Spearfish Canyon Healthcare

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, and interview, the provider failed to ensure one of one sampled resident (1) remained free from verbal abuse by one of one certified nurse aide (CNA) D.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure a homelike environment for one of one sampled resident (39) due to the noise level in his room and that one of one sampled resident (61) had a hand towel available to dry himself after he had used his handwashing sink.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to implement a process that ensured an accurate accounting of daily fluid intake for one of one sampled resident (4) on dialysis with a physician-ordered fluid restriction.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure:The whiteboard communication board in one of one sampled residents' rooms (61) was updated to reflect the amount and type of caregiver assistance required for him to safely transfer from his toilet to his wheelchair. The safety of one of one sampled resident (61) who was not transferred by one of one certified nurse aide (CNA) L as directed in the resident's care plan and the provider's huddle book (a communication tool that informs caregivers of residents' care needs), which may have increased his risk for falling and/or injury.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure two of two observed medication refrigerators had not contained expired vaccines that were available for administration to the residents.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were followed by:One of one observed certified medication aide (CMA) (M) who did not clean one of one sampled resident's (76) inhaler after it was used for medication administration. One of one observed certified nurse aide (CNA) (N) who did not complete hand hygiene (handwashing) during a transition in cleaning urine from the floor and handling one of one sampled resident's (63) catheter urine collection bag valve. One of one observed CNA (L) who had not reminded or assisted one of one sampled resident (61) to perform hand hygiene after he had used the bathroom.

Inspectors wroteBased 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.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation and policy review the provider failed to ensure the safety of one of one sampled resident (2) when the resident left the facility without staff knowledge or staff supervision (eloped). This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure one of one resident's (1) repositioning and incontinence care needs were being provided according to her plan of care. Failure to follow the plan of care for her repositioning and incontinence needs potentially placed resident 1 at a higher risk for discomfort, infection, and skin breakdown. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on review of provider's 4/24/24 South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure a thorough investigation was completed for one of one resident (1) who had a burn from hot coffee. 1. Review of provider's SD DOH FRI revealed the following: *On 4/24/24 resident 1 had a coffee burn from spilling her hot coffee on her lap at breakfast. *A certified nursing assistant (CNA) [D] alerted licensed practical nurse (LPN) C of the spill. *LPN C assessed the skin and noted redness and two small blisters to the right upper, inner thigh. CNA [D] stated that resident was in dining room for breakfast and resident spilled coffee in own lap. Review of resident 1's electronic medical record revealed the following: [...]

Inspectors wroteBased on interview, and policy review, the provider failed to ensure mail delivery was available on Saturdays for all 67 residents residing in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the following: *Four of four Resident Council members' (22, 28, 32, and 47) preference to have menu information posted was accommodated. *One of one sampled resident (33) had not received his requested food choice at meals.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the following: *One of one sampled resident (116) was provided timely incontinence care by one of one certified nurse aide (CNA) (P). *Physical therapy recommendations regarding bed mobility for one of one sampled resident (25) were followed by one of one activities director (H) and one of one CNA (N).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure one of one licensed practical nurse (LPN) (X) had removed and cleaned the nebulizer mask and the medicine reservoir when the treatment was completed for one of one sampled resident (33).

Inspectors wroteBased on interview, resident council minutes review, and policy review, the provider failed to ensure resident expressed concerns were thoroughly investigated including follow-up with complainants, and resolved as much as possible to everyone's satisfaction for six of six sampled residents.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure: *One of one certified nurse assistant (I) had not reused disposable razors on more than one resident. *One of one licensed practical nurse (F) had performed proper hand hygiene procedures during one of two observed wound care treatments.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure reasonable care for the protection of personal property from loss or theft by confused wandering residents for one of one sampled resident (62) who had created his own space.

Inspectors wroteBased on record review, interview, and policy review the provider failed to ensure two separate injuries to her arm(s) for one of one resident (9) were thoroughly investigated and documented as well as reported to the South Dakota Department of Health (SD DOH).