7Risk Axes

National percentile · lower = less risk · staffing gap is context only (not in composite)

How we calculate
SeverityElevated

90th national percentile — 14.7% high-severity citations

ChronicityElevated

80th national percentile — 11 repeat citations

Staffing integrityClean

None on file

Fire safetyWatch

3 citations

Weekend staffing dropElevated

91th national percentile — 22.8%

Contract staff shareElevated

82th national percentile — 10.4%

Clinical trendModerate

38th national percentile — 1/5 measures worsened

Staffing gapWatch

Reported 3.30 vs expected 3.54 · −0.24 hr/res/day

Recent Health Violations

Health inspection citations from official Medicare records

34 citations on file
F-0880
E
Provide and implement an infection prevention and control program
Potential Harm

Provide and implement an infection prevention and control program.

Survey date: Feb 12, 2026 · Pattern — no actual harm with potential for more
F-0727
F
Have a registered nurse on duty 8 hours a day; and select a registered …
Potential Harm

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.

Survey date: Feb 12, 2026 · Widespread — no actual harm with potential for more
F-0761
E
Ensure drugs and biologicals used in the facility are labeled in accorda…
Potential Harm

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.

Survey date: Feb 12, 2026 · Pattern — no actual harm with potential for more
F-0554
D
Allow residents to self-administer drugs if determined clinically approp…
Minimal Harm

Allow residents to self-administer drugs if determined clinically appropriate.

Survey date: Feb 12, 2026 · Isolated — no actual harm with potential for more

Recent Fire Safety Violations

Fire safety inspection citations from official Medicare records

3 citations on file
F-0004
C
Develop and maintain an Emergency Preparedness Program (EP)
Minimal Harm

Develop and maintain an Emergency Preparedness Program (EP).

Survey date: Oct 17, 2024 · Widespread — no actual harm
F-0039
C
Conduct testing and exercise requirements
Minimal Harm

Conduct testing and exercise requirements.

Survey date: Oct 17, 2024 · Widespread — no actual harm
F-0712
C
Have simulated fire drills held at unexpected times
Minimal Harm

Have simulated fire drills held at unexpected times.

Survey date: Sep 27, 2023 · Widespread — no actual harm

Better Nearby Options

Within 25 km · sorted by overall risk percentile

Full nearby list
Facility
CMS
Risk %ile
Tier
SPEARFISH CANYON HEALTHCARE
17.4 km · SPEARFISH, SD
★★
CMS
71th
Risk %ile
Higher risk