Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spearfish Canyon Healthcare during CMS and state inspections, most recent first.
A CNA verbally abused a cognitively impaired resident with dementia and anxiety during morning walking rounds when the resident asked for assistance, responding with an expletive-laden statement and refusing help. Another CNA intervened by assisting the resident back to her room and directing the abusive CNA to leave. The involved CNA had prior training on abuse/neglect, residents' rights, and the facility's grievance policy, and maintained a current CNA certification with a clear background check, yet still engaged in this verbally abusive interaction, leading to a deficiency at F600.
The facility did not consistently monitor or document the low-temperature dishwasher's wash temperatures, resulting in multiple instances where the required minimum of 120°F was not met and numerous undocumented temperature checks. Staff, including the dietary supervisor and maintenance technician, were unaware of the ongoing issue, and the facility's policy for dishwasher sanitation was not followed.
Two residents experienced deficiencies in their environment: one was not consistently provided with preferred cloth towels for handwashing, despite requests, and another was subjected to loud, disruptive noise from bulk oxygen tanks outside his room, which aggravated his anxiety and disturbed his daily activities. Staff were largely unaware of the impact of these issues, and facility policies regarding clean linens and comfortable sound levels were not followed.
A resident on dialysis with a physician-ordered fluid restriction was found with multiple bottled waters and sodas in her room, and her daily fluid intake was not being tracked or calculated as required. Staff did not consistently remove excess fluids from her room, and the fluid restriction order was not added to the TAR, resulting in a failure to monitor and enforce the prescribed fluid limit.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment was not maintained to minimize risks, and supervision protocols were insufficient.
Expired influenza and pneumococcal vaccines were found in two medication room refrigerators, with staff interviews revealing confusion about who was responsible for checking and removing expired medications. Both nursing staff and the DON were unaware of the expired vaccines, despite facility policy requiring proper storage and disposal.
Surveyors identified infection control deficiencies when a CMA failed to clean an inhaler after use, a CNA did not change gloves or perform hand hygiene between cleaning urine and handling a catheter bag valve, and another CNA did not remind a resident to wash hands after bathroom use. Facility policies for glove use and resident hand hygiene were also lacking.
Two residents experienced preventable injuries when staff failed to follow established safety procedures: one resident suffered a burn from hot broth that was not prepared according to safe temperature protocols, and another resident fell and sustained skin tears when a CNA assisted her without using a gait belt as required by her care plan. Both incidents involved staff not adhering to facility policies designed to prevent accidents.
A resident on comfort care with a pending hospice referral and a urinary tract infection did not receive necessary repositioning and incontinence care during a night shift. The CNA responsible admitted to not providing the care, leading to the resident being found in a urine-saturated brief and linens, potentially increasing the risk of discomfort, infection, and skin breakdown.
A resident with cognitive impairment and tremors sustained a burn from spilling hot coffee. The investigation was incomplete, lacking witness statements and clear documentation. The provider's policies on incident investigation were not adequately followed, leading to the deficiency.
Verbal Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
Non-compliance at F600 occurred when a CNA verbally abused a resident during morning walking rounds. At approximately 6:30 a.m., two CNAs were conducting bedside handoff rounds on the 400 Hall when the resident exited her room and asked for assistance. In response, CNA D told the resident, "I don't have time for your [expletive word]." This interaction was witnessed by CNA C and other staff members nearby, who confirmed hearing the verbal exchange. CNA C then intervened by assisting the resident back into her room and directing CNA D to leave the facility. The resident involved had been admitted with diagnoses including dementia with behavioral disturbances and anxiety, and a BIMS score indicating moderately impaired cognition. At the time of the surveyor’s observation months later, the resident was asleep and unable to be interviewed. CNA D’s personnel file showed she had received education on abuse/neglect reporting, residents’ rights, and the facility’s grievance policy at hire, had signed understanding of the abuse policy, and had a current CNA certification and a clear background check. Despite this training and background, CNA D engaged in verbally abusive conduct toward the resident, resulting in the cited deficiency for failure to ensure the resident remained free from verbal abuse.
Failure to Consistently Monitor and Document Dishwasher Temperatures
Penalty
Summary
The facility failed to ensure that standard food safety practices were followed regarding the monitoring and documentation of the low-temperature dishwasher's wash temperature. Observations revealed that the dishwasher temperature logs for two consecutive months showed multiple instances where the recorded wash temperatures were below the required minimum of 120 degrees Fahrenheit, with thirty-six low readings in August and five in July. Additionally, there were numerous undocumented temperature checks, with forty-one missing entries out of ninety-three opportunities in July. Staff interviews confirmed that the dietary supervisor was unaware of the low temperature readings and had not checked the logs due to being preoccupied with training new staff. The dietary aide reported needing to run the dishwasher multiple times before reaching the required temperature, and the maintenance technician was not previously informed of the issue and had not performed recent maintenance on the dishwasher. The administrator was also unaware of the dishwasher's low wash temperature readings and expected kitchen staff to notify the dietary supervisor of any issues. The facility's policy required a minimum wash temperature of 120 degrees Fahrenheit for low-temperature dishwashers, but this standard was not consistently met or documented. There were no reports of gastrointestinal outbreaks at the time of the survey. The deficiency was identified through observation, record review, and staff interviews, which demonstrated a lack of consistent monitoring and documentation of dishwasher temperatures as required by facility policy.
Failure to Provide Homelike Environment Due to Noise and Linen Preferences
Penalty
Summary
The facility failed to ensure a homelike environment for two residents due to issues with noise levels and the availability of preferred linens. For one resident, staff did not consistently provide a clean washcloth and hand towel on the towel rack for use after handwashing, despite repeated requests from the resident and his spouse. The resident was able to use the handwashing sink independently and preferred cloth towels over paper towels, as was his custom at home. Observations confirmed that a used washcloth remained on the sink countertop for an extended period, and no clean cloth towels were provided, contrary to the facility's policy to maintain clean bed and bath linens. Another resident was exposed to loud, intermittent hissing noises from bulk oxygen tanks placed directly outside the wall of his room. The noise from the tanks' pressure release was significant enough to interrupt conversations, television viewing, and the resident's ability to listen to books on tape. The resident, who had a history of generalized anxiety disorder, PTSD, and other mental health conditions, reported that the noise startled him, increased his anxiety, and disturbed his sleep. Staff interviews revealed a lack of awareness regarding the impact of the noise on the resident, and the tanks had been in that location since before the resident's admission. The facility's policy defined a homelike environment as one with comfortable sound levels and the provision of clean linens. In both cases, the facility did not meet these standards, as the resident's preferences for linens were not accommodated and the noise from the oxygen tanks created an uncomfortable and disruptive environment.
Failure to Monitor and Enforce Fluid Restriction for Dialysis Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a process to ensure accurate accounting of daily fluid intake for a resident on dialysis with a physician-ordered fluid restriction. The resident had a documented order limiting fluid intake to 1500 cc per day, with specific allocations for dietary and medication administration. During observation, the resident was found with multiple bottled waters, a six-pack of soda, and a lidded cup of water in her room, and was seen drinking from one of the bottles. The resident confirmed she had been advised by her medical provider to limit fluid intake. Staff interviews revealed that while the resident was listed as having a fluid restriction in the huddle book, excess fluids were not consistently removed from her room, particularly after returning from dialysis when unused bottled water was brought back and left in her room. Further review showed that the resident's fluid restriction order had not been added to her treatment administration record (TAR), and her daily fluid intake was not being calculated or monitored as required. The facility's policy stated that fluid intake should be recorded on the medication record and that water should not be provided at the bedside unless included in the daily restriction or specifically ordered. The director of nursing acknowledged that the facility's processes for tracking and limiting the resident's fluid intake were not followed, and unnecessary fluids were not removed from the resident's room.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Expired Vaccines Found in Medication Refrigerators
Penalty
Summary
Surveyors observed that two medication room refrigerators contained expired vaccines, including influenza and pneumococcal 13-valent vaccines. Specifically, ten expired influenza vaccines and one expired pneumococcal vaccine were found in one refrigerator, while three expired influenza vaccines and one expired pneumococcal vaccine were found in another. Staff interviews revealed confusion and lack of clarity regarding responsibility for checking and removing expired vaccines. One RN believed night staff were responsible, while an LPN thought the pharmacist checked for expired medications monthly and was unaware of the expired vaccines' presence. The DON was also unaware of the expired vaccines and stated that the consultant pharmacist was expected to check for expired medications monthly, but all staff administering vaccines should have checked expiration dates. Facility policy required staff to store, administer, and discard pharmaceuticals according to procedures, including sending expired medications for destruction. Despite these policies, expired vaccines remained accessible in the medication refrigerators, available for administration to residents.
Infection Control Lapses in Medication Administration, Catheter Care, and Resident Hand Hygiene
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices among staff. A certified medication aide (CMA) administered medication to a resident using an inhaler and returned the uncleaned inhaler to its box in the medication cart, despite acknowledging that the mouthpiece should have been cleaned with an alcohol pad after use. The inhaler was stored with other residents' medications, increasing the risk of cross-contamination. Additionally, a certified nurse aide (CNA) was observed cleaning urine from the floor and then, without changing gloves or performing hand hygiene, adjusted a resident's urinary catheter bag valve before resuming cleaning. The CNA admitted uncertainty about when to change gloves and perform hand hygiene, and agreed that his actions increased the resident's risk of infection. Another CNA assisted a resident after bathroom use but did not remind or assist the resident to perform hand hygiene, even though the resident was capable of independently washing his hands but did not always remember to do so. The CNA acknowledged the importance of resident hand hygiene after bathroom use. The facility's policies on metered-dose inhaler administration and hand hygiene were reviewed and found to require cleaning and hand hygiene in the situations observed, but there were no facility policies for glove use or resident hand hygiene.
Failure to Prevent Accidents Due to Unsafe Hot Liquid Handling and Omission of Gait Belt Use
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent avoidable accidents for two residents. In one incident, a resident sustained a burn injury to her right leg after spilling hot broth that had been improperly prepared by a new cook who did not follow the facility's established procedures for safe food preparation and service. The cook used water from a stovetop kettle instead of the coffee machine, which is calibrated to maintain a safer temperature, and did not check the temperature of the broth before it was delivered to the resident's room. The resident, who had a history of left hip fracture, transient ischemic attack, macular degeneration, and tremor, was found with redness and later a blistered area on her right thigh after the spill. In a separate incident, another resident fell while being assisted back from the bathroom by a CNA who failed to use a gait belt, contrary to the resident's care plan and facility policy. The resident, who had a history of osteoporosis, multiple lumbar compression fractures, and moderate cognitive impairment, was identified as being at risk for falls and required assistance with transfers and ambulation using a front-wheeled walker and a gait belt. During the incident, the CNA applied the resident's TLSO brace but did not use a gait belt, and the resident was guided to the floor after reporting weakness in her knees. The resident sustained skin tears during the assisted fall. Both incidents involved staff not adhering to established facility policies and procedures designed to prevent accidents and injuries. The first incident resulted from a failure to follow safe food handling protocols for hot liquids, while the second incident was due to the omission of a required safety device during resident transfer. These actions directly contributed to the residents' injuries and represented a failure to maintain a safe environment as required by facility policy.
Failure to Provide Repositioning and Incontinence Care
Penalty
Summary
The provider failed to ensure that a resident's repositioning and incontinence care needs were met according to her plan of care. At the time of the incident, the resident was on comfort care with a pending hospice referral, incontinent of urine, and unable to reposition herself without staff assistance. She also had a urinary tract infection with pending lab results and anticipated antibiotic treatment orders. On the morning of the incident, a bath aide found the resident lying in bed with a urine-saturated incontinence brief and linens. The certified nursing assistant responsible for the resident's care admitted during the investigation that he had not provided the necessary repositioning or incontinence care during his night shift. This lack of care potentially placed the resident at a higher risk for discomfort, infection, and skin breakdown. The incident was identified during a facility-reported incident review by the South Dakota Department of Health, which included observations, interviews, and record reviews.
Failure to Conduct Thorough Investigation of Resident's Burn Incident
Penalty
Summary
The provider failed to ensure a thorough investigation was completed for a resident who sustained a burn from spilling hot coffee. The incident occurred when the resident, who had cognitive impairment and tremors, spilled coffee on her lap during breakfast. A CNA alerted an LPN, who assessed the resident and noted redness and blisters on her thigh. However, the investigation lacked statements from individuals who may have had knowledge of the event, and there was confusion about who initially reported the incident. The resident's medical record indicated she was not at risk for spilling hot liquids, but a subsequent evaluation revealed she had cognitive impairment and tremors, necessitating the use of a cup with a lid and drinking hot liquids at a table only. Interviews with the DON, LPN, and CNA revealed inconsistencies and gaps in the investigation process. The CNA could not recall who informed her of the spill, and the LPN was unsure about the identity of the CNA who reported the incident. The provider's policies on abuse, neglect, and incident investigation were not adequately followed, as the investigation did not include comprehensive documentation or witness statements. The lack of a thorough investigation and clear documentation led to the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spearfish
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rolling Hills Healthcare | 10.8 mi | ★★★★★ | 12 | 0 |
| Monument Health Sturgis Care Center | 17.9 mi | ★★★★★ | 4 | 0 |
| Crook County Medical Services District Long Term C | 26.8 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - St Martin Village | 38.2 mi | ★★★★★ | 3 | 0 |
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