Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avera Rosebud Country Care Center during CMS and state inspections, most recent first.
A resident with intact cognition and orders for Ventolin via nebulizer was observed self-administering her treatment without staff present. The EMR had no completed medication self-administration assessment and no physician order authorizing self-administration, and an RN stated the resident was okay to give it to herself despite the facility policy requiring both an assessment and provider order.
Advance Directive and Code Status Not Properly Documented: A resident's chart lacked a current advance directive addressing code status, and no physician order was present. Although a living will was scanned into the EMR, it did not address resuscitation wishes. Staff relied on a posted sheet, chart stickers, and a CNA care plan book, but the resident's records contained conflicting code status information, including DNR/DNI on the unit sheet and Full Code on a chart form, which the DPCS acknowledged.
Failure to Provide NOMNCs to Two Residents Two residents whose Medicare Part A skilled services were ending while they remained in the facility did not receive the required NOMNC. The SWD stated he was unaware the notices were needed, and the SWC said her quarterly review with him focused on discharge planning and did not include when NOMNCs should be issued.
Nebulizer infection control practices were not followed for two residents receiving scheduled treatments. One resident with SOB, wheezing, and OSA and another resident with COPD were observed with nebulizer mouthpieces and reservoirs left wet, uncovered, or with visible moisture on the bedside table. RN C acknowledged forgetting to clean one resident's nebulizer after treatment, and the facility policy required rinsing after each treatment and washing all components every 24 hours.
Urinary catheter bags for a resident with a kidney transplant, CKD, and urinary retention were observed stored in the resident’s bathroom shower without caps over the tubing connectors and without dates showing when they were last used. One bag was on a shower bench and another was hanging on a handrail near a toilet, and a syringe used for cleaning was also present. Staff and the IP confirmed that an uncapped bag stored next to a toilet would be considered contaminated, and the facility policy did not clearly define when the cleaning syringe should be changed or who should do it.
The facility failed to provide baseline care plan summaries to seven residents or their representatives within 48 hours of admission. Record reviews and interviews revealed missing documentation and signatures in the care plans, and staff admitted to being unaware of the requirement. The facility's policy mandates timely development and communication of care plans, which was not followed.
An LPN failed to properly prepare medications for three residents by dispensing them into unlabeled cups and storing them for later administration. The LPN confirmed using a personal system for administering medications without confusion, despite the facility's policy against such practices. The DON had previously addressed the issue with the LPN, but was unaware of the lack of labeling.
A long-term care facility failed to ensure its mechanical dishwasher met required sanitization temperatures. Observations showed the dishwasher consistently failed to reach the minimum wash and rinse temperatures. Interviews revealed a lack of awareness and communication among staff, and inadequate policies contributed to the issue. Maintenance efforts were insufficient, leading to dishes being transported to the main kitchen for proper sanitization.
The facility failed to assess the safety of grab bars for residents with cognitive impairments, who used them for mobility and repositioning. Device evaluations were outdated or incomplete, and maintenance had not conducted necessary safety assessments. Observations showed many beds with grab bars in the up position, indicating a widespread issue.
A resident was not provided with a Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) form after their Medicare Part A Skilled Services Episode ended. The social services designee was unaware of the requirement and believed the necessary notice had been completed. A consultant confirmed the oversight.
Failure to Complete Self-Administration Assessment and Obtain Order for Nebulizer Use
Penalty
Summary
The provider failed to ensure that resident 21’s medication self-administration assessment was completed and that a physician’s order was obtained before she self-administered nebulizer medication. During observation, the resident was seen in her room with a nebulizer machine on her nightstand and later was observed holding the nebulizer mouthpiece in her mouth while the machine was running, with no staff present in the room or hallway to monitor the medication administration. When interviewed, an RN stated the resident was okay to give it to herself. Review of the resident’s EMR showed she was admitted with diagnoses including shortness of breath, wheezing, and obstructive sleep apnea, and her BIMS score was 15, indicating intact cognition. She had a physician order for Ventolin 2.5 mg via nebulizer three times daily, but there was no completed medication self-administration assessment in the record and no physician order authorizing her to self-administer the nebulizer medication. The DPCS stated she expected both the assessment and a physician order to be documented and acknowledged that the facility’s medication self-administration policy was not followed.
Advance Directive and Code Status Not Properly Documented
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was included in the medical record after admission. Review of the electronic medical record for the resident showed that a living will had been scanned into the chart, but it did not address resuscitation status, and there was no physician order documenting code status. The EMR banner displayed "Resuscitation status not ordered," indicating that the resident's code status had not been formally entered in the record. Additional record review and staff interviews showed conflicting information about the resident's code status. A paper sheet posted at the nurses' station listed the resident as DNR/DNI, and the outside of the paper chart had a red DNR/DNI sticker. However, inside the chart, a Patient Evacuation Form listed "Code Status Full Code." The DPCS stated that the resident was full code because the medical POA had not decided the resident's code status, and acknowledged that the living will did not address resuscitation status and that no physician order specified code status. She also acknowledged that the posted sheet and chart form contained conflicting information that would be confusing to staff if life-saving measures were needed.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The provider failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) was given to two sampled residents whose Medicare-covered skilled services were ending while they still had remaining Medicare benefit days and remained in the facility. Resident 19’s CMS SNF Beneficiary Notification Review form showed a Medicare Part A skilled services episode start date of 10/28/25 and a last covered day of 12/31/25, but he was not given the NOMNC. Resident 21’s CMS SNF Beneficiary Notification Review form showed a Medicare Part A skilled services episode start date of 12/9/25 and a last covered day of 1/15/26, but she was also not given the NOMNC. During interview, the social worker designee stated he was unaware that residents 19 and 21 should have received the NOMNC, and the social worker consultant stated she met quarterly with him to review resident items but did not discuss when NOMNC forms should be provided.
Nebulizer Components Left Wet and Uncovered After Treatments
Penalty
Summary
Infection control practices were not followed for the cleaning of nebulizers for two residents who received scheduled nebulizer treatments. Resident 21, who had diagnoses of shortness of breath, wheezing, and obstructive sleep apnea and a BIMS score of 15, was observed with a nebulizer machine on her nightstand with the tubing and mouthpiece connected and the medication reservoir appearing wet; the mouthpiece was lying directly on the nightstand, uncovered. She stated she received three nebulizer treatments a day and that staff sometimes disconnected the nebulizer to clean it, and that staff usually took the medication reservoir to the bathroom and rinsed it out before giving her treatment. Resident 8, who had COPD and a BIMS score of 9, was observed with a nebulizer machine and attached mouthpiece lying on his bedside table, and the medication reservoir had multiple small wet spots and a mist film inside. He stated he received two nebulizer treatments a day, and staff cleaned the nebulizer components but he was unsure how often they were cleaned during the day. RN C stated she had forgotten to return to resident 8's room to clean the nebulizer components after his morning treatment, and that after each use the mouthpiece, extender, and medication reservoir should be cleaned. The provider's updated May 2026 nebulizer policy stated the components should be rinsed after each treatment, placed on a clean towel and covered with a clean paper towel, and washed with soap and water every 24 hours.
Urinary Catheter Bags Stored Uncapped in Bathroom
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when urinary catheter bags for one resident were observed stored in the resident’s bathroom shower without the catheter tubing connector capped. On 5/19/26, surveyors observed in Resident 31’s bathroom a urinary catheter bag placed on a towel on the shower bench and another hanging on a handrail in the shower stall; neither bag was labeled with the date last used, and neither had a cover over the catheter tubing connector. A plastic container with a syringe dated 1/19/26 was also observed next to the bag on the bench. The same two urinary catheter bags were observed in the same positions on 5/20/26. Resident 31 was admitted to the facility with a BIMS score of 15, indicating intact cognition, and had diagnoses including a kidney transplant, chronic kidney disease, and urinary retention requiring a urinary catheter. His care plan directed staff to change the urinary catheter monthly and clean the catheter and measuring devices per facility policy. Staff interviews indicated they were expected to clean urinary catheter bags with a syringe filled with a vinegar mixture, change syringes once per week, label the syringes with the date, resident name, and room number, and place a cap over the open end of the tubing after cleaning. The infection preventionist and DPCS both acknowledged that a urinary catheter bag without a tubing cap stored next to a toilet would be considered contaminated, and they also acknowledged the policy did not clearly state when the syringe used to clean the catheter tubing or bag should be changed or who was expected to perform those tasks.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that seven out of twelve sampled residents or their representatives received a summary of their baseline care plan within 48 hours of admission. This deficiency was identified through record reviews and interviews, revealing that residents with varying levels of cognitive impairment, as indicated by their BIMS scores, did not have documentation in their paper medical records (PMRs) showing that a baseline care plan summary was provided. For instance, Resident 22, with a BIMS score of 12, and Resident 130, with a BIMS score of 10, both lacked documentation of receiving a baseline care plan summary. Further investigation showed that the interdisciplinary team members did not sign the baseline care plans for some residents, and there were missing pages in the baseline care plan forms, which included areas for signatures and documentation of the baseline completion date. Interviews with residents and staff, including the MDS Coordinator and the Director of Nursing, confirmed that the facility did not provide a written summary of the baseline care plan to residents or their representatives within the required timeframe. The MDS Coordinator admitted to being self-taught and unaware of the requirement to provide the baseline care plan summary within 48 hours of admission. The facility's policy, which mandates the development of a baseline care plan within 48 hours to ensure continuity of care and communication, was not adhered to. The policy also requires that the baseline care plan include initial goals, medication summaries, dietary instructions, and other essential information, which was not consistently documented or communicated to residents and their representatives. This lack of compliance with the policy and regulatory requirements led to the identified deficiency.
Improper Medication Preparation by LPN
Penalty
Summary
The provider failed to ensure proper medication preparation for three residents by an LPN who dispensed medications into unlabeled paper cups and stored them for later administration. During an observation, the LPN was seen placing medications for three residents into white paper medication cups without labeling them to identify which resident's medications were in each cup. The LPN left one resident's medications on top of the medication cart and placed the other two residents' medications in the top drawer of the cart. The LPN confirmed that he did not dispense and prepare the residents' medications individually and stated that he had a system for administering the medications later without confusion. The director of nursing (DON) revealed that she had previously spoken to the LPN about the improper practice of setting up medications in advance and that he was aware it was not allowed. However, she was not aware that the LPN did not label the medication cups. The facility's medication policy, revised in October 2023, clearly states that medications should not be routinely set up in cups and stored for later administration. The policy also emphasizes the importance of the five rights of medication administration, which the LPN failed to adhere to.
Dishwasher Temperature Deficiency in LTC Facility
Penalty
Summary
The deficiency involves the failure of a long-term care facility to ensure that one of its mechanical dishwashers met the required minimum wash and rinse temperatures for proper sanitization. Observations revealed that the mechanical dishwasher in the LTC kitchenette consistently failed to reach the minimum wash temperature of 150 degrees Fahrenheit and the minimum rinse temperature of 180 degrees Fahrenheit. Recorded temperatures from the Dishmachine Temperature Record showed numerous instances where both wash and rinse temperatures were below the required levels, indicating a persistent issue with the dishwasher's performance. Interviews with food service staff, including the food service manager and workers, highlighted a lack of awareness and communication regarding the dishwasher's temperature deficiencies. The food service manager expressed surprise that the issue had not been reported, despite staff acknowledging that the dishwasher often failed to reach the necessary temperatures. Maintenance personnel were involved in attempts to address the problem, but the dishwasher continued to operate below the required standards, with staff resorting to transporting dishes to the main kitchen for proper sanitization. The facility's policies and procedures regarding dishwasher temperature monitoring were found to be inadequate. The February 2025 Dishwasher Temperature Policy was vague and lacked specific guidance on minimum temperature requirements, contributing to the ongoing issue. Additionally, the facility's records for previous months showed a significant percentage of recorded temperatures that did not meet the required standards, further indicating a systemic problem with the facility's dishwashing and sanitization processes.
Failure to Assess Safety of Grab Bars for Residents
Penalty
Summary
The provider failed to assess the safety of grab bars for four residents who had them installed on their beds. Observations and interviews revealed that these residents, who had varying degrees of cognitive impairment, used the grab bars for mobility and repositioning. However, there was no documentation of assessments to determine the safe use or measurement of the grab bars for any of these residents. The device evaluations for the use of grab bars were outdated or incomplete, with the last assessments conducted months prior to the survey. Interviews with the Director of Nursing and a registered nurse confirmed that device evaluations for the safe use of grab bars were supposed to be completed every 90 days, but they had not been conducted. Additionally, the facility's maintenance department had not completed measurement assessments for the safe use of grab bars for any resident. Observations showed that a significant number of resident beds had grab bars in the up position, indicating a widespread issue. The facility's policies on restraints, entrapment, and preventative maintenance were reviewed, highlighting the importance of ensuring equipment safety for residents.
Failure to Provide Timely Medicare Non-coverage Notice
Penalty
Summary
The provider failed to ensure that appropriate and timely Medicare notices were provided to a resident who was discharged from skilled services. Specifically, the resident's Medicare Part A Skilled Services Episode began on September 2, 2024, and the last covered day was November 13, 2024. However, the resident was not given a Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) form and remained in the facility. The social services designee, who was hired on September 11, 2023, was unaware that the resident should have been provided with the SNF ABN form and mistakenly believed that the Notice of Medicare Non-coverage form had been completed for the resident. A licensed social service consultant confirmed that the SNF ABN form was not provided to the resident, acknowledging that it should have been.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gregory
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winner Regional Healthcare Center | 23.4 mi | ★★★★★ | 0 | 0 |
| Platte Care Center | 31.3 mi | ★★★★★ | 4 | 0 |
| Butte Senior Living | 36.6 mi | — | 0 | 0 |
| Sanford Chamberlain Care Center | 38.9 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.