Avera Rosebud Country Care Center
Gregory, South Dakota · CCN 435029
12 surveys since 2011, 2 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 38
- Surveys
- 12
- Harm or worse
- 2
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 30
- Ownership
- Non profit - Corporation
- Chain
- AVERA HEALTH
- County
- Gregory · rural
- Medicare-certified since
- 1975
CMS ratings
- Overall
- 4
- Health inspection
- 4
- Staffing
- 4
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=14, floor 20).
Last survey on record
May 21, 2026
172 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 5.39 | 3.73 |
| Registered-nurse hours per resident day | 1.05 | — |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D861.5% | E538.5% | F— |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F5822×
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- F5541×
Allow residents to self-administer drugs if determined clinically appropriate.
- F5781×
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- F6091×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F6101×
Respond appropriately to all alleged violations.
In the surveyor’s words
From the most serious findings on record at Avera Rosebud Country Care Center, in the surveyor’s own words.
- Actual harm, isolatedF684Aug 25, 2022
Based on observation, interview, record review, and policy review, the provider failed to: *Provide timely notification to one of one sampled resident's (8) primary care provider as the initial burn injury evolved. *Follow their policies and procedures regarding wound assessments. *Provide timely investigation of and notification of resident injury to South Dakota Department of Health. Findings include: 1. Observation and interview on 8/24/22 at 11:20 a.m. with registered nurses (RN) G and H during a wound dressing change for resident 8 revealed: *She had a burn wound on the outside of her left mid-thigh. *The burn wound edges were raised and white in color, with depression noted in the middle of the burn wound. […]
- No harm, potential for more than minimal, patternF655Feb 13, 2025
Based on record review, interview, policy review, the provider failed to ensure seven of twelve sampled residents (1, 22, 23, 26, 80, 81, and 130) or their representatives had received a summary of their baseline care plan within 48 hours. Findings include: 1. Record review of resident 22's paper medical record (PMR) revealed: *She had been admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 12 which indicated moderate cognitive impairment. *There was no documentation in her PMR that indicated a baseline care plan summary had been provided to the resident or the resident's representative. -Her current medication list was provided to her on 10/29/24. *Her representative was her son. 2. […]
- No harm, potential for more than minimal, patternF658Feb 13, 2025
Based on observation, interview, and policy review, the provider failed to ensure proper medication preparation for three of three residents (13, 19, and 21) by one of one licensed practical nurse (LPN) (I) who prepared their medications and stored them to administer to the residents later. Findings include: 1. Observation and interview on 2/12/25 at 11:27 a.m. with LPN I at a medication (med) cart revealed: *He had dispensed resident 13, 19, and 21's medications into white paper medication cups and did not label them to identify which resident's meds were in each cup. *He left resident 13's medications on top of the med cart and then placed resident 19 and 21's medications in the top drawer of the cart and shut the drawer. […]
- No harm, potential for more than minimal, patternF812Feb 13, 2025
Based on observation, record review, interview, and policy review, the provider failed to ensure one of two mechanical dishwashers that used high temperature sanitizing met the required minimum wash and rinse temperatures. Findings include: 1. Observation on 2/11/25 at 8:36 a.m. of the long-term care (LTC) kitchenette revealed: *The mechanical dishwashing machine had a label that revealed HOT WATER SANITIZING: -WASH TEMPERATURE 150 [degrees] F [Fahrenheit] MIN [minimum]. -RINSE TEMPERATURE 180 F MIN. *Posted on the door of the reach-in refrigerator was the February 2025 Dishmachine Temperature Record that included: -Columns to record the Start Wash/rinse and Finish Wash/rinse for each of the three mealtimes Breakfast, Lunch, and Supper. -Each column had two recorded temperatures. […]
- No harm, potential for more than minimal, patternF909Feb 13, 2025
Based on observation, interview, record review, and policy review, the provider failed to assess grab bars for safety for four of four sampled residents (8, 26, 1, and 15) who had grab bars on their beds. Findings include: 1. Observation on 2/11/25 at 8:53 a.m. of resident 8's room revealed grab bars were on both sides of the bed. Review of resident 8's electronic medical record (EMR) revealed: *She had a Brief Interview for Mental Status (BIMS) assessment score of 5 which indicated she had severe cognitive impairment. *A device evaluation for her use of grab bars was last completed on 8/1/2024. -She utilized the right and left grab bars for turning and repositioning while in bed. […]
Read 21 findings in full →The most serious and the most recent: 21 of 38 on record.
Every survey on record
FindingsAt actual harm or above
- May 21, 2026Standard5 findings
- Feb 13, 2025Standard5 findings
- Jan 23, 2024Complaint2 findings
- Oct 26, 2023Standard1 finding
- Aug 25, 2022Standard1 finding · 1 harm
- Jan 29, 2020Standard1 finding
- Dec 19, 2018Standard3 findings
- May 26, 2016Standard1 finding
Show the 4 earlier surveys
- Jul 15, 2015Standard2 findings
- May 21, 2014Standard9 findings
- Apr 24, 2013—3 findings
- Mar 2, 2011—5 findings · 1 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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