Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.