Lake Winona Manor
865 Mankato Avenue, Winona, MN 55987 · Non profit - Corporation · 80 certified beds · (507) 457-4366 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for mishandling residents’ money or property (F0565, F0570)
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.5% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.8% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.3% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.9% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.0% | 4.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.2% | 4.0% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.6% | 20.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.0% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.7% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.1% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.3% | 17.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 82.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.0% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 27.3% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 1.61 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 4.28 | 1.90 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 32 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.4%CMS range 47.9–68.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.0–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 59.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.89 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 80 beds and averages 63.9 residents a day — about 80% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.28 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.18 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.76 hrs/resident/day on weekends vs 4.49 on weekdays — 16% thinner on weekends. RN hours go from 0.75 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2025-12-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the turning and repositioning care plan requiring assist of two staff for 1 of 3 residents (R1) which resulted in actual harm when R1 fell off the bed sustaining a right tibia and fibula fracture, and a distal end of left femur fracture. The facility had put corrective measures in place on 11/13/25, prior to the start of the survey, therefore, was issued at past non-compliance Findings include: R1's face sheet dated 12/17/25, identified diagnoses of multiple sclerosis (disease that causes numbness, weakness, trouble walking, vision issues, etc.), fracture of upper end of right tibia (fracture just below the knee), fracture of lower end of left femur (lower part of thigh bone), and anxiety. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was able to understand and make self-understood to others, had no cognitive deficits, no behaviors, impairments on both sides of upper and lower extremities, dependent on staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure a self-administration of medication assessment (SAM) was completed for 1 of 1 resident (R8) reviewed for self-administration of medication.Findings include:R8's Quarterly Minimum Dat Set (MDS) assessment, dated 2/10/26 indicated R8 was cognitively intact. Further, R8 was independent with eating and basic personal hygiene and dependent on facility staff for mobility and transfers.R8's record lacked an assessment to self-administer medications.During observation and interview on 3/2/26 at 7:01 p.m., a Voltaren Gel (pain relief) tube was observed sitting in a basket on R8's tray table. R8 stated he used the Voltaren Gel on both his knees when he had pain. R8 stated he would use the gel throughout the day and is unsure how many times per day.R8 lacked an order for Voltaren Gel. During observation and interview on 3/4/26 at 8:54 a.m., licensed practical nurse (LPN)-A was observed administering R8's morning medications. The Voltaren Gel remained in the basket on R8's tray table. R8 again stated, he uses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and document review the facility failed to ensure proper food safety practices when food service workers (FSW-A and FSW-B) were observed not having hair secured, not properly disinfecting food thermometer, not recognizing need to reheat food when needed, and touching food with contaminated gloves. This practice had the potential to affect all 65 residents who received meals from 2 of 2 dining rooms observed. Findings include: During an observation and interview on 12/2/24 at 5:04 p.m., in the second-floor dining room, observed FSW-A standing behind the steam table preparing to plate food for the evening meal. FSW-A's hair which was long and curly, had not been fully secured in his hairnet -- all hair below the level of his ears was outside of the hairnet. FSW-A was asked not to proceed and to secure his hair. FSW-A stated he would try and left the dining room. FSW-A returned a few minutes later and his hair was still not fully secure. He tucked the rest of his hair into the hairnet, washed his hands and donned gloves. During an observation on 12/2/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 3 of 3 residents (R27,R24,R58) reviewed for wounds, and proper donning and doffing of personal protective equipment (PPE) was completed per standard guidelines for 2 of 3 residents (R20,R27). Findings include: R20's facesheet printed on 12/5/24, included diagnosis of chronic foot ulcer. R20's quarterly MDS assessment dated [DATE], indicated R20 was cognitively intact; was usually understood and could understand. R20 was dependent on staff for most activities of daily living (ADL), and had a stage 2 pressure ulcer on her foot. R20's care plan dated 10/4/24, indicated impaired skin integrity related to left foot pressure ulcer and enhanced barrier precautions were in place. During an observation on 12/2/24 at 2:38 p.m., in hallways on the north and south units on second floor, PPE carts and doffing receptacles (metal stands with blue garbage bags) were observed lining the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess wounds including measurements weekly for 1 of 3 residents (R24) reviewed for pressure ulcers. Findings include: R24's facesheet printed 12/5/24, included diagnoses of severe dementia, difficulty in walking, and dysphagia (difficulty swallowing). R24's quarterly minimum data set (MDS), dated [DATE], identified R24 had severely impaired cognitive decision making skills, disorganized thinking and inattention constantly present. R24 required substantial to maximum assist with bed mobility and dependent on staff for wheelchair mobility. R24 did not have a pressure ulcer but was identified at risk of pressure ulcer development and had a pressure reducing device in wheelchair. R24's physician orders dated 10/15/24, included left heel wound: Cut to fit Aquacel Ag (sterile dressing to cover wounds that excrete fluids and includes antimicrobial) to the wound bed, cover with 4x4 Allevyn gentle border foam…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and document review, the facility failed to complete a comprehensive, person-centered care plan, to promote fecal continence to the extent possible that is dignified, and per resident choice for 1 of 2 residents (R34) who were reviewed for bowel incontinence. Findings include: R34's minimum data set set (MDS) dated [DATE], indicated R34 had a Brief Interview for Mental Status (BIMS) score of 9, indicated moderate cognitive impairment. R34 required extensive assistance for mobility, transfers, and toileting. R34 had a diagnosis of diarrhea. R34 did not have an active bowel program to manage bowel continence. R34's care plan dated 10/9/2024 did not include bowel care interventions or a bowel management regimen. R34 required a two-wheeled walker, gait belt, and assist of one for transfers. R34's physician orders did not address bowel diagnosis and incontinence care and prevention. During observation on 12/2/24 1:57 p.m., R34 stated he has a full depends (disposable product used for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0700 — isolatedTry 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure side rails were comprehensively assessed to determine if they were appropriate and safe, discuss risks and benefits, and obtain informed consent prior to use of bed rails for 3 of 3 residents (R1, R27, R38), who were observed to have assist bars raised on their beds. This had the potential to affect all 48 residents who utilized an assist bar(s) for mobility. Findings include: R1's facesheet printed on 12/5/24, included diagnoses of spastic cerebral palsy and osteoarthritis. R1's annual Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R1 was dependent upon staff for activities of daily living, including rolling from side to side in bed, transferring and toileting. R1 was not able to move from lying in bed to sitting on the edge of the bed. R1's care plan dated 4/12/23, indicated R1 required assistance of two staff and a Hoyer lift…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene and glove use practices were maintained for 1 of 1 resident (R1) observed during peri care and full body lift transfer. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's diagnoses included non-traumatic brain dysfunction including dementia. MDS identified R1 was usually understood and usually able to understand others. However, the cognitive patterns indicated R1 was rarely or never understood and had severe cognitive impairment with fluctuating behaviors present. In addition, R1's MDS identified R1 was dependent on staff for all activities of daily living (ADL)'s. R1's care plan revised on 1/31/24, indicated R1 needed assist of 2 staff with toileting using a full body lift due to safety concerns with the use of the standing lift. Staff to provide peri hygiene and apply barrier cream with cares. During an observation on 3/7/24 at 12:59 p.m., nursing assistant (NA)-A and NA-B…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-10-26 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure continued monitoring and surveillance for efficacy and appropriateness was completed for 2 of 2 residents (R7, R20) who were on long-term, prophylactic antibiotics. In addition, the facility failed to ensure an appropriate antibiotic was administered for 1 of 1 (R9) residents who had an infected wound and were prescribed an ineffective antibiotic. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 had severe cognitive deficits and had diagnoses that included diabetes, epilepsy, morbid obesity, and urinary tract infections (UTI's). R7's Care Area Assessment (CAA) dated 3/28/23, indicated R7 triggered for indwelling catheter, cognitive loss/dementia, and pressure ulcers. R7's care plan dated 8/17/23, indicated R7 had a self-care deficit related to alteration in urinary/bowel function. Interventions included monitoring void patterns, assess for a UTI, administering medications as ordered and observing for side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-26 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review the facility failed to ensure residents were provided a private meeting place without staff present for resident council meetings. In addition the facility failed to ensure concerns brought forward at the resident council meetings were addressed in a timely manner. This deficiency had the potential to affect all 13 residents who attended the monthly resident council meetings. Findings include: During an interview with resident council members, R3, R12, R55, R48, and R46 on 10/25/23 at 1:00 p.m., residents indicated resident council meetings were held in the open dining room and provided no privacy. The residents stated staff being present was intimidating and There are times you hate to bring up concerns in front of staff. Residents also stated follow up regarding their concerns was not there and things didn't often change. During an observation on 10/25/23 at 1:54 p.m., 13 residents, two family members and five staff members were gathered in the resident main dining room for the resident council meeting. The main dining room is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to keep remote to chair within reach for 1 of 1 residents (R31) reviewed for possible restraint. Findings include: R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 had severely impaired cognition and required moderate staff assistance to transfer and walk, extensive assistance to stand, and was dependent on staff for personal hygiene. The MDS indicated a bed alarm was used for R31's care. R31's Face Sheet dated 10/24/22, indicated R31 was diagnosed with Alzheimer's disease, arthritis, and osteoporosis (a condition causing weak, brittle bones that are much more likely to break). R31's care plan dated 4/12/23, indicated R31 had a risk for falls, and to intervene, staff should ensure R31's recliner remote was not tucked into the recliner seat but left on the side of the chair. During an observation on 10/24/23 at 12:46 p.m., R31 sat in the recliner on the right side of her room with the leg rest in the extended…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2023-10-26 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) within fourteen (14) days after the facility determined, or should have determined, that there had been a significant change in the resident's physical or mental condition for 2 of 2 residents (R15 and R20). Findings include: The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11 dated October 2023, Chapter 2, page 2-25, indicated a significant change in status assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care. The current RAI manual indicates on page 2-26: The MDS completion date must be no later than 14 days from the assessment reference date (ARD) (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to implement the care to provide restorative range of motion (ROM) for 1 of 1 resident (R5) reviewed for range of motion. Findings include: R5 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting right dominant side and contracture of muscle, unspecified upper arm. R5's quarterly Minimum Data Set (MDS) assessment, dated 09/14/23, indicated Impairment on one side for both upper and lower extremity. R5's care plan, dated 8/11/23, identified R5 has a functional maintenance program with a goal to maintain joint mobility. R5 was at risk for decline in ROM related to diagnosis of hemiplegia. Care plan indicates for upper and lower extremities: 5 reps and hold count for 5 seconds to provide short stretch to bilateral wrists, elbows, shoulders, knees, ankles, feet, and toes. M-W-F. To be performed by aide. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure that reported symptoms of a urinary tract infection (UTI) were assessed and acted upon to reduce the risk of severe infection or complication for 1 of 1 residents (R9) who reported burning and increased frequency with urination. Findings include: R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R9 had intact cognition with diagnoses including heart failure, hypertension, and debility. R9 was independent with toileting hygiene and transfers and required moderate assistance with bathing. R9 was occasionally incontinent of the bladder and did not have a UTI during the review period (past 30 days). R9's care plan dated 5/26/23 (with no update), indicated R9 had a current UTI infection so staff were to observe and report signs or symptoms of worsening infection or medication reactions to the physician/nurse practitioner (NP). R9's care plan dated 7/25/23, indicated R9 was independent with toileting and used a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to comprehensively analyze the root cause of falls and promptly incorporate new fall interventions to help prevent future falls and possible injury for 2 of 2 resident (R31, R10) reviewed for accidents. Findings include: R31 R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 had severely impaired cognition and required moderate staff assistance to transfer and walk, extensive assistance to stand, and was dependent on staff for personal hygiene. R31's Face Sheet dated 10/24/22, indicated R31 was diagnosed with Alzheimer's disease, arthritis, and osteoporosis (a condition causing weak, brittle bones with a high likelihood of breaking). During an observation on 10/24/23 at 12:46 p.m., R31 sat in the recliner with the leg rest in the extended (elevated) position. The cord for the recliner remote was observed in the pocket on the side of the recliner. During an observation on 10/24/23 at 3:29 p.m., R31 was observed lying in her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure respiratory equipment was changed weekly according to professional standards to prevent infection for 2 of 2 residents (R17, R52) reviewed for respiratory care. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had severe cognitive impairments and had diagnoses that included stroke with right-sided paralysis, aspiration pneumonia, diabetes, chronic obstructive pulmonary disease (COPD-resulting in difficulty breathing and low oxygen levels), obstructive sleep apnea (OSA-breathing periodically ceases during sleep), and morbid obesity. R17's care plan dated 6/14/23, indicated R17 had potential for ineffective breathing patterns related to COPD, OSA, cough and aspiration pneumonia. R17 also became short of breath when lying down. Interventions lacked indication R17 was on supplemental oxygen. R17's orders dated 5/11/23, indicated to maintain R17's oxygen levels between 90-94%. The orders lacked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure appropriate and manufacturer-directed steps to prevent post-administration complication (i.e., thrush) of a dry powedered inhaler (DPI) were completed for 1 of 1 residents (R48) observed to receive a DPI during the recertification survey. Findings include: An Advair Diskus Highlights of Prescribing Information manual, dated 6/2023, identified the medication was used to treat asthma and COPD, along with various dosage, storage instructions, and administration information for the medication. The manual outlined some patients had experienced localized candida albicans (i.e., oral fungal infections) with use of the medication and directed, Advise patients to rinse the mouth with water without swallowing after inhalation to help reduce the risk of thrush. In addition, a section labeled, How should I use ADVAIR DISKUS?[,] directed a bulleted point which read, Rinse your mouth with water without swallowing [bolded] after each dose . This…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure a prophylactic antibiotic without an end date was monitored and evaluated for the appropriateness of its continued use for 1 of 2 residents (R20) reviewed for antibiotic administration. Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], indicated R20 had intact cognition and was dependent for all ADLs. R20's diagnoses included multiple sclerosis (MS), urinary tract infection, heart disease, high blood pressure, and congestive heart failure (CHF, causing fluid in the lungs and body, and shortness of breath), obesity, neuromuscular dysfunction of the bladder, constipation, and diarrhea. R20's Care Area Assessment (CAA) dated 12/22/22, indicated R20 triggered for indwelling catheter. R20's care plan dated 4/12/23, indicated R20 had an indwelling urinary catheter related to a neurogenic bladder. The care plan lacked indication of, or interventions for R20's long-term, prophylactic antibiotic use related to recurrent UTI's and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure psychotropic medications were reviewed for the appropriateness of a gradual dose reduction (GDR) for 1 of 1 residents (R17) reviewed for unnecessary medications. Findings include: R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R17 had severe cognitive impairments and diagnoses that included bipolar disorder. R17's care plan dated 6/13/23, indicated R17's mood was to be monitored due to bipolar disorder, depression, and cognitive changes due to a stroke. Interventions included assessing medication effectiveness. R17 also had a potential for alteration in thought process due to late effect cognitive deficits, difficulty making decisions, and an inability to express self. Interventions included observing for medication effectiveness and side effects. R17's orders dated 12/5/22, indicated R17 received 50 milligrams (mg) of sertraline (an antidepressant) for bipolar disorder. The orders indicated R17's order was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 2 of 5 residents (R25, R39) over [AGE] years old whose vaccinations histories were reviewed. Findings include: The Center for Disease Control and Prevention identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adult [AGE] years of age or older who had received the PPSV23 (pneumococcal polysaccharide vaccine 23) only at any age should receive one dose of either pneumococcal 20-valent Conjugate Vaccine (PCV20) or pneumococcal 15-valent Conjugate Vaccine (PCV15). The dose of PCV20 or PCV15 should be administered at least one year after the most recent PPSV23 dose. R15's facility immunization record indicates she was [AGE] years old. The record indicated she received the PPSV23 vaccine on 3/6/2017 followed by the PCV13 on 3/19/2018. There was no evidence that R15 was offered or received PCV20 or PCV15 following the PCV13. R39's facility immunization record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-03-05 · tag F0572 — widespreadGive residents a notice of rights, rules, services and charges.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident residing in the facility and displayed for residents, visitors and staff to review. This had the potential to affect all 64 residents currently residing in the facility as well as all staff and visitors.Findings include: During observation on 3/3/26, at 11:45 a.m. the Resident [NAME] of Rights poster, dated 1/2019, was observed near the entrance to the building. A second Combined [NAME] of Rights poster, dated 1/2016, was posted next to the elevator going to the second floor.During interview 3/4/26, at 3:29 p.m., administrator stated she was unaware of the newly released Resident [NAME] of Rights poster, effective 1/1/26, which was to replace any previous posters.The facility policy, effective 8/1/21, titled Resident Rights, was reviewed, and identified residents had the right to be informed by the facility of rights granted within the [NAME] of Rights, which was to also include the recourse residents had if…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2026-03-05 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to ensure facility survey results were posted in an accessible location for residents, staff and visitors. This had the potential to affect all 64 residents residing in the facility as well as staff and visitors.Findings include: On 3/3/26, at 11:45 a.m. a review of the survey results binder located near the elevator was completed. Although the previous recertification survey of 12/5/24 was found within the survey binder, the Life Safety Code (LSC) 2567, completed 12/4/25, was not located 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 not in the survey binder. Administrator stated it was important for the survey results to be available for review by residents, staff and visitors for so they may be aware of the previous survey results.A request was made for the facility policy for posting of survey results, however, a policy was unavailable.
- No harm found · C2023-10-26 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to ensure nurse staffing information was posted with required information and in a timely manner at the start of the shift. This had potential to affect all 56 residents, staff, and visitors who could wish to review this information. Findings include: During entrance to the nursing home, on 10/23/23 (Monday) at 1:35 p.m., a one-page document hanging on a bulletin board was observed in the entryway between the double doors before full entry into the building on the right side. It was titled Daily nurse staffing form dated 10/23/23. The document had the facility name along with the census. The form contained areas to be filled out for the total number of hours worked for each respective shift (i.e., day shift, evening shift, night shift) for registered nurses, licensed practical nurses, CNA- bath aides, and certified nursing assistants. The form was completed for day shift (5:30-2p and 6:45-3:15p). The form lacked the actual number of certified nursing assistants, licensed practical nurses, registered nurses, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-10-26 · tag F0570 — patternAssure the security of all personal funds of residents deposited with the facility.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview, and document review, the facility failed to ensure the surety bond contained sufficient funds to insure and protect the residents' trust fund, which had the potential to affect 50 of 56 residents who kept personal funds with the facility. Findings include: The facility Residents Trust Fund Report, dated 9/30/23, noted the current balance of the fund at $54,596.99 dollars. The facility Residents Trust Fund Report, dated 7/30/23, noted the current balance of the fund at $50,414.21 dollars. The facility's surety bond (legally binding contract protecting the trust fund), active from 10/01/23, to 10/01/26, contained a sum of $50,000 dollars. A sum which was inadequate to cover the current amount of the resident trust fund. During interview on 10/25/23 at 1:11 p.m., the administrator stated she would expect the surety bond amount would cover the money in the account. She acknowledged upon review, that surety bond would not cover the amount in the account.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WINONA HEALTH SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2011 |
| ATKINSON, LINDA | Individual | W-2 MANAGING EMPLOYEE | — | since 11/05/2018 |
| CEPLECHA, AUDREY | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2021 |
| BAKER, RODNEY | Individual | CORPORATE DIRECTOR | — | since 01/01/2014 |
| BLUE, STEVEN | Individual | CORPORATE DIRECTOR | — | since 01/01/2007 |
| BROGHAMMER, MATTHEW | Individual | CORPORATE DIRECTOR | — | since 01/01/2007 |
| BROSNAHAN, JAN | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/2011 |
| BURKE, SANDRA | Individual | CORPORATE DIRECTOR | — | since 01/01/2016 |
| DECKER, VICKY | Individual | CORPORATE DIRECTOR | — | since 01/01/2007 |
| EVANS, GREG | Individual | CORPORATE DIRECTOR | — | since 06/01/2016 |
| GILMER, DAVID | Individual | CORPORATE DIRECTOR | — | since 08/01/2018 |
| HAMMEL, KATRINA | Individual | CORPORATE DIRECTOR | — | since 02/01/2019 |
| HEISING-SCHULTZ, RACHELLE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2007 |
| MILLER, HUGH | Individual | CORPORATE DIRECTOR | — | since 01/01/1993 |
| MODJESKI, NICHOLAS | Individual | CORPORATE DIRECTOR | — | since 12/01/2017 |
| MOGREN, KENNETH | Individual | CORPORATE DIRECTOR | — | since 01/01/2007 |
| PAULSON, TODD | Individual | CORPORATE DIRECTOR | — | since 08/01/2018 |
| SAID, FATIMA | Individual | CORPORATE DIRECTOR | — | since 08/01/2018 |
| SEMLING, BRIAN | Individual | CORPORATE DIRECTOR | — | since 11/01/2016 |
| WAGNER, MARK | Individual | CORPORATE DIRECTOR | — | since 01/01/2007 |
| WHYTE, BRETT | Individual | CORPORATE DIRECTOR | — | since 10/18/2016 |
| WILLIAMS, ROBERT | Individual | CORPORATE DIRECTOR | — | since 11/01/2016 |
| HOEG, ROBIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2014 |
CMS files one row per role, so the 26 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245240. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.