Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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 Device evaluations were outdated or incomplete, and maintenance had not conducted necessary safety assessments.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 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 | — | 0 | 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 August 2026) and official state health department websites.