Aurora Brule Nursing Home Inc

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to thoroughly investigate an allegation of abuse involving one of one certified nursing assistant (CNA) (V) who threw an incontinence brief at one of one sampled resident (8), told him to do it yourself, and left him on the toilet without providing care. The provider's failure to conduct a thorough investigation placed the other residents at risk for abuse and neglect by not determining if similar incidents had occurred, or if additional residents were affected. The facility's census at the time of survey was 44.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure that required physician visits (every 30 days for the first 90 days after the resident's admission and every 60 days thereafter) were alternated between personal visits by the physician and by the physician assistant (PA) after the physician makes the initial comprehensive visit for residents under a SNF stay (skilled nursing care covered by Medicare part A) for four of four sampled residents (4, 8, 29, and 43) who had SNF stays at the facility in the period reviewed from 7/4/25 through 7/29/26.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to protect the residents' right to confidential personal medical information for two of two sampled residents (41 and 40) by one of one observed certified nurse aide (CNA) (S) who left residents' electronic medical records (EMR) information displayed on a computer screen mounted to the wall in the East hallway.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to protect the residents' right to be free from verbal and physical abuse for one of one sampled resident (8) who reported that he had an incontinence (involuntary urine or bowel leakage) absorbent brief thrown at him, was told to do it himself, and was left on the toilet without assistance by one of one certified nursing assistant (CNA) (V).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure an environment free of accident hazards for two of two sampled residents (29 and 43) who used electronic lift chairs in their rooms and were not assessed to determine the residents' ability to safely use those chairs independently, to mitigate the risk of accidents.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure medications were labeled and administered according to the physician's orders for one of one (25) sampled resident who was administered lorazepam (an antianxiety medication) by one of one observed certified nursing assistant (CNA)/medication aide (MA) (M) from a medication blister pack (pre-formed plastic and foil packages that hold individual doses of pills or capsules in separate small pockets) with labeled administration instructions that did not match the physician's order for that medication in the resident's electronic medical record (EMR).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure that the staff followed standard safe food service practices regarding handwashing and glove use when handling ready-to-eat (RTE) foods by one of one dietary aide (L) during one of two meals observed.

Inspectors wroteBased on record review and interview, the provider failed to ensure the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Centers for Medicare and Medicaid Services (CMS) Part A form (CMS-10055) was provided for two of three sampled residents ( 26 and 43) reviewed for notification of Medicare benefits ending or their representatives to inform residents of potential financial liability for non covered Skilled Nursing Facility (SNF) Part A services.

Inspectors wroteBased on interview, record review, resident admission packet review, and policy review, the provider failed to ensure the binding arbitration agreement forms provided to residents or their representatives for review and signature contained the required information for one of one sampled resident (25).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to identify necessary care interventions, ensure resident care plans had been reviewed and revised, to reflect the current needs for two of two sampled residents (7 and 15) who had fallen more than once.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure one of one certified medication aide (CMA) (K) followed accepted standards of practice and facility policy during medication administration that included:*Proper administration technique for two of two sampled resident's (11 and 13) eye drops.*Inquiring about and accurately recording pain level for one of one resident (13) receiving a scheduled pain medication.*Not returning two stock supply acetaminophen (a pain-relieving medication) tablets back into the bottle after being prepared for administration to resident (17).*Appropriately identifying and administering medications per physician orders according to the rights of medication administration.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (15) who was transferred without the use of a gait belt (a waist strap gripped as support for safe mobility and transfers) by five of five staff members (certified nursing assistant (CNA) M, administrator A, CNA N, certified medication aide (CMA) J, and registered nurse (RN) G) observed.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the medication error rate remained under 5%. Certified medication aide (CMA) K had three errors out forty-one total medication administration observations, including failing to verify resident physician orders with the medication prescription label, failing to document he had given a PRN (as needed) eyedrop medication, and preparing one sampled resident's (15) medications to administer to another sampled resident (39). This resulted in a calculated error rate of 7.3%.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow food safety standards by not having monitored and documented food temperatures for 29 of 153 meals served from 6/1/25 through 7/21/25, and not having stored applesauce at or below 40 degrees Fahrenheit for three sampled residents (9, 20, and 39) who were given applesauce with their medications administered by certified medication aide (CMA) (K).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow infection prevention and control processes to ensure:*Resident personal care products were properly stored and labeled in one of two resident shared bathrooms (shared by sampled residents 3, 16, 19, and 27) reviewed.*Staff (certified nursing assistant (CNA) M, certified medication aide (CMA) K, licensed practical nurse (LPN) H, and registered nurse (RN) G) performed proper hand hygiene and glove use during resident care activities for sampled resident 31, and medication administration for sampled residents 3, 6, 9, 11, 13, 17, 19, 20, 24, 39, and 46.*Proper cleaning and sanitizing of one of one mechanical lifts (a mechanical lift used to assist from a seated to standing position) used to transfer resident 31 to the toilet by CNAs M and R.*Contact precautions protocols were followed by one of [...]

Inspectors wroteBased on interview, record review, and policy review, the provider failed to provide documentation of a signed bed-hold notice from the resident and/or their responsible party regarding a transfer to the hospital for one of two sampled resident (7) who had transferred to the hospital.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of thirteen sampled residents (39) observed during medication administration observation were free from significant medication errors when certified medication aide (CMA) K would have administered the wrong resident's medications without surveyor intervention.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure insulin pens had pharmacy labels on them that included the required identifying and instructional information for one of three sampled resident (24) who used insulin.

Inspectors wroteBased on facility reported incident review, observation, interview, record review, facility elopement investigation review, and facility policy review, past noncompliance was confirmed for incident occurring 5/3/24.

Inspectors wroteSubstantial compliance was confirmed on 4/23/24 after record review revealed the facility had followed their quality assurance process; after the dietitian was contacted for acceptable hot beverage temperatures; after the hot beverage vender was contacted to lower the dispenser's temperature; after the dispensers were unplugged until the vender could arrive; after the facility created new policies and provided education to all staff regarding: acceptable hot beverage temperatures, monitoring of assisted dining, and first aid to a burn; after observations of residents and staff during the assisted dining meal service; after assisted dining residents were assessed for safety; after assisted dining resident interview confirming safety lids were provided and hot beverages were not served until staff were present; and after staff interviews confirming knowledge on the new policies.

Inspectors wroteBased on Certification and Survey Provider Enhanced Reports (CASPER) data review, observation, record review, interview, and policy review, the provider failed to ensure: *Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the appropriate care of the residents) data was accurately completed prior to submission to the Center for Medicare and Medicaid Services (CMS) for three of four federal fiscal quarters (Quarter 1, 2023; Quarter 2, 2023; and Quarter 4, 2023). *PBJ data was submitted to CMS for one of four federal fiscal quarters (Quarter 3, 2023).