Winner Regional Healthcare Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 57% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 40 beds and averages 25.1 residents a day — about 63% occupied, or roughly 15 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.98 hrs/resident/day on weekends vs 5.39 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.85 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · Kcited before2026-06-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The bed was unlocked and moved away from the wall; the mattress slid away from the side rail/grab bar with minimal effort, creating a gap of more than five inches. The bed frame did not have mattress guards, which held the mattress in place,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-06-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The nurse assessed resident 13 and confirmed that she had bruises on both arms and a skin tear on her right arm. Resident 13 told the CNA and RN that a girl from the night shift was mean, grabbed her arm, and wanted her to get out of bed to go to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. -The pain was manageable with the help of her pain medication. Interview on 8/24/23 at 10:35 a.m. with licensed practical nurse R about resident 18's fractured left arm revealed: *Resident 18 usually propelled herself throughout the building in her wheelchair. *She had not witnessed the fall, but she had received a report of the incident. Interview…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-06-02 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 residents and residents' representatives to be able to make informed decisions regarding psychotropic medication use, the filing of grievances, the residents' right to be free from abuse and neglect, the right to be free from…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-06-02 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. Medical director L was a member of the LTC QAPI committee, attended the meetings when he was able to, and was involved in the policy and procedure process as much as his time allowed. 2. Interview on 6/2/26 at 10:01 a.m. with medical director L revealed that he attended the facility's QAPI meetings quarterly (meaning occurring every three months) when he was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-02 · tag F0552 — pattern
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. His diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), dementia with agitation and behavioral disturbance, and neurocognitive disorder with Lewy Bodies (a progressive brain disorder caused by abnormal protein clumps that damage nerve cells that affects…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-02 · tag F0605 — failed to not use drugs as a restraint — pattern
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of resident 9's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 2/27/26 Brief Interview of Mental Status (BIMS) assessment score was 3, which indicated her cognition was severely impaired. Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-06-02 · tag F0657 — failed to keep the care plan current — pattern
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include:1. Observation on 5/26/26 at 1:22 p.m. in resident 18's room revealed a nebulizer machine on her bedside table, with a mask and tubing attached and stored on top of the machine. 2. Review of resident 18's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her 3/10/26 Brief Interview of Mental Status (BIMS) assessment score was 05, which indicated her cognition was severely impaired. She had diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe (COPD), type 2 diabetes mellitus (a condition involving disruptions in how the body regulates blood…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Ecited before2026-06-02 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include:1. Observation and interview on 5/26/26 at 3:39 p.m. with resident 22 revealed she had a scoop mattress (a mattress designed with raised, contoured edges and a lower, scooped center) and bed rails/grab bars (bars attached to the bed) on both sides of her bed. She stated that she fell out of bed about a year ago.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-02 · tag F0712 — pattern
  Ensure that the resident and his/her doctor meet face-to-face at all required visits.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include:1. Review of resident 9's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Resident 9's January 2025 through May 2026 physician's visit documentation revealed she was seen by medical director L on 1/14/25 and then not seen by a physician in the facility until 4/18/15. There were 94 days between the two physician's visits. After the 4/18/25 physician's visit she did not have a physician's visit until 8/14/25. There were 118 days between the two physician's visits. On 10/16/25 resident 9 was seen by medical director L, there were no signed physician's orders for that visit. She had physician's visit with medical director L on 12/12/25 and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-02 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: 1. Observation and interview on 5/27/26 at 3:31 p.m. of the medication storage room with contracted travel registered nurse (RN) V revealed that the door was locked and that she used a key to enter. She stated that she held the key to the medication storage room for her shift and that every nurse had access to the medication room key during their shifts at the facility. The resident's medication refrigerator contained the resident's personal beverages and their medications stored together. Resident 5's Trulicity 3mg/0.5ml syringe box was wet, as two boxes of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · E2026-06-02 · tag F0756 — failed to review each resident's drug regimen — pattern
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include:1. Review of resident 3's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her 5/15/26 Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated her cognition was moderately impaired. Her diagnoses included anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbance. She had a 12/23/25 physician's order for haloperidol 5…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-02 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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.Findings include:1. Observation and interview on 5/27/26 at 3:31 p.m. of the medication storage room with contracted travel registered nurse (RN) V revealed that the door was locked and that she used a key to enter. She stated that she held the key to the medication storage room for her shift and that every nurse had access to the medication room key during their shifts at the facility. The resident's medication refrigerator contained resident's personal beverages and their medications stored together. Resident 5's Trulicity 3mg/0.5ml syringe box was wet, as two boxes of opened, unlabeled wine boxes were stored above the medications. One box…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$13,039 in federal fines across 2 penalties.

• $3,728 — penalty dated 2023-08-24
• $9,311 — penalty dated 2023-08-24

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

CMS files one row per role, so the 20 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

What families pay in SD