Cycle 1
Health 2025-02-13 · Fire 2025-02-13
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Gregory, SD
Avera Rosebud Country Care Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
126 S Logan Ave, Gregory, SD
(605) 835-8296
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Avera Health
Operator or chain grouping
Approved since
1975-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.15
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
3.00
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
4.71
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.46
CMS adjusted RN staffing hours
Adjusted total hours
6.01
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
283
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
74.58
Composite VBP score used to determine payment impact.
Payment multiplier
1.0243
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.92
Baseline 35.13% · Performance 43.59% · Measure score 4.92 · Achievement 4.92 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.72 hours · Performance 5.82 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 4 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 53 |
| Staff flu vaccination coverage | 69.49% |
42%
27.5 pts better
|
Numerator 41 · Denominator 59 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.4%
4.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.9%
3.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
5.1%
5.1 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.6%
4.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.5%
1.8 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 4.5% · Q4 4.5% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
17.8%
4.8 pts worse
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q3 18.2% · Q4 39.1% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.2% |
25.1%
3.9 pts better
|
16.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 23.8% · Q4 25.0% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 36.4% |
21.3%
15.1 pts worse
|
16.3%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
21.6%
4.9 pts better
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q3 4.5% · Q4 17.4% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.5% |
2.0%
4.5 pts worse
|
1.0%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.3% · Q3 4.1% · Q4 10.9% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.3%
3.3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
25.8%
10.3 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 4.5% · Q3 10.3% · Q4 29.4% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.6%
4.6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
83.2%
14.1 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 97.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-25 · Fire 2022-08-25
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2025-02-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-17
C · Minimal harm
2025-02-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-17
B · Minimal harm
2025-02-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-02-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-02-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-02-13
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-03-30
D · Potential for more than minimal harm
2025-02-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-03-17
D · Potential for more than minimal harm
2024-01-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-08
E · Potential for more than minimal harm
2023-10-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-12-10
G · Actual harm
2022-08-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-21
Penalties and ownership
What sits behind the stars
Ownership
Avera Health
5% Or Greater Direct Ownership Interest · Organization
Avera Health
Operational/Managerial Control · Organization
Biegler, Joseph
Corporate Director · Individual
Bunkers, Jennifer
Corporate Director · Individual
Chrystal, Candyce
Corporate Director · Individual
Costello, Joseph
Corporate Director · Individual
Curran, Mary
Corporate Director · Individual
Fishback, Van
Corporate Director · Individual
Gordon, Jeffrey
Corporate Director · Individual
Hill Jensen, Cristina
Corporate Director · Individual
Kallemeyn, Brenda
Corporate Director · Individual
Kirby, Jennifer
Corporate Director · Individual
Knecht, Randy
Corporate Director · Individual
Knutson, Laurie
Corporate Director · Individual
Lautt, Julie
Corporate Officer · Individual
Nazir, Jawad
Corporate Director · Individual
Place, Ronald
Operational/Managerial Control · Individual
Place, Ronald
Corporate Officer · Individual
Ramirez, Alejandro
Corporate Director · Individual
Reindl, Alisa
Corporate Director · Individual
Seifert, Roxanne
Corporate Director · Individual
Solomon, Benjamin
Corporate Director · Individual
Sutton, Bobby
Corporate Officer · Individual
Timanus, Anthony
W-2 Managing Employee · Individual
Welbig, Lucille
Corporate Director · Individual
Yocum, Harriet
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Winner Regional Healthcare Center
Winner, SD
2-star overall rating with 3-star inspections with $13,039 in total fines with 3 recent health deficiencies
#2
Platte Care Center
Platte, SD
4-star overall rating with 4-star inspections with $6,168 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Sanford Chamberlain Care Center
Chamberlain, SD
1-star overall rating with 1-star inspections with abuse icon flag with $81,866 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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