Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winner Regional Healthcare Center during CMS and state inspections, most recent first.
Two residents' care plans were not updated to reflect current needs: one resident with dementia and severe cognitive impairment exhibited verbally aggressive behaviors toward staff and a roommate, while another cognitively intact resident was vulnerable to verbal aggression from her roommate. Despite documentation of these issues in nurse progress notes, neither care plan included interventions or strategies to address the behaviors or vulnerabilities, as confirmed by the DON and director of social services.
The facility failed to conduct regular side rail assessments for three residents who used them for repositioning. One resident, cognitively intact, used side rails due to medical conditions, while another, moderately cognitively impaired, also lacked follow-up assessments. A third resident had an outdated assessment and consent but no recent evaluations. Staff interviews revealed that the therapy department handled initial assessments, while the nursing department was responsible for quarterly reviews, which were not completed. The facility's policy required regular assessments, but this protocol was not followed, leading to a deficiency.
The facility failed to provide proper respiratory care for two residents using oxygen. One resident's oxygen tubing had not been changed since September, despite documentation indicating weekly changes. Another resident used oxygen at night without a physician's order or care plan documentation. The DON confirmed the lack of supervision and documentation for oxygen equipment maintenance.
Failure to Update Care Plans for Residents with Behavioral and Vulnerability Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect the current care needs of two residents. One resident with dementia and severe cognitive impairment exhibited verbally aggressive behaviors towards both staff and his roommate, including yelling, cussing, and making threats. Despite these documented behaviors in nurse progress notes, his care plan did not include any mention of his aggressive behaviors or interventions for staff to address these issues. Additionally, an alarm was placed on this resident, but the care plan did not specify the type, location, or purpose of the alarm. Another resident, who was cognitively intact and did not have mental health diagnoses, was vulnerable to verbal aggression from her roommate. Nurse progress notes indicated that her roommate had been observed to holler at her, and her family was aware of the situation. However, her care plan did not address her vulnerability or include interventions to limit her exposure to verbal aggression. Both the director of social services and the DON confirmed that the care plans for these residents were not updated to reflect their current needs, citing a lapse in communication and responsibility between staff members.
Failure to Conduct Regular Side Rail Assessments
Penalty
Summary
The facility failed to ensure that side rail assessments were completed for safe and appropriate use for three of seven sampled residents who used them for repositioning. Resident 14, who was cognitively intact with a BIMS score of 14, used side rails for self-mobility and repositioning due to her medical conditions, including a nondisplaced comminuted fracture of the left patella, Parkinson's disease, and pneumonia. Although an initial safety screen was completed, no further assessments were conducted. Similarly, Resident 9, with a BIMS score of 8 indicating moderate cognitive impairment, had an initial safety screen but lacked subsequent assessments. Resident 1, cognitively intact with a BIMS score of 15, had a side rail use assessment completed in 2019 and a consent signed in 2022, but no additional assessments were performed. Interviews with facility staff revealed that the therapy department was responsible for initial side rail assessments, while the nursing department was tasked with completing quarterly assessments. However, the Director of Nursing acknowledged that these quarterly assessments were not being completed. The facility's side rail policy, dated June 2021, required that side rail assessments be conducted by therapy and/or nursing when a need was expressed or reported, and that assessments be completed quarterly and as needed. Despite these policy requirements, the facility did not adhere to the protocol, resulting in a deficiency in ensuring the safety and appropriateness of side rail use for the residents involved.
Failure to Ensure Proper Oxygen Equipment Maintenance and Documentation
Penalty
Summary
The provider failed to ensure proper respiratory care for two residents receiving oxygen. Resident 9, who is moderately cognitively impaired and dependent on supplemental oxygen, had her oxygen nasal cannula tubing dated 9/5/24, indicating it had not been changed as required. Despite documentation in her electronic medical record (EMR) showing weekly tubing changes, observations confirmed the tubing had not been replaced since September. The Director of Nursing (DON) acknowledged the oversight and admitted that there were no chart audits or supervision to ensure staff performed and documented oxygen tubing changes correctly. Resident 27, who used oxygen at night, did not have a physician's order for oxygen use, and her care plan did not reflect her oxygen needs. There was no documentation in her Medical Administration Record (MAR) or Treatment Administration Record (TAR) regarding oxygen equipment maintenance or tubing changes. The DON confirmed that oxygen use required a physician's order and should have been documented in the resident's care plan and EMR. The facility's policy required weekly changes of oxygen equipment, but this was not adhered to for Resident 27.
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Illustrative
What surveyors actually found near you
We read the 5 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avera Rosebud Country Care Center | 23.4 mi | ★★★★★ | 5 | 0 |
| Sanford Chamberlain Care Center | 38.9 mi | ★★★★★ | 4 | 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 July 2026) and official state health department websites.