Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 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.
A facility failed to assess multiple beds, side rails/grab bars, and mattresses for entrapment hazards. Surveyors found loose or unsecured rails and mattresses on several residents’ beds, including one resident with an improperly used rail secured with a zip tie and another with a five-inch gap between the mattress and headboard. The DON said she was unaware these items needed entrapment assessment, and the CEO could not produce documentation showing when the rails were installed or inspected.
Failure to protect a resident with severe cognitive impairment from physical abuse by a contracted travel CNA. Staff found bruising, a skin tear, and a lip cut after the resident reported that a staff member grabbed and twisted her arm. The CNA said she grabbed both forearms when the resident began to fall. The facility lacked complete investigation documentation, did not document required incident reporting in the risk management system, did not document family notification or IDT review, and did not show that the care plan addressed safety interventions related to the resident’s cognitive or behavioral status.
CEO A and DON B failed to administer and operate the facility in a manner that ensured the quality of life and overall well-being of all 26 residents. Survey findings showed a widespread breakdown in resident education, grievance handling, abuse and neglect protections, reporting allegations, baseline and updated care plans, hazard mitigation, physician visit documentation, controlled medication security, pharmacist review, medication access, expired supply removal, staff training, and the QAPI program.
Failure to Operate an Effective QAPI Program: The facility did not identify, investigate, or correct known quality deficiencies through its QAPI program, and no PIPs were implemented for resident safety and quality of care concerns. The DON led quarterly QAPI meetings, but attendance was inconsistent, the CEO and medical director did not routinely participate, staff were not trained on QAPI goals, and there was no evidence of safety data collection, root cause analysis, or monitoring of corrective actions for cited issues.
A facility failed to ensure residents or their representatives were informed of the risks versus benefits, alternative treatments, and consent requirements before multiple psychotropic medications were started or changed. Four residents with varying cognitive impairment had orders for antipsychotics, antidepressants, and anti-anxiety medications, but the records lacked documentation of education or consent. Staff interviews confirmed there was no consistent process for psychotropic medication consent, and some medications lacked appropriate diagnoses or clear documentation of use.
A facility failed to ensure psychotropic meds were properly ordered and justified for several residents. Residents received PRN and scheduled antipsychotics, anxiolytics, sedatives, and antidepressants without required stop dates, without clear diagnoses or indications, and without documented risk/benefit review or informed consent. Care plans often lacked behavior details, triggers, and non-pharmacological interventions, and the pharmacist and DON acknowledged gaps in review and documentation.
Care plans were not kept current for multiple residents with changing care needs, behaviors, equipment, and medication regimens. Surveyors found missing or inaccurate documentation for psychotropic meds, agitation, anxiety, suicidal thoughts, transfer status, bathing and toileting assistance, Broda chair use, and a scoop mattress. Records and observations showed residents using nebulizers, stand aid lifts, Broda chairs, and bed equipment that were not reflected in their care plans, and several plans contained incorrect medication doses or outdated hospice information.
Bed rails, grab bars, and related bed equipment were used for multiple residents without required documentation of physician orders, attempted alternatives, risk-benefit review, informed consent, or entrapment assessments. Surveyors observed loose or improperly secured rails and gaps between the mattress and rail on several beds. One resident also had a scoop mattress in place without documentation of safe-use assessment or a care plan entry, and the DON stated the facility did not have a policy for scoop mattress use.
Failure to Ensure Required Physician Visit Intervals: The facility did not ensure timely face-to-face physician visits for multiple residents. Two residents were not seen every 30 days during the first 90 days after admission, and one resident had multiple gaps beyond the required 60-day interval after that. The medical director said he followed the schedule set by the DON and ADON, and the DON acknowledged the missed visit intervals.
Expired meds and supplies were left in the med storage room, and a resident med refrigerator contained unlabeled alcohol and other beverages stored with resident meds and vaccines. Staff acknowledged that a resident’s medication box was wet from leaking wine stored above it. Refrigerator temp logs were incomplete, and controlled meds awaiting destruction were kept in a disorganized locked cupboard for weeks to over two months, with multiple staff having access to the keys.
The facility failed to consistently identify and address psychotropic medication irregularities during monthly DRRs for several residents. Orders included PRN and scheduled antipsychotics, antidepressants, and anti-anxiety medications with missing end dates, unclear or absent diagnoses, duplicate therapy, and mismatches between the chart and the actual order directions. Interviews showed the DON, pharmacist, and MD lacked a reliable process for psychotropic review, GDR follow-up, and consent/risk-benefit documentation.
Controlled meds for multiple residents were kept in a disorganized locked cupboard for over two months without routine counting or destruction, and several staff had access to the keys. The medication room also contained expired supplies, missing refrigerator temp logs, and resident food and beverages stored with meds, including unlabeled alcohol that had leaked onto a resident’s medication container.
Mandatory QAPI training was not documented for five of five employees reviewed, including a dietary manager, CNAs, a housekeeping aide, and a contracted travel LPN. The DON said staff were informed about PIPs through department managers but did not receive training on the elements and goals of the QAPI program. The HR director said QAPI training had not been assigned and was not recognized as required, and the CEO acknowledged required training was incomplete. The facility policy required ongoing education for personnel, but QAPI was not listed as required training.
Missing Annual CNA Performance Evaluations: The facility failed to complete yearly performance evaluations for three sampled CNAs, including two contracted travel CNAs and one regular CNA. Personnel record review showed no annual review for two CNAs and an outdated evaluation for another. The DON stated she relied on the travel agency to complete evaluations for contracted staff, while her job description and the facility assessment reflected responsibility for staff evaluation, coaching, and annual evaluations.
Grievance Process Not Available or Followed: The facility did not make grievance forms or filing instructions readily available in resident areas, and residents in council interview said they did not know how to file a grievance or where forms were located. Staff were unclear about who the grievance official was, and the grievance policy did not identify one clearly. The issue also involved a resident’s hot liquid burn injury, where the family voiced concern that staff caused the injury, but staff gave inconsistent accounts of whether a grievance was completed or followed through after the concern was raised.
Failure to Timely Report Suspected Abuse or Neglect: The facility did not report two allegations of suspected abuse or neglect to the SD DOH within the required time frame. One resident sustained a hot liquid burn after a family member believed staff may have caused the injury, and another resident with severe cognitive impairment had bruises, a skin tear, and a lip cut after alleging a CNA grabbed and twisted her arm. Staff interviews and record review showed delayed escalation, incomplete incident documentation, and no facility investigation report available for review.
A provider failed to complete baseline care plans and to review them with residents or representatives, or offer a copy, within 48 hours for three newly admitted residents. The records for residents with conditions including stroke, falls, DM, CKD, dementia, AFib, HTN, and other diagnoses were missing key items such as diagnoses, diet, transfer status, code status, and social services documentation. The DON stated she expected the baseline care plan to be completed within 48 hours but was unaware it had to be reviewed and a copy provided.
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.
Bedrail and Mattress Entrapment Hazards Not Assessed
Penalty
Summary
The facility failed to ensure resident safety by not assessing multiple beds, side rails/grab bars, and mattresses for entrapment hazards. Surveyors observed loose or unsecured side rails/grab bars on the beds of residents 17, 21, 25, and 26, and unsecured mattresses on the beds of residents 6, 14, 17, 21, and 25. Resident 17 also had a side rail/grab bar that was not indicated for use on the bed and was held in place with a zip tie. Resident 25 had a five-inch gap between the top of the mattress and the headboard, and residents 6 and 14 had mattresses that slid away from the side rail/grab bar, creating gaps when the mattresses moved. On observation, resident 14’s bed was unlocked and moved away from the wall, and the mattress slid away from the side rail/grab bar with minimal effort, creating a gap of more than five inches. Resident 6’s bed also lacked mattress guards. Resident 25 had bilateral side rails, with the right rail loose and able to be pulled away from the bed; he was lying in bed with his head against the left side rail and had a history of a fall in which he hit the headboard and lacerated his nose. Resident 21 had a loose right-side rail with a five-inch gap when the mattress slid to the wall, and resident 26 had a loose right-side rail that moved approximately four inches away from the mattress when touched. The DON stated she was unaware that side rails/grab bars and mattresses needed to be assessed for entrapment risks and was unsure whether maintenance had performed such assessments. She also stated that when a resident or representative requested a side rail/grab bar, therapy would assess the resident using a checklist that did not include entrapment risk, prior interventions, or resident consent. The CEO stated there was no documentation available showing when the side rails were installed or whether maintenance staff had inspected the beds, rails, or mattresses. The maintenance clipboard contained no resident bed or side rail repair requisitions during the reviewed period, and no maintenance staff member was available to interview about installation or inspection of the equipment.
Failure to Protect a Cognitively Impaired Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident with severely impaired cognition from physical abuse by a contracted travel CNA. The resident had a BIMS score of 4 on 12/30/25 and 7 on 3/24/26, indicating severe cognitive impairment. On the morning of 2/24/26, staff found the resident with three large purple bruises on the right forearm, a small skin tear near the wrist, one purple bruise on the left forearm, and a small cut on the left side of the lip. The resident stated that a staff member had grabbed her arm and twisted it. The CNA later stated that while assisting the resident the prior evening, the resident began to fall and she grabbed both forearms to steady her, which she said may have caused the bruising. The resident’s account remained consistent when she was interviewed again by the DON and CEO, and the facility treated the event as an abuse allegation with physical harm. The CNA was placed on administrative leave pending investigation, and law enforcement was notified. However, the facility did not have investigation documentation available when requested later, and the incident tracking reports in the electronic system did not show a completed incident report in the risk management section for the required period. The resident’s first emergency contact was not documented as being notified of the abuse allegation on the day it occurred, and there was no documentation that the allegation was reviewed with the family and the IDT team. The resident’s EMR also lacked documentation that her care plan addressed interventions to help ensure her safety related to her cognitive or behavioral status. The licensed social worker stated she was not aware of the allegation and did not complete documentation in the resident’s EMR. The CEO acknowledged that no audits or education were provided to staff regarding resident abuse, and no further follow-up was conducted with other residents to determine whether they had been harmed by staff or felt safe at the facility. The DON also acknowledged that no other residents were interviewed as part of the investigation, no additional abuse-prevention education was provided to staff, and no audits related to resident interviews or staff education were completed after the incident.
Failure to Ensure Effective Facility Administration and Resident Care Oversight
Penalty
Summary
The facility failed to ensure it was operated and administered by CEO A and DON B in a manner that supported the quality of life and overall well-being of all 26 residents. Survey observations, interviews, record reviews, and policy reviews conducted during the survey identified a widespread system breakdown affecting multiple areas of resident care and facility administration, including resident and representative education about psychotropic medication use, grievance filing, residents’ rights related to abuse, neglect, and chemical restraints, investigation and reporting of allegations to the South Dakota Department of Health within required timeframes, baseline care plans within the first 48 hours of admission, updating care plans to reflect current needs, accident hazard identification and mitigation for bed side rail entrapment risks and hot liquid injury, physician visit timeliness and documentation, controlled medication accountability and securement, pharmacist medication regimen review, medication accessibility, removal of expired supplies, staff training, and the effectiveness of the QAPI program. CEO A stated he had worked at the facility since [DATE] and was responsible for daily operations of the facility, which also included the clinic and attached hospital. The provider’s job descriptions stated the CEO was responsible for overall administrative management and operation of the hospital, clinics, long-term care program, and related entities, and that the DON planned, organized, developed, and directed the overall operation of the LTC nursing department while working with the Medical Director and interdisciplinary teams to maintain a high degree of quality care in accordance with federal and state guidance, regulations, and established policies and procedures.
Failure to Operate an Effective QAPI Program
Penalty
Summary
The facility failed to ensure its QAPI program identified, investigated, and corrected quality deficiencies, and failed to initiate or monitor PIPs in response to known areas of concern. The CEO stated that the DON managed the QAPI program and that he did not routinely attend LTC QAPI meetings because he was not required to be present. The medical director stated he attended quarterly QAPI meetings when able, either in person or online, and received the minutes for review each quarter. The DON stated she was the QAPI Manager and led the quarterly meetings, tracked attendance, and expected each committee member to attend and present reports on the information they monitored. Review of the QAPI attendance records showed that on one meeting date the CEO and medical director did not attend and no other governing board member or facility owner was present, and on another meeting date no committee members were marked as attending. The DON acknowledged that potentially harmful systemic issues and concerns were not identified or corrected since the last survey, and that staff did not receive training on the elements and goals of the facility's QAPI program. The facility's QAPI documentation and meeting minutes showed no PIPs were implemented to address concerns regarding resident safety and quality of care. Interviews throughout the survey confirmed that the QAPI committee did not review or act on the problems that resulted in citations under F600, F605, F609, F689, F700, F755, and F761. There was no evidence that the facility collected safety data, conducted root cause analyses, or monitored corrective actions for the known issues. The facility's QAPI plan stated that the committee was to identify opportunities for improvement, implement initiatives to address problems, document follow-up and resolution, and use data collection and reassessment to demonstrate measurable improvement in resident care, but the survey findings showed these activities were not occurring.
Failure to Obtain Consent and Educate on Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents or their representatives were informed of the risks versus benefits, alternative treatments, and consent requirements before psychotropic medications were administered or changed for four sampled residents. The report identified this issue for residents 3, 6, 21, and 32, and documented that no consent forms or related education were found in the records for multiple antipsychotic, antidepressant, and anti-anxiety medications. The deficiency was identified through record review, staff interviews, and policy review. Resident 21 had severe cognitive impairment with diagnoses including Alzheimer’s disease, dementia with agitation and behavioral disturbance, and neurocognitive disorder with Lewy Bodies. He had orders for temazepam, trazodone, lorazepam Intensol oral concentrate, lorazepam, Risperdal, and sertraline, but the record did not show that his representative was informed of the risks versus benefits, alternative treatments, or consent for these medications. The chart also showed a 1/30/26 order note to discontinue lorazepam, but active orders still reflected the PRN lorazepam doses, and there was no documentation that the lorazepam orders were discontinued. The resident did not have a diagnosis of depression despite being ordered sertraline. Resident 6 had severe cognitive impairment and did not have diagnoses of schizophrenia, bipolar disorder, anxiety, depression, or a severe behavioral disorder. He had orders for sertraline for depression, Haldol PRN for agitation, and Seroquel for agitation, but the record did not show that his representative was informed of the risks versus benefits, alternative treatments, or consent for these medications. The behaviors treated by Seroquel were not identified, and there was no diagnosis for use documented for that medication. Resident 3 had moderately impaired cognition and diagnoses of anxiety disorder and dementia with behavioral disturbance. She had orders for alprazolam PRN, escitalopram, haloperidol PRN, Seroquel at bedtime, and trazodone at bedtime, but there was no documentation that she or her representative was informed of the risks versus benefits, alternative treatments, or consent for these medications. Resident 32 had intact cognition and a diagnosis of dementia with agitation. She had orders for lorazepam PRN, scheduled lorazepam, mirtazapine, quetiapine, and olanzapine, but the record did not show that she or her representative was informed of the risks versus benefits, alternative treatments, or consent for these medications. Staff interviews confirmed the facility did not have a process in place to review risks versus benefits, discuss alternatives, or obtain consent before starting or changing psychotropic medications, and the DON and CEO acknowledged that consent forms were not being completed and that appropriate diagnoses were not documented for some medications.
Unnecessary psychotropic medications and missing documentation for use
Penalty
Summary
The facility failed to protect residents’ rights to be free of unnecessary psychotropic medications for five sampled residents who were receiving psychotropic drugs without required usage stop dates, without documented reasons for continuing PRN psychotropic use beyond 14 days, without completed risk-versus-benefit evaluations for informed consent, without documented diagnoses supporting use, and without documented physician responses to pharmacy recommendations. The report identified deficiencies involving lorazepam, haloperidol, quetiapine, risperidone, temazepam, sertraline, mirtazapine, olanzapine, and duplicate antipsychotic therapy, along with care plans that did not consistently identify behaviors, triggers, or non-pharmacological interventions. One resident with severely impaired cognition and dementia with agitation had a PRN lorazepam order for agitation or anxiety without a usage end date, no anxiety diagnosis, and a care plan that did not identify agitation, anxiety, or non-drug interventions. Another resident with anxiety disorder and dementia with behavioral disturbance had PRN haloperidol without an end date and scheduled quetiapine for behaviors without the behaviors being identified in the order; the care plan did not describe the behaviors or non-pharmacological interventions, and also referenced hallucinations and olanzapine without non-drug interventions. A third resident with severe cognitive impairment and multiple neurologic diagnoses had PRN temazepam and PRN lorazepam orders without 14-day stop dates or physician evaluations supporting continued PRN use, and also had scheduled risperidone and sertraline without a documented depression diagnosis. A resident with severe cognitive impairment and multiple medical diagnoses had scheduled quetiapine and PRN haloperidol without an end date, with no diagnosis of schizophrenia, bipolar disorder, anxiety, depression, or severe behavioral disorder, and the care plan did not include psychotropic medication documentation or behavior interventions. Another resident with intact cognition and dementia with agitation had mirtazapine ordered for depression without a depression diagnosis, PRN lorazepam without an end date, scheduled lorazepam without an indication, and scheduled olanzapine plus quetiapine in the same drug class. Her care plan listed psychotropic use for depression, anxiety, and behavioral management but did not identify non-pharmacological interventions, triggers for aggression, or interventions for suicidal thoughts. Interviews confirmed behaviors were not consistently charted, the pharmacist reviewed PRN psychotropics for end dates but did not ensure diagnoses were active or follow through on recommendations, and the DON stated there was no documentation of risk-versus-benefit review, education on alternatives, informed consent, or signed consent before psychotropic medications were started or changed.
Care Plans Not Updated to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised to reflect the current care needs of nine sampled residents. Surveyors observed and reviewed records showing that multiple residents had current diagnoses, treatments, equipment, behaviors, and levels of assistance that were not accurately reflected in their care plans, despite the facility policy stating that care plans are to be maintained in current status and revised as changes in condition dictate. Resident 18 was observed with a nebulizer machine, mask, and tubing at the bedside, and her record showed COPD with physician orders for inhalation treatments. Her comprehensive care plan did not document the COPD diagnosis, the need for respiratory treatment, or interventions related to medications or cleaning of nebulizer equipment. Resident 9 was observed being assisted to the bathroom with a stand aide lift, but her care plan did not identify agitation or anxiety, did not include non-pharmacological interventions for those behaviors, and did not describe how she transferred, whether she walked or used a wheelchair, or the assistance she needed with dressing, bathing, or eating. Resident 32 was observed seated in a Broda chair, and her record showed psychotropic medications, suicidal thoughts, and an OT recommendation for Broda chair positioning; however, her care plan did not identify her suicidal thoughts, triggers, interventions, or the use of the Broda chair, and it lacked non-pharmacological interventions for her behavioral needs. Resident 22 was observed with a scoop mattress and bed rails/grab bars, but her care plan did not include the scoop mattress or the level of assistance she needed for bathing, dressing, transfers, or mobility in her room. The DON stated no assessment for safe use of the scoop mattress had been completed and that the use of the scoop mattress was not included in the care plan. Resident 6 was observed in a Broda chair, and his record showed antidepressant and antipsychotic medications and a behavior of inappropriate touching of female staff; his care plan did not document the medications, mental health diagnosis, severe behavioral disorder, Broda chair use, or the level of assistance needed for bathing, dressing, transfers, and toileting. Resident 14 was also observed in a Broda chair, but his care plan did not include the chair or his assistance needs for bathing, dressing, transfers, and toileting. Resident 5 was observed transferring with a stand aid lift, and her record showed dependence for toileting and substantial/maximal assistance with bathing and dressing, yet her care plan did not document those assistance levels. Resident 21’s care plan contained multiple incorrect medication entries, including wrong doses and frequencies for donepezil, lorazepam, risperidone, and sertraline, and it continued to reference hospice services after hospice had been discontinued. The care plan also did not address the risks associated with psychotropic medication use and was not individualized or person-centered. Resident 3’s care plan identified psychotropic medication use and hallucinations, but it did not identify her actual behaviors or non-pharmacological interventions, and it listed olanzapine without a physician order. Her care plan also did not reflect the behaviors treated by haloperidol or quetiapine. The facility’s own policy stated that interdisciplinary care plans are to be kept current, reviewed at least quarterly, and revised when resident condition changes, and that behavioral health care plans must identify behaviors, triggers, early warning signs, and specific interventions.
Bed rails and grab bars installed without required orders, consent, or entrapment assessments
Penalty
Summary
The facility failed to ensure physician orders, resident or representative review of risks and benefits, informed consent, alternatives, and entrapment assessments were completed before bed rails or grab bars were installed for multiple residents. Surveyors found that several residents had side rails, grab bars, or related bed equipment in place without documentation showing when the equipment was installed, whether alternatives had been tried first, whether the risks and benefits had been reviewed, or whether consent had been obtained. Quarterly side rail assessments were also missing entrapment risk evaluations for the affected residents. Resident 22 was observed with a scoop mattress and bed rails/grab bars on both sides of the bed. She stated she had fallen out of bed about a year earlier, could get in and out of bed without assistance, did not use the grab bars, and was unsure why the scoop mattress remained on her bed. Her record showed a physician order for a pressure reducing mattress and a separate order for bilateral bed rails, but there was no documentation showing when the mattress or rails were installed, that alternatives were attempted, that risks and benefits were reviewed, or that consent was obtained. The DON stated no assessment for safe use of the scoop mattress had been completed, the scoop mattress was not included in the care plan, and the facility did not have a policy for scoop mattress use. Other residents had similar documentation gaps. Resident 6 had side rails/grab bars on the bed with no physician order, no documentation of alternatives, no risk-benefit review, no consent, and quarterly assessments that did not address entrapment risk. Resident 14 had a physician order for side rails, but there was no documentation of installation date, alternatives, risk-benefit review, consent, or entrapment assessment. Resident 17 had a loose side rail attached with a zip tie and a bar that was not secured to the bed frame; the consent on file was signed by a former DON rather than the resident, and there was no documentation of alternatives, risk-benefit review, installation date, or entrapment assessment. Resident 26 had side rails/grab bars on both sides of the bed with no physician order, no documentation of alternatives, no consent, and no entrapment assessment. Resident 25 had bilateral side rails, but the record did not show when they were installed, whether alternatives were tried, whether risks and benefits were reviewed, or whether consent was obtained, and quarterly assessments did not address entrapment risk. Resident 21 had a half-rail and a gap between the rail and mattress, but there was no documentation of consent, installation date, alternatives, risk-benefit review, or entrapment assessment.
Failure to Ensure Required Physician Visit Intervals
Penalty
Summary
The provider failed to ensure that residents were seen face-to-face by a physician at the required intervals after admission and thereafter. Resident 3 was admitted to the facility and was not seen by a physician until 96 days after admission, which did not meet the requirement for physician visits every 30 days during the first 90 days. Resident 6 was admitted to the facility and, during the reviewed period, had physician visits on 12/12/25, 1/22/25, 3/24/25, and 5/13/26; there were 61 days between the 1/22/25 and 3/24/25 visits, exceeding the required 30-day interval during the initial 90 days after admission. Resident 9 was admitted to the facility and had physician visits documented on 1/14/25, 4/18/25, 8/14/25, 10/16/25, 12/12/25, and 4/21/26. The record showed 94 days between the 1/14/25 and 4/18/25 visits, 118 days between the 4/18/25 and 8/14/25 visits, and 130 days between the 12/12/25 and 4/21/26 visits, which did not meet the required 60-day physician visit schedule after the initial 90 days. The medical director stated he saw residents according to the schedule made by the DON and assistant DON and was aware of the required visit frequency. The DON acknowledged that resident 9 was not seen during several required intervals and that resident 3 was not seen every 30 days for the first 90 days after admission.
Medication Storage and Controlled Drug Handling Deficiencies
Penalty
Summary
Pharmaceutical services were not maintained to meet resident needs in the medication storage room and resident medication refrigerator. During observation, expired medications and supplies were found stored on shelves in the medication storage room, including expired COVID-19 antigen rapid tests, ear curettes, PureWick catheters, and influenza vaccine syringes. Staff acknowledged that these items had expired and should have been removed during the monthly check. The resident medication refrigerator also contained resident beverages, including opened boxes of wine and an unlabeled 12-pack of beer, stored with resident medications and vaccine supplies. Resident 5’s Trulicity medication box was observed wet, and staff acknowledged that the wet cardboard container had been compromised by liquid leaking from an opened wine box stored above it. A clear plastic bag containing influenza vaccine was also wet. The contracted travel RN and the ADON acknowledged that resident beverages should not have been stored in the medication refrigerator and that the wine boxes were unlabeled. The DON later removed the beverages and stated that resident food and beverages should have been kept in the hospitality refrigerator instead. Temperature monitoring for the resident medication refrigerator was not consistently documented. The facility’s log stated that the refrigerator temperature was to be monitored and documented daily, but the February, March, and April logs contained numerous missing entries, and no temperature log was maintained for May. The DON stated that temperatures should be monitored once or twice daily but was unsure of the exact frequency. In addition, controlled medications awaiting destruction were stored in a locked cupboard in the medication storage room in a disorganized manner, with disposition forms not stored with the medications. Staff reported that the controlled medications had remained there for weeks and then over two months without being destroyed, and the cupboard and medication room keys were accessible to multiple nurses and maintenance staff.
Failure to Identify and Act on Psychotropic Medication Irregularities
Penalty
Summary
The facility failed to have an effective system in place to identify medication irregularities, report those irregularities to the physician, and ensure the physician addressed them during monthly drug regimen reviews for four sampled residents receiving psychotropic medications. The deficiency involved residents 3, 6, 21, and 32, whose records showed psychotropic orders with missing or unclear indications, missing end dates, duplicate therapy, and orders that did not match the documented diagnoses or the actual medication directions in the chart. Resident 3 had orders for haloperidol PRN for agitation without an end date and quetiapine at bedtime for behaviors, but the behaviors were not identified. Monthly medication reviews and GDR recommendations did not identify that haloperidol lacked an end date or that quetiapine lacked a diagnosis or identified behavior. Resident 32 had orders for mirtazapine for depression despite no diagnosis of depression, lorazepam PRN without an end date, scheduled lorazepam without an identified diagnosis, olanzapine for dementia with agitation, and quetiapine. The monthly review documented quetiapine as PRN when the order was for afternoon administration, did not identify duplicate therapy between olanzapine and quetiapine, and did not address the psychiatrist-recommended transition from quetiapine to olanzapine. Resident 21 had PRN temazepam and PRN lorazepam Intensol orders without documented 14-day stop dates or physician evaluations supporting continuation beyond 14 days, trazodone for insomnia without documented physician evaluation for continued use, and sertraline ordered for depression despite no diagnosis of depression. Licensed pharmacist reviews noted some concerns, including PRN psychotropic use and GDR needs, but the record did not show consistent physician follow-up or resolution of the identified issues. Resident 6 had sertraline ordered for depression despite no diagnosis of depression, PRN haloperidol without an end date or supporting diagnosis, and scheduled quetiapine for agitation without an identified behavior or diagnosis; the pharmacist’s reviews repeatedly failed to address these discrepancies, and the physician did not respond to at least one GDR recommendation. Interviews confirmed the facility lacked a psychotropic medication policy process, did not consistently review risk versus benefit, alternatives, or consent for psychotropic use, and did not ensure pharmacist recommendations reached the medical director in a timely manner. The DON stated there was no policy related to psychotropic medications, the pharmacist acknowledged she did not verify that diagnoses in the chart matched the medication indications, and the medical director acknowledged missed GDR recommendations and expected staff to notify him if reviews were missed. The provider’s policies reviewed by surveyors addressed medication review and behavioral health management generally, but psychotropic medications, PRN stop dates, and the 14-day limits were not included in the discontinuation policy, and a requested monthly medication review/GDR policy was not provided.
Controlled Medications Not Timely Destroyed and Improperly Stored
Penalty
Summary
The facility failed to ensure timely destruction and proper accountability of controlled medications for six sampled residents, and controlled medications awaiting destruction were stored in a manner that did not maintain restricted access. During observation of the medication storage room, the controlled medications were kept in a locked cupboard, but multiple nurses had access to the key, maintenance also had access to the medication storage room, and the cupboard containing the controlled medications was disorganized with no clear system of order. The controlled medication disposition forms were not stored with the medications, requiring staff to search through the cupboard to match medications with forms. The controlled medications had remained in the cupboard for more than two months without being destroyed. The cupboard contained unreconciled controlled medications for residents 7, 8, 11, 13, 32, and 100, including lorazepam, diazepam, morphine, hydromorphone, buprenorphine, hydrocodone/APAP, tramadol, haloperidol, and fentanyl patches. An unidentified medication was also stored in an unlabeled clear plastic medication cup. Staff interviews confirmed that the medications were supposed to be counted and destroyed every one to two weeks, but this had not occurred for over two months, and the controlled medications awaiting destruction were not counted each shift. The medication storage room also contained expired medications and supplies, and the resident medication refrigerator had missing temperature documentation for multiple days across February, March, and April 2026, with no temperature log maintained for May 2026. During observation, resident personal beverages were stored in the medication refrigerator with medications, including unlabeled wine boxes and an unlabeled 12-pack of beer. One resident’s Trulicity box was wet from a leaking wine spicket stored above the medications, and staff acknowledged that the resident’s medication container had been compromised. Interviews with the DON, ADON, RN, pharmacist, and CEO confirmed that the facility lacked consistent oversight of medication storage, temperature monitoring, and controlled medication destruction practices.
Missing QAPI Training for Newly Hired and Contracted Staff
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program was not provided to five of five employees reviewed: dietary manager G, CNA O, contracted travel CNA Z, housekeeping aide Y, and contracted travel LPN R. Personnel record review showed these employees were hired between 7/28/25 and 4/27/26, and there was no documentation that they received training on the elements and goals of the facility’s QAPI program. Interviews confirmed the training gap. The DON stated she managed QAPI meetings and that staff were informed about performance improvement plans through their department manager, but staff did not receive training on the elements and goals of the QAPI program. The HR director stated she was responsible for assigning required staff training, but QAPI training had not been assigned and she was not aware it was a required topic. The CEO acknowledged that required training had not been completed. The facility’s August 2018 Required Annual Training of Long-Term Care Healthcare Workers policy stated training was to be completed in accordance with state and federal regulations and that the provider would maintain a formal orientation program and ongoing education program for all personnel; however, QAPI elements and goals were not listed as required staff training in the policy.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The provider failed to ensure yearly performance evaluations were completed for three of three sampled CNAs, including two contracted travel CNAs and one regular CNA. Review of the personnel records showed CNA S was hired on 3/19/24 and had no yearly performance review in her file, CNA U was hired on 3/7/23 and also had no yearly performance review in her file, and CNA AA was hired on 1/15/08 with her last performance evaluation completed on 4/2/25. The deficiency was identified through personnel record review and interview with the DON. During interview on 6/2/26, the DON stated she completed yearly performance evaluations for the facility's nursing staff, but for contracted travel CNAs she provided feedback to their travel agency and expected the agency to complete the yearly evaluations. Review of the DON job description stated the DON has a primary role in evaluation and improvement of nursing and other services, provides effective onboarding, education, and training to assure staff competencies, and provides ongoing coaching, mentoring, and performance feedback. Review of the facility assessment stated annual evaluations had been implemented using an evaluation form intended to support more substantial dialogue between directors and staff members.
Grievance Process Not Available or Followed
Penalty
Summary
The facility failed to honor residents’ right to voice grievances without discrimination or reprisal and did not establish or follow a workable grievance process. During observation on 5/27/26, there were no grievance forms or instructions on how to file a grievance in resident care areas, at the nurses’ station, near the dining room, or in the activities room. The social services designee stated she thought the grievance official was either the licensed social worker or the CEO, and she had not assisted any resident or family member in completing a grievance form. The licensed social worker stated she had been the grievance official until she began working remotely about two years earlier, but she only worked at the facility two days per month. She expected grievance forms to be available in resident hallways and outside the DON and social services offices, yet confirmed there were no forms outside the DON office or in the 300 hallway. She also acknowledged that the grievance binder in the 200 hallway was placed in a clear file holder with trash bags about five feet from the floor, which would not be accessible to residents using wheelchairs. The binder near the front door was outside the social services office and not in a resident care area, and residents would not likely know it was there. Residents in council interview stated they did not know how to file a grievance or where forms were located. The deficiency also involved resident 5’s hot liquid burn injury and the family member’s concern that a staff member caused it. Resident 5’s family member stated resident 5 told her, “they burned me,” showed her the injured inner thigh area, and later repeated that staff had caused the burn. She said she was not notified when the injury occurred and expected follow-up after she voiced her concern to staff and again at the care conference. Facility staff, including the DON, RD, SSD, and LSW, gave inconsistent accounts of when they learned of the family’s concern and whether a grievance form should have been completed. The DON stated she was not notified of the injury at the time because staff believed resident 5 spilled hot tea on herself, and she expected a grievance form to be completed when the family voiced concern at the care conference. The SSD and RD were unsure whether a grievance was completed, and the LSW stated she became aware of the family’s concern only later and was unaware when the concern was first shared. The grievance policy and procedure reviewed by the facility did not identify the grievance official in the policy, and the procedure listed the LSW as the grievance official while the SSD’s contact information was not included.
Failure to Timely Report Suspected Abuse or Neglect
Penalty
Summary
The provider failed to report allegations of suspected abuse or neglect to the SD DOH within the required time frame for two residents. For one resident, a hot liquid burn injury occurred when the resident spilled a hot beverage in the dining room and developed a blister on the inner thigh with redness to both inner thighs. The resident later told a family member that a staff member had spilled the hot tea on her, and the family member expressed concern to facility staff that the injury may have been caused by staff. The facility did not report the allegation to the SD DOH until after the family concern was raised and the incident was reviewed at a care conference, and staff interviews showed confusion about when the concern was first reported and who was responsible for reporting it. The resident’s family member stated she told staff that she believed a staff member caused the burn injury and that she was upset that she and the other emergency contact were not notified. Facility staff, including the DON, RD, SSD, and LSW, gave inconsistent accounts of when they learned of the family’s concern and when the matter was escalated. The DON stated she was not notified on the day of the injury and did not report the incident until after learning of the family’s allegation weeks later. The facility’s policies required prompt reporting and investigation of suspected abuse or neglect, but the report showed the incident was not handled within the required reporting time frame. For the second resident, the facility received an allegation of staff abuse after the resident was found with bruises, a skin tear, and a cut to the lip, and the resident stated that a staff member grabbed and twisted her arm. The contracted travel CNA involved gave a statement describing assisting the resident and grabbing her forearms when she began to fall. The facility notified law enforcement and state agencies, but the survey found that no facility investigation report was available, no incident report was completed in the electronic risk management system, and there was no documentation that the resident’s emergency contact had been notified of the abuse allegation and resulting physical harm. The resident had severe cognitive impairment on BIMS testing and no diagnosis of dementia or another cognitive disorder was documented.
Baseline care plans were incomplete and not reviewed or offered to residents within 48 hours
Penalty
Summary
The provider failed to ensure baseline care plans were completed, reviewed with the resident or the resident’s representative, and a copy was offered within 48 hours of admission for three newly admitted residents. Resident 14, who had hemiparesis affecting the right dominant side, adult failure to thrive, repeated falls, hypertension, chronic ischemic heart disease, and vitamin D and B deficiencies, had a baseline care plan assessment started but not completed; the record did not show his diagnoses, diet, or completion of the social services section, and there was no documentation that the care plan was reviewed with him or his representative or that a copy was offered within 48 hours. Resident 6, who had type 2 DM, peripheral vascular disease, CKD, cerebral infarction, repeated falls, weakness, and tremor, had a baseline care plan completed but it did not document his diagnoses, bed-to-chair transfer status, or completion of the social services section, and there was no documentation that it was reviewed with him or his representative or that a copy was offered within 48 hours. Resident 5, who had diverticulosis, atrial fibrillation, type 2 DM, HTN, low back pain, depressive episodes, a cardiac pacemaker, Alzheimer's disease, and dementia, also had a baseline care plan that did not document her diagnoses, code status, or completion of the social services section, and there was no documentation that it was reviewed with her or her representative or that a copy was offered within 48 hours of admission. During interview, the DON stated she expected the baseline care plan to be completed as soon as possible, within 48 hours after admission, but she was unsure whether social services contributed to it and was unaware that the regulation required the baseline care plan to be reviewed with the resident or representative and a copy to be provided. The provider’s policy stated that each resident should have a preliminary care plan developed at admission to address immediate care needs.
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
A prioritized, do-first checklist
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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 | ★★★★★ | 0 | 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.