Winner Regional Healthcare Center
805 E 8th St, Winner, SD 57580 · Tripp County · 40 certified beds · avg 25 residents/day · certified since Mar 1, 1991
Abuse citation flag (CMS)SFF Candidate
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jun 2, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jul 9, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 2, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 9, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 24, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 10, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (29)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 2, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 2, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 2, 2026 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Jun 2, 2026 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Jun 2, 2026 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Jun 2, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Jun 2, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jun 2, 2026 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| May 21, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Dec 19, 2024 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 20, 2023 | E · Potential for harm, repeated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint |
| Aug 24, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 24, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Aug 24, 2023 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Aug 24, 2023 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 24, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 24, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 24, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 24, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 15).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 1 | G ▲ |
| 2024 | 2 | 0 | E |
| 2025 | 1 | 0 | D |
| 2026 | 17 | 2 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $13,039.
| Date | Type | Amount / length |
|---|---|---|
| Aug 24, 2023 | Fine | $3,728 |
| Aug 24, 2023 | Fine | $9,311 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.85 | 4.32 | 3.95 | top 8% in South Dakota; top 5% in the U.S. |
| Registered Nurse hours | 0.88 | 0.91 | 0.69 | top 50% in South Dakota; top 22% in the U.S. |
| Weekend total nurse staffing | 4.67 | 3.71 | 3.50 | top 13% in South Dakota; top 10% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.51 | 0.51 | 0.48 | top 43% in South Dakota; top 32% in the U.S. |
| Total nursing staff turnover (%) | 68.4 | 48.2 | 45.8 | bottom 7% in South Dakota; bottom 7% in the U.S. |
| RN turnover (%) | 66.7 | 34.7 | 42.9 | bottom 12% in South Dakota; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.99, RN 0.75, weekend 3.98. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Atteberry, Lucy | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/20/2021 |
| Burns, Nielsen | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/21/2025 |
| Burns, Nielsen | Individual | ADP of the SNF | NOT APPLICABLE | 03/31/2025 |
| Chambers, Mari | Individual | Corporate Officer | NOT APPLICABLE | 11/11/2025 |
| Haiar, Cody | Individual | Corporate Director | NOT APPLICABLE | 06/01/2024 |
| Hammerbeck, Sara | Individual | Corporate Director | NOT APPLICABLE | 01/01/2022 |
| Heenan, Casey | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Kingsbury, Roger | Individual | Corporate Director | NOT APPLICABLE | 09/01/2016 |
| Lewis, Dana | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2026 |
| Nicholas, Dave | Individual | Corporate Director | NOT APPLICABLE | 05/01/2025 |
| Olson, Nicole | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/13/2023 |
| Olson, Nicole | Individual | ADP of the SNF | NOT APPLICABLE | 08/13/2023 |
| Petersek, Sara | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Pravecek, Betsy | Individual | Corporate Director | NOT APPLICABLE | 09/01/2014 |
| Rowe, Dione | Individual | Corporate Director | NOT APPLICABLE | 04/01/2020 |
| Schroeder, Rhonda | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/11/2016 |
| Vanneman, Kim | Individual | Corporate Director | NOT APPLICABLE | 09/01/2015 |
| Williams, Brian | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2023 |
| Williams, Brian | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2024 |
| Williams, Brian | Individual | ADP of the SNF | NOT APPLICABLE | 03/31/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "How does your quality improvement program work, and can you share a recent example of a problem you found and fixed?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avera Rosebud Country Care Center | 23.4 mi | Gregory, SD | ★★★★☆ | 4/5 | |
| Sanford Chamberlain Care Center | 38.9 mi | Chamberlain, SD | ★☆☆☆☆ | 2/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435056.