Lake Winona Manor

In the surveyor’s words

From the most serious findings on record at Lake Winona Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 27, 2022

  Based on observation, interview and document review, the facility failed to operationalize their abuse prohibition policy to identify and protect a resident(s) following witnessed verbal and physical abuse by staff for 1 of 1 residents (R1) reviewed for staff to resident abuse allegations. This resulted in an immediate jeopardy (IJ) for R1 and potential to affect 12 of 35 residents with behaviors who resided on the Sugar Loaf unit. The IJ began on 7/16/22, when three staff members witnessed licensed practical nurse (LPN)-A covering R1's mouth to stop R1 from yelling, and made demeaning comments. LPN-A finished her shift on 7/16/22 and worked on 7/17/22 with R1 and other resident who were cognitively impaired with behaviors. […]

• Actual harm, isolatedF689Dec 18, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF727Jul 17, 2026

  Based on interview and record review, the facility failed to maintain and clearly define a full-time director of nursing (DON). This practice had the potential to affect all 66 residents who resided at the facility.Findings include:The facility Change of Director of Nursing form dated 5/1/26, indicated the administrator, who was also an RN, was the previous DON and designated RN-B as the new interim DON.The interim DONs time card dated Friday, 7/10/26 to Sunday, 7/19/26, indicated the interim DON worked eight hours on Monday, Wednesday, and Thursday for a total of 24 hours in one week.During an interview on 7/17/26 at 1:59 p.m., registered nurse (RN)-A stated the administrator was not present at the facility this week, and the interim DON worked part-time. […]

• No harm, potential for more than minimal, widespreadF881Oct 26, 2023

  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. […]

• No harm, potential for more than minimal, patternF812Dec 5, 2024

  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. […]