ElderGrade

Inspection citations at Lake Winona Manor

24 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 3 0
2025 1 1
2024 6 0
2023 14 0
C March 5, 2026 Tag F0577 Corrected Mar 2026

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

No actual harm, minimal potential

C March 5, 2026 Tag F0572 Corrected Mar 2026

Resident Rights Deficiencies

Give residents a notice of rights, rules, services and charges.

No actual harm, minimal potential

D March 5, 2026 Tag F0554 Corrected Mar 2026

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

G December 18, 2025 Tag F0689 Complaint investigation Corrected Nov 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D December 5, 2024 Tag F0700 Complaint investigation Corrected Jan 2025

Quality of Life and Care Deficiencies

Try 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.

No actual harm, potential for more than minimal harm

D December 5, 2024 Tag F0690 Complaint investigation Corrected Jan 2025

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D December 5, 2024 Tag F0686 Complaint investigation Corrected Jan 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

E December 5, 2024 Tag F0880 Complaint investigation Corrected Jan 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E December 5, 2024 Tag F0812 Complaint investigation Corrected Jan 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D March 12, 2024 Tag F0880 Complaint investigation Corrected Apr 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

B October 26, 2023 Tag F0570 Corrected Oct 2023

Resident Rights Deficiencies

Assure the security of all personal funds of residents deposited with the facility.

No actual harm, minimal potential

C October 26, 2023 Tag F0732 Corrected Dec 2023

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

D October 26, 2023 Tag F0883 Corrected Dec 2023

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, potential for more than minimal harm

D October 26, 2023 Tag F0758 Corrected Dec 2023

Pharmacy Service Deficiencies

Implement 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.

No actual harm, potential for more than minimal harm

D October 26, 2023 Tag F0757 Corrected Dec 2023

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

D October 26, 2023 Tag F0755 Corrected Dec 2023

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D October 26, 2023 Tag F0695 Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D October 26, 2023 Tag F0689 Corrected Dec 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D October 26, 2023 Tag F0684 Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D October 26, 2023 Tag F0656 Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D October 26, 2023 Tag F0637 Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

No actual harm, potential for more than minimal harm

D October 26, 2023 Tag F0558 Corrected Dec 2023

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E October 26, 2023 Tag F0565 Corrected Nov 2023

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

No actual harm, potential for more than minimal harm

F October 26, 2023 Tag F0881 Corrected Dec 2023

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.