Avera Rosebud Country Care Center
126 S Logan Ave, Gregory, SD 57533 · Gregory County · 30 certified beds · avg 28 residents/day · certified since Jul 1, 1975
Part of chain: AVERA HEALTH (13 facilities, chain avg rating 3.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (13)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 21, 2026 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 13, 2025 | E · Potential for harm, repeated | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 23, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | E |
| 2024 | 2 | 0 | D |
| 2025 | 5 | 0 | E |
| 2026 | 5 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.70 | 4.32 | 3.95 | top 3% in South Dakota; top 2% in the U.S. |
| Registered Nurse hours | 1.31 | 0.91 | 0.69 | top 10% in South Dakota; top 7% in the U.S. |
| Weekend total nurse staffing | 5.99 | 3.71 | 3.50 | top 3% in South Dakota; top 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.56 | 0.51 | 0.48 | top 34% in South Dakota; top 26% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 48.2 | 45.8 | — |
| RN turnover (%) | 0.0 | 34.7 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.39, RN 1.05, weekend 4.82. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Avera Health | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/12/1992 |
| Abourezk, Sanaa | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Avera Health | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2000 |
| Bartling, Melissa | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2006 |
| Bartling, Melissa | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2006 |
| Boschee, Ryan | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Bunkers, Jennifer | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Chrystal, Candyce | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Costello, Joseph | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Curran, Mary | Individual | Corporate Director | NOT APPLICABLE | 07/01/2018 |
| Dover, James | Individual | Corporate Director | NOT APPLICABLE | 10/23/2023 |
| Fishback, Van | Individual | Corporate Director | NOT APPLICABLE | 07/01/2018 |
| Hill Jensen, Cristina | Individual | Corporate Director | NOT APPLICABLE | 07/01/2018 |
| Kirby, Jennifer | Individual | Corporate Director | NOT APPLICABLE | 07/01/2020 |
| Knecht, Randy | Individual | Corporate Director | NOT APPLICABLE | 07/01/2018 |
| Lautt, Julie | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2020 |
| Lautt, Julie | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2020 |
| Nazir, Jawad | Individual | Corporate Director | NOT APPLICABLE | 07/01/2020 |
| Place, Ronald | Individual | Corporate Officer | NOT APPLICABLE | 06/05/2023 |
| Place, Ronald | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/05/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Winner Regional Healthcare Center | 23.4 mi | Winner, SD | ★☆☆☆☆ | 1/5 | abuseSFF |
| Platte Care Center | 31.3 mi | Platte, SD | ★★★★★ | 4/5 | |
| Sanford Chamberlain Care Center | 38.9 mi | Chamberlain, SD | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435029.