Inspection Reports for
Spearfish Canyon Healthcare
1020 N. 10th St, Spearfish, SD, 57783
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
112% worse than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 6
Date: Aug 28, 2025
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements related to resident care, environment, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide a homelike environment due to noise and lack of preferred towels, inadequate fluid intake monitoring for a resident with fluid restrictions, failure to update transfer assistance information leading to unsafe transfers, expired vaccines stored in medication refrigerators, inadequate dishwasher temperature monitoring, and lapses in infection prevention practices including hand hygiene and cleaning protocols.
Deficiencies (6)
F 0584: The facility failed to provide a homelike environment for residents 39 and 61 due to loud oxygen tank noise disturbing resident 39 and inconsistent provision of preferred cloth towels for resident 61.
F 0684: The provider failed to ensure accurate accounting and monitoring of daily fluid intake for resident 4 with a physician-ordered fluid restriction, placing the resident at risk for potential harm.
F 0689: The facility failed to update and communicate resident 61's transfer assistance needs accurately, resulting in unsafe transfer practices and increased fall risk.
F 0755: Two medication refrigerators contained expired vaccines available for administration, indicating failure in medication management and storage practices.
F 0812: The provider failed to ensure dishwasher temperatures consistently met the minimum required 120°F for sanitation, risking inadequate cleaning of food service items.
F 0880: Infection prevention and control practices were not followed, including failure to clean inhalers after use, improper hand hygiene by staff, and lack of resident hand hygiene policies.
Report Facts
Expired vaccines: 15
Dishwasher temperature noncompliance: 36
Dishwasher temperature noncompliance: 5
Dishwasher temperature missing logs: 41
Fall Assessment-Post Incident score: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA L | Certified Nurse Aide | Named in findings related to failure to assist resident 61 with hand hygiene and improper transfer without gait belt initially. |
| DON B | Director of Nursing | Interviewed regarding multiple deficiencies including fluid intake monitoring, whiteboard updates, expired vaccines, and infection control. |
| LPN R | Licensed Practical Nurse | Interviewed regarding resident 4's fluid restriction and fluid management. |
| Physical Therapist Q | Physical Therapist | Responsible for updating resident 61's transfer information, which was found outdated. |
| Physical Therapy Assistant P | Physical Therapy Assistant | Confirmed transfer information for resident 61 was outdated on whiteboard. |
| RN G | Registered Nurse | Interviewed regarding expired vaccines and unaware of oxygen tank noise. |
| CMA M | Certified Medication Aide | Observed failing to clean inhaler after use. |
| CNA N | Certified Nurse Aide | Observed failing to perform hand hygiene properly when cleaning urine spill and handling catheter bag valve. |
| Dietary Supervisor J | Dietary Supervisor | Interviewed regarding dishwasher temperature issues. |
| Maintenance Technician E | Maintenance Technician | Interviewed regarding dishwasher and oxygen tank noise. |
| Administrator A | Administrator | Interviewed regarding oxygen tank placement, dishwasher issues, and infection control policies. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 9, 2025
Visit Reason
The inspection was conducted following complaints and facility reported incidents involving resident safety issues including an elopement incident, a burn injury from hot liquid, and a fall related to improper use of a gait belt.
Complaint Details
The investigation was complaint-driven based on incidents reported by the facility and complaints regarding resident safety. The elopement incident was substantiated with corrective actions implemented. The burn injury and fall incidents were also substantiated with findings of deficient practices and subsequent corrective measures.
Findings
The facility failed to ensure resident safety in multiple areas: a resident eloped without staff supervision, a resident sustained a burn from improperly prepared hot liquid, and a resident fell when assisted without a gait belt. Corrective actions and policy revisions were implemented following these incidents.
Deficiencies (3)
F684: The facility failed to ensure the safety of a resident who eloped without staff knowledge or supervision. The resident was found outside the facility and was unharmed. Corrective actions included placing a Wander Guard bracelet and educating staff and families on supervision.
F689: The facility failed to provide an environment free from accident hazards when a resident sustained a skin burn from hot liquid prepared improperly by dietary staff. The broth was made using water from a stovetop kettle instead of the coffee machine. Staff education and audits were implemented.
F689: The facility failed to ensure proper supervision when a resident fell while being assisted to walk without the use of a gait belt. The resident sustained fractures and skin tears. The facility revised gait belt policies and provided staff re-education.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
BIMS score: 7
BIMS score: 13
BIMS score: 12
Date of elopement incident: Jun 1, 2025
Date of burn incident: Mar 25, 2025
Date of fall incident: Apr 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA O | Certified Nursing Assistant | Named in fall incident for assisting resident without gait belt; received re-education on 4/9/25; voluntarily terminated employment on 4/29/25. |
| DON B | Director of Nursing | Notified of incidents; confirmed gait belt policy and training; involved in corrective actions and interviews. |
| Administrator A | Administrator | Interviewed regarding elopement and burn incidents; confirmed corrective actions and policy changes. |
| Cook H | Cook | Named in burn incident for improper preparation of hot liquid; had only been working 2-3 days at time of incident. |
| CMA L | Certified Medication Aide | Observed and responded to elopement incident; educated resident's family member. |
| PT I | Physical Therapist | Observed resident ambulating with gait belt; stated gait belts should always be used. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 19, 2024
Visit Reason
The inspection was conducted based on a facility-reported incident regarding failure to provide repositioning and incontinence care to a resident according to her plan of care.
Complaint Details
The complaint was substantiated based on the investigation of a facility-reported incident involving one resident who did not receive repositioning or incontinence care during a night shift. Corrective actions were confirmed by follow-up review.
Findings
The provider failed to ensure one resident's repositioning and incontinence care needs were met, potentially increasing risk for discomfort, infection, and skin breakdown. The provider implemented corrective actions including staff education, care plan reviews, and ongoing audits, resulting in the non-compliance being considered past.
Deficiencies (1)
F 0684: The provider failed to provide appropriate treatment and care according to orders and resident preferences. One resident did not receive repositioning or incontinence care as required, placing her at risk for discomfort and skin breakdown.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Admitted to not providing repositioning or incontinence care during the night shift. |
| DON B | Director of Nursing | Conducted investigation and confirmed corrective actions. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 2, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to a resident who sustained a burn from hot coffee spilled on her lap during breakfast on 4/24/2024.
Complaint Details
The complaint investigation was triggered by a reported incident on 4/24/24 involving a resident who spilled hot coffee on herself, resulting in a burn. The investigation was found to be incomplete and lacking witness statements.
Findings
The provider failed to ensure a thorough investigation was completed for the resident's coffee burn incident. The resident was cognitively impaired, and the investigation lacked statements from witnesses and sufficient documentation.
Deficiencies (1)
F 0610: The provider failed to conduct a thorough investigation of a resident's coffee burn incident on 4/24/24. The investigation lacked statements from individuals with knowledge of the event and adequate documentation.
Inspection Report
Routine
Deficiencies: 6
Date: Feb 7, 2024
Visit Reason
Routine inspection of Spearfish Canyon Healthcare to assess compliance with regulatory standards including resident care, environment, infection control, and staff practices.
Findings
The facility failed to accommodate resident preferences for menu posting and food choices, maintain a clean and homelike environment, ensure timely incontinence care, follow physical therapy recommendations for resident transfers, properly clean nebulizer equipment, and implement infection prevention practices including cleaning of whirlpool tubs and proper handling of urine collection bags.
Deficiencies (6)
F 0558: Failed to accommodate resident preferences for menu posting and food choices, including not posting menus and serving incorrect food to a resident.
F 0576: Failed to ensure mail delivery was available on Saturdays for all 67 residents.
F 0584: Failed to maintain a home-like environment including unclean refrigerator, stained carpet and loveseat cushions, multiple unused screw holes in walls, and unclean faucet heads in residents' rooms.
F 0600: Failed to provide timely incontinence care to a resident and did not follow physical therapy recommendations for safe resident transfers causing pain.
F 0658: Failed to ensure licensed practical nurse removed and cleaned nebulizer mask and medicine reservoir after treatment for a resident.
F 0880: Failed to implement infection prevention practices including inadequate cleaning of whirlpool tubs and improper handling of uncovered urine collection bags touching the floor.
Report Facts
Residents affected: 67
Residents affected: 34
Residents affected: 6
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN X | Licensed Practical Nurse | Named in nebulizer treatment cleaning deficiency |
| CNA P | Certified Nurse Aide | Named in failure to provide timely incontinence care |
| Activities Director H | Activities Director | Named in failure to follow physical therapy recommendations for resident transfers |
| CNA N | Certified Nurse Aide | Named in failure to follow physical therapy recommendations for resident transfers |
| Dietary Supervisor E | Dietary Supervisor | Named in menu posting and food choice deficiencies |
| Director of Nursing B | Director of Nursing | Interviewed regarding multiple deficiencies including incontinence care and infection control |
| Administrator A | Administrator | Interviewed regarding multiple deficiencies including mail delivery and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 2, 2023
Visit Reason
The inspection was conducted in response to complaints regarding resident safety, wandering residents entering other residents' rooms, and concerns about abuse and infection control practices.
Complaint Details
The investigation was complaint-driven based on resident and family concerns about wandering residents entering rooms, personal property theft or damage, and suspected abuse incidents involving resident injuries. The complaint was substantiated with findings of inadequate investigation, follow-up, and reporting.
Findings
The facility failed to adequately investigate and resolve resident complaints about wandering residents entering rooms and causing disturbances. There were also failures in reporting and investigating suspected abuse incidents and lapses in infection control practices including reuse of disposable razors and improper hand hygiene during wound care.
Deficiencies (4)
F 0565: The provider failed to ensure resident concerns about wandering residents entering rooms were thoroughly investigated and resolved for six sampled residents.
F 0584: The provider failed to protect personal property from confused wandering residents for one sampled resident, resulting in repeated intrusions and loss or damage of personal items.
F 0609: The provider failed to timely report and investigate two separate injuries to one resident and notify proper authorities as required.
F 0880: The provider failed to prevent reuse of disposable razors on multiple residents and ensure proper hand hygiene during wound care treatment by licensed staff.
Report Facts
Grievances filed: 5
Residents sampled: 6
Incident dates: Resident 9 sustained injuries on 2022-11-08 and 2022-12-02
Years worked: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Emergency Permit Holder/Administrator | Grievance officer and administrator aware of resident council concerns and abuse incident reporting |
| Director of Nursing B | Director of Nursing | New DON aware of wandering resident concerns and infection control issues |
| Activities Director D | Activities Director | Facilitated resident council meetings and acknowledged lack of grievance documentation |
| Certified Nursing Assistant H | Certified Nursing Assistant | Reported on staffing and wandering resident challenges |
| Social Services Coordinator E | Social Services Coordinator | Managed grievances and replacement of personal property |
| Licensed Practical Nurse F | Licensed Practical Nurse | Observed performing improper hand hygiene during wound care |
| Registered Nurse Consultant N | Registered Nurse Consultant | Interviewed regarding infection control practices |
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