation. During observation, the resident was sitting in a wheelchair in her room on the locked memory care unit and had intact teeth in the upper and lower jaw; she stated she did not have dentures, staff had not asked her about dental appointments, and she could not recall the last time she visited a dentist. Interviews with SS, RN, RC, IP, the resident’s guardian, and the DON confirmed the facility had no reliable process to identify, document, or track routine dental visits or refusals, and the DON verified the record did not show that the resident was offered or provided routine dental visits.
Failure to Provide or Document Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided or offered for one resident with significantly impaired cognition who was dependent on staff for all cares, including oral hygiene. The resident had diagnoses including neurocognitive disorder with Lewy body dementia, fibromyalgia, and arthritis. A dental consult noted multiple broken teeth and recommended extraction of any teeth that became symptomatic, but the resident’s EMR did not show evidence of a follow-up dental visit after that consult. The resident’s care plan stated dental appointments were to be based on resident or resident representative preferences. During interviews, the resident’s emergency contact stated he expected the facility to arrange routine dental services and could not recall the last time the resident was seen by a dentist, adding that the resident did not have many teeth left and wanted to be seen. Staff interviews showed the social services department did not coordinate routine dental visits, the nurse manager for the memory care unit was not involved in coordinating them, and the infection control preventionist sent an annual email to family members and guardians asking if they wanted the resident seen by a dentist. The regional director of clinical services stated the facility did not have a process to identify and document refusals or when the last dental visit occurred, and both she and the infection control preventionist stated residents could be missed for routine dental visits. The DON verified the EMR failed to show the resident was offered or provided routine dental visits, and the facility policy stated routine and emergency dental services are provided and all dental services are recorded in the medical record.
Unlabeled and Undated Food Stored in Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure food stored in a unit refrigerator was labeled, dated, and discarded properly. During an observation on 05/20/26 at 9:05 a.m., the fourth-floor kitchen refrigerator contained three clear sandwich-size bags with egg salad sandwiches labeled with a room number but undated, a small uncovered paper bowl of [NAME] tot and a taco wrapped in brown paper from Taco [NAME] that were not labeled and undated, and three small plastic portion cups with a creamy, medium-consistency substance that were not labeled and undated. The refrigerator also contained a medium-size food container with a red lid holding a mixture of ground brown meat and reddish liquid that was labeled with a room number and dated 5/14/26. During interviews, NA-A confirmed the egg salad sandwiches were undated, the ranch dressings were not labeled and undated, and the [NAME] tot and taco from Taco [NAME] were not labeled and undated. NA-A stated dietary staff was responsible for monitoring the kitchen refrigerator daily for proper food labeling, dating, and removal of outdated food items. An LPN stated any food item placed in the kitchen refrigerator needed to be dated and labeled, and dietary staff was responsible for monitoring for proper labeling, dating, and removal of outdated food items. The culinary supervisor also stated dietary staff was responsible for monitoring the kitchen refrigerators for proper labeling and removal of outdated food items daily. The facility policy titled Safe Food Storage and Handling for Food Brought in stated all food stored in refrigerator/freezer units should be in covered, seamless containers or otherwise suitably protected with date, used-by date, name, and room number of resident.
Failure to Ensure Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents who required assistance with eating. Observations revealed that nursing staff were standing while feeding residents and moving from table to table without engaging with them during meals. This behavior was noted on multiple occasions in both the main dining room and the 5th floor common area. Interviews with nursing assistants and the culinary director confirmed that staff were not adhering to the expected practice of sitting with residents to provide assistance, which was acknowledged as a dignity concern. The Regional Director of Nursing (RDON) indicated that the expectation was for nursing staff to sit at the tables with residents, assist them with their meals, and offer choices in how they consume their food. The facility's policy on Assistance with Meals, dated 2018, stated that residents who cannot feed themselves should be assisted with attention, safety, comfort, and dignity. However, the observations and interviews highlighted a discrepancy between the policy and the actual practice, affecting the quality of care provided to residents who depend on staff for their nutritional intake.
Deficiency in Controlled Drug Storage During Remodel
Penalty
Summary
The facility failed to maintain separately locked, permanently affixed compartments for the storage of controlled drugs in four observed medication storage areas during a facility-wide remodel. Observations revealed that the refrigerators used to store medications on the 2nd, 3rd, 4th, and 5th floors were locked but not affixed to any permanent surface. These refrigerators were located in temporary nurse's stations, which were accessible through a half-height wooden door that did not lock, allowing potential access by staff, visitors, or construction workers. The medications stored included flu shots, insulin pens, tuberculin, and Ativan, an antianxiety medication. Interviews with the LPN and the RDON confirmed that the current process involved storing most medications in locked carts, with medication storage refrigerators on each floor behind temporary nurse's stations. The facility's policy required controlled substances to be stored in a permanently affixed, double-locked compartment separate from other medications, with refrigerated controlled substances stored within a locked box attached to the inside of the refrigerator. However, the facility did not adhere to this policy during the remodel, as the refrigerators were not permanently affixed, and the temporary storage areas were not adequately secured.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to ensure that compression stockings were applied as ordered for a resident with a medical history of disorders of veins, localized edema, essential hypertension, and a history of acute embolism and thrombosis related to deep veins of the lower extremities. The resident, who had an intact cognitive status and required minimal assistance with activities of daily living, had a physician's order for compression stockings to be applied daily in the morning and removed at night. However, observations on multiple occasions revealed that the resident did not have the compression stockings on, and the resident reported that staff did not consistently assist with their application. Interviews with the resident and staff confirmed that the nursing staff were expected to assist the resident with the compression stockings, but this assistance was not consistently provided. The resident expressed that they could not apply the stockings themselves and that staff often forgot to help. The LPN and the regional director of nursing verified the existence of the physician's order and the expectation for staff to assist the resident. Despite requests, the facility did not provide a policy on edema or compression stockings, indicating a lack of procedural guidance for staff.
Failure to Ensure Routine Grooming for Dependent Resident
Penalty
Summary
The facility failed to ensure routine grooming for a resident, identified as R62, who was dependent on staff for personal care. R62's minimum data set assessment indicated mild cognitive impairment and a dependency on facility staff for personal hygiene tasks. The resident's care plan highlighted a self-care deficit related to personal hygiene and bathing, requiring substantial assistance from facility staff. During an observation, R62 was noted to have facial hair on the right upper lip and chin, which the resident expressed a desire to have removed. However, the grooming task was not completed as expected. Interviews with facility staff revealed a lack of communication and task entry in the task administration record (TAR), which led to the oversight. Nursing assistants rely on the TAR for their care tasks, and if a task is not entered, it may not be completed. The licensed practical nurse confirmed that if an order or care plan is not entered, staff may not be aware of the need to perform the task. The registered nurse stated that R62's bath, which includes facial hair removal, is scheduled for Thursdays, but the task was not completed despite the resident having a bath the previous Thursday. The facility's policy states that residents unable to perform activities of daily living independently should receive assistance, but this was not adhered to in R62's case.
Failure to Maintain and Replace Oxygen Tubing
Penalty
Summary
The facility failed to maintain and replace oxygen tubing for two residents who required respiratory care. One resident, with severe cognitive impairment and diagnoses including primary emphysema and respiratory failure, was observed with dirty oxygen tubing that was tied in a knot and had their wheelchair sitting on top of it. The licensed practical nurse confirmed the tubing should have been changed for sanitary reasons, and the nursing assistant was unaware of the process for changing the tubing or the need for a portable oxygen tank. Another resident, also with severe cognitive impairment and multiple diagnoses including dementia and heart failure, was observed with oxygen tubing lying on the floor and frequently taking the nasal cannula on and off. The registered nurse acknowledged concerns about the tubing's cleanliness and the lack of labeling on the portable tank. The infection preventionist and director of nursing confirmed the facility's policy required weekly changes and labeling of oxygen tubing, and that residents should be on portable tanks for sanitary and safety reasons.
Infection Control and PPE Deficiencies in Resident Care
Penalty
Summary
The facility failed to appropriately clean resident medical equipment after use and did not place a barrier between resident high-touch surfaces and a multiuse basket. During medication administration, a registered nurse (RN) placed a basket containing medical supplies on a resident's tray table without a barrier and did not clean the glucometer after use. This practice was repeated with another resident, where the RN was reminded by the surveyor to clean the equipment. Another RN also failed to place a barrier and clean the equipment after use, indicating a pattern of non-compliance with infection control protocols. The facility also failed to ensure proper use of personal protective equipment (PPE) during care for a resident requiring enhanced barrier precautions (EBP) due to a g-tube. The resident's care plan required the use of gloves and gowns for high-contact care activities. However, a licensed practical nurse (LPN) only used gloves and did not don a gown while performing g-tube site care and medication administration. The LPN was unaware of the full PPE requirements for EBP, despite the facility's policy and training requirements. The infection preventionist confirmed that the facility uses shared glucometers and expects them to be cleaned between residents. The infection preventionist also stated that appropriate PPE, including gowns and gloves, is required for all high-contact care activities for residents on EBP. The facility's policy on EBP specifies the use of PPE for residents with indwelling medical devices, such as feeding tubes, to prevent the transfer of multidrug-resistant organisms (MDROs).
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to follow a care planned intervention to prevent or reduce the risk of falls for a resident with severely impaired cognition and multiple diagnoses, including dementia and anxiety disorder. The resident required extensive assistance with bed mobility, transfers, and toileting, and had a history of falls with injuries. The care plan included specific interventions such as waking and assisting the resident to the bathroom at designated times and using a night light due to the resident's preference for a dark room. On the night of the incident, the nursing assistant did not offer toileting at the scheduled time of 11:00 p.m. and failed to check on the resident during midnight rounds. As a result, the resident attempted to use the bathroom independently, leading to a fall that resulted in a right fibular fracture. The fall was unwitnessed, and the resident was found on the floor in pain, requiring emergency transport to the hospital for further assessment. Interviews with staff revealed that the nursing assistant was busy and did not adhere to the care plan, which could have prevented the fall. The licensed practical nurse on duty was unfamiliar with the resident and had not been in the room prior to the fall. The director of nursing and regional nurse consultant confirmed that the care plan was not followed, leading to the fall and subsequent injury.
Removal Plan
- R1 was assessed and fall protocols were followed.
- R1 was transferred to the ED.
- Facility investigation was coordinated with interviews of staff and R1, along with care plan review.
- NA-A was provided verbal coaching and education after it was determined she failed to follow R1's plan of care.
- The facility reviewed falls at IDT to ensure the care plan was followed for each fall.
- Reviewed all falls to ensure current prevention interventions that were in place were effective.
- The facility was free of additional falls related to failure to follow plan of care.
Failure to Ensure Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during personal care and wound care for a resident with chronic heart failure, dementia with behavioral disturbances, and difficulty walking. The resident required enhanced barrier precautions, including the use of gloves and gowns during high-contact care activities. During an observation, two LPNs assisted the resident with incontinent care and wound care but did not follow proper hand hygiene protocols. One LPN did not tie her gown properly, causing it to fall and requiring adjustments during care. She also did not use gloves while applying a new dressing, citing that the dressing would stick to her gloves. Both LPNs failed to change gloves and perform hand hygiene after removing the old dressing and before putting on a new brief for the resident. Interviews with the LPNs revealed that they were aware of the hand hygiene protocols but did not follow them during the observed care. The facility's policy on hand hygiene, revised in September 2023, clearly outlined the times when hand hygiene should be performed, including before and after direct resident contact, after removing gloves, and before and after changing a dressing. Despite this, the LPNs did not adhere to these guidelines, leading to a deficiency in infection control practices as observed by the surveyors.
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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) |
|---|---|---|---|---|
| Sauer Health Care | 0.5 mi | ★★★★★ | 15 | 0 |
| Lake Winona Manor | 2.9 mi | ★★★★★ | 4 | 0 |
| Marinuka Manor | 16.6 mi | ★★★★★ | 2 | 0 |
| Good Shepherd Lutheran Home | 18.1 mi | ★★★★★ | 2 | 0 |
| Whitewater Health Services | 20 mi | ★★★★★ | 3 | 0 |
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