Winner Regional Healthcare Center

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure a thorough investigation was completed regarding an allegation of resident abuse for one of one resident (1) by one of one former contracted travel certified nursing assistant (CNA) (G) who bruised resident 1's upper right arm while providing her personal care.

Inspectors wroteA. 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. The bed was unlocked and moved away from the wall; [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the staff educated the resident or the resident's representative of the risks versus benefits of medications or of alternative treatments to make an informed decision for the consent for the use of psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) before they were administered to four of four sampled residents (3, 6, 21, and 32). Findings Include:1. Review of resident 21's EMR revealed he admitted to the facility on [DATE]. His 4/21/26 BIMS assessment score was 3, which indicated his cognition was severely impaired. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to protect the residents' rights to be free of unnecessary medications, specifically psychotropic medications (drugs that affect brain activities associated with mental processes and behavior), for five of five sampled residents (3, 6, 9, 21, and 32) who were administered psychotropic medications without usage order stop dates or documented reasoning for continuation of use of as needed psychotropic medications beyond fourteen days, completed risk versus benefit evaluations for informed consent for use, documented diagnoses for use, documented and physician responses to pharmacy recommendations.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the residents' care plans (personalized plan that addresses a resident's care needs, goals, and interventions) were reviewed and revised to reflect the current care needs for nine of thirteen sampled residents (3, 5, 6, 9, 14, 18, 21, 22 and 32).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure physician's orders, in accordance with the provider's policy, were obtained before bed rails/grab bars (bars attached to the bed) were installed for two of ten sampled residents (6 and 26), alternatives to the bed rails/grab bars were attempted before the bed rails/grab bars were installed, the risks versus benefits of bed rails/grab bars were reviewed with the resident, or the resident's representative, entrapment zone assessments were completed, and a consent for the bed rails/grab bars were obtained for seven of ten (6, 14, 17, 21, 22, 25, and 26) who had bed rails/grab bars on their bed.

Inspectors wroteBased on record review, interview, and admission packet review, the provider failed to ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission for two of four sampled residents (3 and 6), and at least once every 60 days thereafter for one of four sampled residents (9).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure proper medication storage practices for one of one resident medication refrigerators in one of one medication storage room. Specifically, expired medications and supplies were not discarded as required; temperatures in the resident medication refrigerator were not consistently monitored and documented; and unlabeled resident beverages were stored in the resident medication refrigerator with resident medications.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to have a system in place to identify medication irregularities, report those irregularities to the physician, and for the physician to address the identified irregularities for four of four sampled residents (3, 6, 21, and 32) on psychotropic medications (drugs that affect brain activities associated with mental processes and behavior).

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure timely destruction of controlled medications (medications with risk for abuse and addiction) for six of six sampled residents (7,8,11,13, 32, and 100) and failed to ensure that the controlled medications awaiting destruction were stored with restricted access and maintained under proper accountability procedures in one of one medication storage room.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the staff received the required training regarding the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for five of five employees reviewed (G, O, R, Y, and Z).

Inspectors wroteBased on personnel record review, interview, and review of the director of nursing (DON)'s job description the provider failed to ensure yearly performance evaluations were completed on three of three sampled certified nursing assistants (CNAs) (S, U, and AA) and their in-service training was tailored to address areas of weakness as determined in the nurse aide's performance reviews and facility assessment.

Inspectors wroteBased on interview, observation, and policy review, the provider failed to make information available on how to file a grievance, ensure the grievance forms were readily available to residents and their representatives, designate who the grievance official was, and follow their grievance process when one of one sampled residents' (5) representative expressed a concern about an injury. Findings Include:1. Observation on 5/27/26 at 8:10 a.m. revealed there were no grievance forms or information on how to file a grievance located in the resident care areas, at the nurses' station, near the dining room, or in the activities room. 2. Interview on 5/27/26 at 8:16 a.m. with social services designee (SSD) F revealed she thought that the grievance official was either licensed social worker (LSW) E or chief executive officer (CEO) A. SSD F was responsible for filing the grievances in a binder. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, document review, record review, and policy review, the provider failed to report within the required time frame to the SD DOH for two of two sampled residents' (5 and 13) allegations of potential resident abuse or neglect.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was completed, was reviewed with, and a copy was offered to the resident or the resident's representative within 48 hours of the resident's admission to the facility for three of four sampled newly admitted residents (3, 6, and 14).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint report review, record review, and interview, the provider failed to ensure care plans were reviewed and revised to reflect the current care needs of two of two sampled residents (1 and 2): *One of one sampled resident (1) with verbally aggressive behaviors. *One of one sampled resident (2) vulnerable to verbal aggression from her roommate.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure side rail assessments were completed for safe and appropriateuse for three of seven sampled residents (1, 9, and 14) wh used them for repositioning.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *One of one resident (9) receiving oxygen had appropriate exchange and maintenance of the cannula. *One of one resident (27) receiving oxygen at night had a current physician order for use and was care planned.

Inspectors wroteBased on review of provider's South Dakota Department of Health (SDDOH) online self-report of neglect, interviews, and policy review, the provider failed to ensure their corrective action regarding all staff educated on abuse and neglect in a timely manner. 1. Review of the SDDOH provider's self-report of neglect allegation intake number SD00002095 revealed the corrective action included that the provider was to educate all staff on abuse and neglect by 11/8/23. Interview on 11/20/23 at 2:04 p.m. with licensed social worker C regarding corrective action of employee education relating to abuse and neglect revealed she: *Had become aware of the allegation of neglect on 11/1/23, after returning from a vacation. -She submitted the online self-report of neglect to the SDDOH. *Had educated Administrator A and Director of nursing (DON) B on abuse, neglect, and reporting requirements on 11/1/23. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to provide a homelike experience in two of two dining rooms that had the potential to affect all residents.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure: *Three of six sampled residents recently admitted (29, 86, 136) had a baseline care plan established and reviewed with the resident, their representative, or their responsible family member. *One of six sampled residents recently admitted (33) had a baseline care plan established and reviewed within 48 hours of admission with the resident, their representative, or their responsible family member.

Inspectors wroteBased on interview, record review, observation, and policy review, the provider failed to: *Review and revise the care plans for 3 of 13 sampled residents (24, 27, and 29) whose care plans were reviewed. *Include the resident or the resident's representative in the care planning process for 3 of 10 sampled residents (2, 15, and 27) who were interviewed about participation in the care planning process.

Inspectors wroteBased on observation and interview, the provider failed to prevent potential cross-contamination by improper glove use and hand hygiene when handling ready-to-eat foods by two of two employees (dietary manager E and dietary assistant K) during one of one meal service observation. 1. Observation on 8/23/23 from 5:13 p.m. to 5:46 p.m. of supper meal service revealed: * Dietary assistant K was serving supper. *She put on a pair of clean gloves. She wore the same pair of gloves throughout the entire supper observation. *Several times throughout the meal service, she would touch serving utensil handles, refrigerator door handles, product packing from the refrigerators, plates, cart handles, and other potentially soiled surfaces. -She also went back and forth between the kitchen and the serving area without performing hand hygiene or changing her gloves. [...]

Inspectors wroteBased on observation, interview, policy review, and resident right's review, the provider failed to protect a resident's rights to privacy and a dignified existence during one of one observed resident care when certified nursing assistant (CNA) (T) was using her personal cell phone while one of one sampled resident (17) was using the bathroom.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to assess injuries of unknown origin for one of seventeen sampled residents (27) screened for non-pressure related skin injuries.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to provide restorative nursing services for two of seventeen sampled residents (24, 27) reviewed for concerns related to limited range of motion and/or decreased mobility.