Inspection Reports for Spearfish Canyon Healthcare

The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, environment, medication management, infection control, and food safety at Spearfish Canyon Healthcare.

The facility was found deficient in multiple areas including failure to provide a homelike environment due to noise and lack of preferred towels, inadequate accounting of fluid intake for a resident with fluid restrictions, failure to update transfer assistance information leading to unsafe transfers, presence of expired vaccines in medication refrigerators, inadequate dishwasher temperature monitoring, and lapses in infection prevention practices including hand hygiene and cleaning of medical equipment.

The inspection was conducted based on complaints and facility reported incidents involving resident safety, including an elopement incident on 6/1/25, a skin burn injury from hot liquid, and a fall incident involving improper use of a gait belt.

The facility failed to ensure the safety of residents by not preventing elopement of one resident, improper preparation and serving of hot liquids leading to a skin burn injury for another resident, and failure to use a gait belt when assisting a resident to walk, resulting in a fall and fractures. The facility implemented corrective actions including education, policy revisions, and monitoring.

The complaint investigation included a resident elopement incident on 6/1/25 where a resident left the facility without staff supervision, a skin burn injury from hot liquid due to improper food preparation, and a fall incident on 4/5/25 involving failure to use a gait belt. The elopement was substantiated as past non-compliance with corrective actions implemented. The fall incident involved actual harm with fractures and was substantiated.

The inspection was conducted based on a facility-reported incident involving failure to provide repositioning and incontinence care to a resident according to her plan of care.

The provider failed to ensure one resident's repositioning and incontinence care needs were met, placing the resident at higher risk for discomfort, infection, and skin breakdown. Corrective actions were implemented immediately, including staff education and quality assurance processes, and the non-compliance was considered past non-compliance as of 6/19/24.

The visit was complaint-related based on a facility-reported incident involving one resident who did not receive repositioning or incontinence care during a night shift. The complaint was substantiated with corrective actions confirmed.

The inspection was conducted following a complaint related to a resident who sustained a burn from spilling hot coffee on her lap during breakfast on 2024-04-24.

The provider failed to ensure a thorough investigation was completed for the resident's coffee burn incident. The resident was cognitively impaired and spilled hot coffee causing redness and blisters. Staff responses and documentation of the incident investigation were incomplete, with missing witness statements and unclear communication.

The visit was complaint-related due to an incident reported on 2024-04-24 involving a resident who spilled hot coffee on herself causing a burn. The complaint investigation found inadequate investigation and documentation of the incident.

The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, infection control, and other facility operations.

The facility was found deficient in accommodating resident food preferences, mail delivery on Saturdays, maintaining a clean and homelike environment, providing timely incontinence care, following physical therapy recommendations, proper nebulizer treatment procedures, and infection prevention and control practices including cleaning of whirlpool tubs and proper handling of urine collection bags.

The inspection was conducted due to complaints from residents about wandering residents entering their rooms, using their belongings, and causing disturbances. The visit aimed to investigate these concerns and the facility's response to resident grievances.

The facility failed to ensure resident concerns about wandering residents entering rooms and taking belongings were thoroughly investigated and resolved. Multiple interviews and resident council minutes revealed ongoing issues with wandering residents, lack of effective interventions, and inadequate follow-up on grievances. One resident experienced repeated intrusions and loss of personal property despite filing grievances. The facility used signage and redirection but had no formal performance improvement plan addressing the issue.

The complaint investigation focused on residents' concerns about wandering residents entering their rooms, using their belongings, and causing disturbances. The investigation found that the facility did not adequately follow up on these complaints or implement effective interventions. The grievance officer and staff acknowledged the issues but no formal grievance was created or resolved. The resident council minutes showed no documentation of follow-up or resolution. One resident filed five grievances about repeated intrusions and loss of personal property, with minimal improvement.

The inspection was conducted due to complaints regarding resident safety, wandering residents entering other residents' rooms, and concerns about abuse and infection control practices.

The facility failed to thoroughly investigate and resolve resident concerns about wandering residents entering rooms and taking belongings, failed to protect personal property from confused residents, did not properly report suspected abuse incidents, and had lapses in infection control practices including reuse of disposable razors and improper hand hygiene during wound care.

The investigation was complaint-driven based on resident complaints about wandering residents entering rooms, personal property being taken or damaged, and concerns about abuse and infection control.