Winner Regional Healthcare Center

In the surveyor’s words

From the most serious findings on record at Winner Regional Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jun 2, 2026

  A. Based on observation, interview, record review, and policy review, the provider failed to ensure resident safety by not assessing the side rails/grab bars and mattresses on the resident's beds for entrapment (trapped between the rail, mattress, or bedframe spaces) for four of six sampled residents (17, 21, 25, and 26) with loose side rails/grab bars on their beds, five of six sampled residents (6, 14, 17, 21, and 25) with an unsecured mattress on their bed, and one of six sampled residents (17) with a side rail/grab bar that was not indicated for use on the bed. Those failures put those residents at risk for entrapment, injury, or harm.Immediate Jeopardy (IJ) at F689, with a scope and severity of K, began on 5/28/26 at 10:05 a.m. upon observation of resident 14's bed. […]

• Actual harm, isolatedF600Jun 2, 2026

  Based on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the facility failed to protect one of one resident's (13) right to be free from physical abuse by contracted travel certified nursing assistant (CNA) BB who used physical force while providing care to resident 13 who subsequently had a skin tear and bruising to her arms. Findings include:1. Review of the provider's 2/25/26 SD DOH FRI revealed on 2/24/26, at around 6:00 a.m., an unidentified CNA entered resident 13's room to assist her with her morning care. The CNA noted that resident 13 had bruises on both her arms and a skin tear on her right arm. The CNA reported her findings to the on-duty contracted travel registered nurse (RN) T. […]

• Actual harm, isolatedF689Aug 24, 2023

  Based on observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (18) prior to pushing the resident in her wheelchair without placing foot pedals to elevate her feet off the floor, and that resulted in the resident falling out of the wheelchair and fracturing her left arm. Findings include: 1. Observation and interview on 8/22/23 at 10:25 a.m. with resident 18 revealed: *She had a cast on her left arm. *When asked about how she got the cast, she stated that she had fallen and broke her arm. *She winced in pain when moving her arm and stated it was quite painful at times. -She indicated she had just taken some pain medication and was waiting for it to start working. […]

• No harm, potential for more than minimal, widespreadF835Jun 2, 2026

  Based on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered by chief executive officer (CEO) A and director of nursing (DON) B in a manner that ensured quality of life and overall well-being for all 26 residents in the facility.Findings include:1. Observations, interviews, record reviews, and policy reviews throughout the survey from [DATE] through [DATE] and [DATE] through [DATE] revealed CEO A and DON B did not ensure the management, safety, quality of life, and overall well-being of all the residents who lived at the facility.Those were evidenced by a widespread system breakdown to ensure services provided met professional standards and the minimum requirements as it pertained to providing education to… […]

• No harm, potential for more than minimal, widespreadF865Jun 2, 2026

  Based on interview, record review, and policy review, the provider failed to ensure they identified, investigated, and corrected quality deficiencies, and to initiate or monitor performance improvement projects (PIPs) in response to known areas of concern within their Quality Assurance and Performance Improvement (QAPI) program.Findings include: 1. Interview on 5/28/26 at 5:00 p.m. with CEO A revealed that director of nursing (DON) B managed the facility's QAPI program. He did not routinely attend the long-term care (LTC) QAPI meetings because he was not required to be present. He received a copy of the LTC QAPI meeting minutes and provided that at the general QAPI meeting and again at the board meetings, where he reviewed them. […]