Inspection Results » Spearfish Canyon Healthcare

Health Inspection on February 7, 2019 ^[1]

1. Pattern: Actual harm that is not immediate jeopardy

   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2019-03-09)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2019-03-09)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-03-09)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-03-09)
   • Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. (Corrected 2019-03-09)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide and implement an infection prevention and control program. (Corrected 2019-03-09)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-03-09)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (Corrected 2019-03-09)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-03-09)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2019-03-09)
   • Post nurse staffing information every day. (Corrected 2019-03-09)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2019-03-09)
   • Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Corrected 2019-03-09)
   • Ensure that paid feeding assistants have the training they need. (Corrected 2019-03-09)
   • Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. (Corrected 2019-03-09)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2019-03-09)