Lake Winona Manor
865 Mankato Avenue, Winona, MN 55987 · Winona County · 80 certified beds · avg 64 residents/day · certified since Feb 1, 1982
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Dec 18, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 13, 2025 (Past Non-Compliance)
All citations in the current public record (24)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 5, 2026 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Mar 5, 2026 | C · Minimal risk, facility-wide | The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. |
| Mar 5, 2026 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Dec 18, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint |
| Mar 12, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 26, 2023 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Oct 26, 2023 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Oct 26, 2023 | B · Minimal risk, repeated | The facility did not properly protect the personal money residents deposited with it for safekeeping. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (5 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 14 | 0 | F |
| 2024 | 6 | 0 | E |
| 2025 | 1 | 1 | G ▲ |
| 2026 | 3 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.05 | 4.83 | 3.95 | top 39% in Minnesota; top 12% in the U.S. |
| Registered Nurse hours | 0.79 | 1.22 | 0.69 | bottom 13% in Minnesota; top 28% in the U.S. |
| Weekend total nurse staffing | 4.44 | 4.27 | 3.50 | top 39% in Minnesota; top 13% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.48 | 0.69 | 0.48 | bottom 33% in Minnesota; top 35% in the U.S. |
| Total nursing staff turnover (%) | 34.1 | 42.2 | 45.8 | top 32% in Minnesota; top 22% in the U.S. |
| RN turnover (%) | 0.0 | 38.6 | 42.9 | top 1% in Minnesota; top 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.28, RN 0.67, weekend 3.76. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Winona Health Services | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/01/2011 |
| Atkinson, Linda | Individual | W-2 Managing Employee | NOT APPLICABLE | 11/05/2018 |
| Baker, Rodney | Individual | Corporate Director | NOT APPLICABLE | 01/01/2014 |
| Blue, Steven | Individual | Corporate Director | NOT APPLICABLE | 01/01/2007 |
| Broghammer, Matthew | Individual | Corporate Director | NOT APPLICABLE | 01/01/2007 |
| Brosnahan, Jan | Individual | Corporate Director | NOT APPLICABLE | 08/01/2011 |
| Brosnahan, Jan | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/24/2013 |
| Burke, Sandra | Individual | Corporate Director | NOT APPLICABLE | 01/01/2016 |
| Ceplecha, Audrey | Individual | W-2 Managing Employee | NOT APPLICABLE | 11/01/2021 |
| Ceplecha, Audrey | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2021 |
| Decker, Vicky | Individual | Corporate Director | NOT APPLICABLE | 01/01/2007 |
| Evans, Greg | Individual | Corporate Director | NOT APPLICABLE | 06/01/2016 |
| Gilmer, David | Individual | Corporate Director | NOT APPLICABLE | 08/01/2018 |
| Hammel, Katrina | Individual | Corporate Director | NOT APPLICABLE | 02/01/2019 |
| Heising-Schultz, Rachelle | Individual | Corporate Director | NOT APPLICABLE | 01/01/2007 |
| Heising-Schultz, Rachelle | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2002 |
| Hoeg, Robin | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2014 |
| Miller, Hugh | Individual | Corporate Director | NOT APPLICABLE | 01/01/1993 |
| Modjeski, Nicholas | Individual | Corporate Director | NOT APPLICABLE | 12/01/2017 |
| Mogren, Kenneth | Individual | Corporate Director | NOT APPLICABLE | 01/01/2007 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "Can I get a written copy of resident rights, house rules, and a full list of services and charges today?"
- "Where do you post your latest state inspection results and the ombudsman's contact information?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Sainte Anne Extended Healthcare | 2.9 mi | Winona, MN | ★★★★☆ | 4/5 | |
| Sauer Health Care | 3.3 mi | Winona, MN | ★☆☆☆☆ | 2/5 | |
| Marinuka Manor | 14.5 mi | Galesville, WI | ★★★★★ | 5/5 | |
| Good Shepherd Lutheran Home | 17.6 mi | Rushford, MN | ★★★★★ | 5/5 | |
| Valley View Healthcare & Rehab | 18.9 mi | Houston, MN | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245240.