Spearfish Canyon Healthcare

In the surveyor’s words

From the most serious findings on record at Spearfish Canyon Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 9, 2025

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, staff interview, and policy review, the provider failed to ensure an environment free of safety hazards for:*One of one sampled resident (4), who sustained a skin burn injury from hot liquid (broth) that was improperly prepared by cook (H) who did not follow the facility's established procedures for safe food preparation and service.*One of one sampled resident (1), who fell when CNA O assisted her to walk without the use of a gait belt.Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF576Feb 7, 2024

  Based on interview, and policy review, the provider failed to ensure mail delivery was available on Saturdays for all 67 residents residing in the facility. Findings include: 1. Interview on 2/6/24 at 9:00 a.m. with resident 19 revealed: *The facility's business office staff delivered resident mail Monday through Friday. -Resident mail was not delivered on Saturdays because there were no business office staff available to deliver it on that day. *There was no delivery of Saturday mail for as long as I can remember. Interview on 2/6/24 at 9:05 a.m. […]

• No harm, potential for more than minimal, patternF812Aug 28, 2025

  Based on observation, record review, interview, and policy review, the provider failed to ensure follow standard food safety practices to ensure:*One of one low-temperature dishwasher's temperature was consistently monitored and documented to ensure it met the required minimum wash temperature for sanitation of items used to prepare and serve food to the residents.Findings included:1. Observations on 8/26/25 at 10:32 a.m. and 10:37 a.m. in the kitchen revealed: *The logs for the dishwasher temperatures for August 2025 were hanging on the wall and included:-Columns to record Temp (temperature) for B (Breakfast), L (Lunch), and D (Dinner), Sanitizer Concentration (PPM) (parts per million), and Initials.-Those temperature columns had documented temperatures that ranged from 110 to 126 degrees… […]

• No harm, potential for more than minimal, patternF584Feb 7, 2024

  Based on observation, interview and policy review the provider failed to ensure: *One of one hallway (400) was maintained in a home-like environment. *One of one hallway (400) refrigerator was clean. *One of one carpet in the sunroom was maintained and clean. *One of one loveseat cushions in the sunroom was maintained and clean. *The faucet heads on the sinks in 34 out of 34 residents' rooms, on the green unit were maintained and clean. Findings include: 1. Observation on 2/6/24 at 11:32 a.m. of hallway 400 and the sunroom revealed: *There were multiple unused screw holes in the walls. […]

• No harm, potential for more than minimal, patternF880Feb 7, 2024

  Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were implemented to ensure the following: *One of two bath aides (O) had demonstrated effective cleaning of the whirlpool (WP) tub, air jets, and bath seat, in one of two sampled multi-use resident WP bathrooms. *Urine collection bags for three of six sampled residents (13, 25, and 54) were kept off of the floor and covered with a protection bag (dignity bag used to hold and protect urine collection bags). Findings include: 1. Observation and interview on 2/07/24 at 11:45 a.m. with bath aide O in the [NAME] hallway multi-resident use WP bathroom revealed: *She had already cleaned the WP tub but was willing to demonstrate her cleaning methods. […]