Avera Rosebud Country Care Center
126 S Logan Ave, Gregory, SD 57533 · Non profit - Corporation · 30 certified beds · (605) 835-8296 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.9% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.3% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 6.0% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.9% | 5.7% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.0% | 5.5% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 35.9% | 19.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 34.4% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.6% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 20.7% | 25.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.1% | 24.6% | 17.1% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 30 beds and averages 27.6 residents a day — about 92% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.39 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.05 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.70 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.82 hrs/resident/day on weekends vs 5.62 on weekdays — 14% thinner on weekends. RN hours go from 1.25 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
13 citations, most serious first — scroll within the box to see all.
- Potential for harm · D2026-05-21 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure the resident's medication self-administration assessment was completed and a physician's order was obtained for one of one sampled resident (21) who was not assessed to determine her ability to safely self-administer her medications or had a physician's order to self-administer those medications.Findings include:1. Observation and interview on 5/19/26 at 1:32 p.m. in resident 21's room revealed she had a nebulizer machine (a device that converts liquid medication into an inhalable mist) on top of her nightstand. She stated she received three nebulizer treatments per day.2. Observation on 5/20/26 at 2:40 p.m. in resident 21's room revealed that she was sitting in her recliner holding the nebulizer mouthpiece in her mouth, and the nebulizer machine was running. No staff members were in her room or the hallway to monitor her nebulizer medication administration.3. Interview on 5/20/26 at 2:47 p.m. with registered nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure that a current copy of the advance directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) was included in the medical record for one of one sampled resident (14) after being admitted to the facility.Findings include:1. Review of resident 14's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE]. There was no documentation indicating that any advance directive paperwork expressing his wishes regarding his code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) was completed upon admission. A copy of his living will was scanned into the EMR, but it did not address his resuscitation status. The banner area where the resident's code status was typically displayed read Resuscitation status not ordered. There was no physician order addressing his code status. 2. Interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-21 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the provider failed to ensure the Notice of Medicare Non-Coverage (NOMNC) was provided for two of two sampled residents (19 and 21) who's Medicare-covered services were ending, still had remaining Medicare benefit days, and remained in the facility.Findings included:1.Review of resident 19's Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Beneficiary Notification Review form provided by social worker designee (SWD) J revealed that resident 19's Medicare Part A Skilled Services Episode start date was 10/28/25. Resident 19's last covered day of Part A was 12/31/25. He was not given the NOMNC (notice that informs residents that their Medicare-covered services are ending on a specific date and explains their right to request an appeal)and he remained in the facility. 2. Review of resident 21's CMS SNF Beneficiary Notification Review form provided by SWD J revealed that resident 21's Medicare Part A Skilled Services Episode start day was 12/9/25. Resident 20's last covered day of Part A was 1/15/26. She was not given…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed for the cleaning of nebulizers (a device that converts liquid medication into an inhalable mist) for two of two sampled residents (8 and 21). 1. Observation and interview on 5/19/26 at 1:32 p.m. of resident 21 in her room revealed there was a nebulizer machine on top of her nightstand that had the tubing and mouthpiece connected to it, and the medication reservoir (the clear container that holds the liquid medication) appeared wet. The mouthpiece was lying directly on the nightstand, uncovered. She stated she received three nebulizer treatments a day and that the staff sometimes disconnected her nebulizer to clean it. When the staff came to administer her treatment, they usually took the medication reservoir to the bathroom and rinsed it out before giving her the treatment. 2. Review of resident 21's electronic medical record (EMR) revealed she was admitted to the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure urinary catheter (flexible tubing inserted into the bladder to drain urine) bags were cleaned and stored in a manner to prevent contamination and potential infection to one of one sampled resident (31) whose urinary catheter bag was stored in his bathroom shower without the catheter tubing connector (that attaches to the resident's indwelling catheter) capped. Findings include:1. Observation on 5/19/26 at 1:58 p.m. in resident 31's bathroom revealed there was a toilet without a lid next to a shower stall with a half-opened plastic shower curtain. Inside the shower stall, there was a bench attached to the shower wall that had a towel with a urinary catheter bag placed on it. The shower stall had a handrail attached to the wall with another urinary catheter bag hanging on that handrail. Neither of the catheter bags were labeled with the date that they were last used, or had a cover over the catheter tubing connector.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-13 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Record review of resident 130's PMR revealed: *She had been admitted on [DATE]. *She had a BIMS score of 10 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-13 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
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. *He confirmed he did not dispense and prepare residents' medications individually. *He stated he had a system and that's the way I do it. *He stated he did not get confused when he administered residents' medications that he placed in unlabeled cups to be given later. 2. Interview on 2/12/25 at 3:26 p.m. with LPN I about the provider's medication policy revealed:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The wash temperature was separated by a dash from the rinse temperature. -The wash temperatures recorded ranged from 142 to 160 degrees F. --Twelve of those recorded wash temperatures were not at the minimum wash temperature of 150…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-13 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. *There was no documentation that an assessment on the grab bars had been completed to determine safe use or measurment of the grab bars. 2. Observation and interview on 2/11/25 at 10:04 a.m. of resident 26 in her room revealed: *She used a walker for ambulation. *Grab bars were on both sides of her bed. *She stated the grab bars had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-13 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the provider failed to ensure appropriate and timely Medicare notices had been provided for one of two sampled resident (20) who was discharged from skilled services. Findings include: 1. Review of resident 20's Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Beneficiary Notification Review form provided by social services designee D revealed: *His Medicare Part A Skilled Services Episode start date was 9/2/24. *His last covered day of Part A Service was 11/13/24. *He had not been given a SNF Advance Beneficiary Notice of Non-coverage (ABN) form and had remained in the facility. 2. Interview on 2/12/25 at 4:40 a.m. with social services designee D regarding Medicare non-coverage notices revealed: *He had been hired on 9/11/23. *He was not aware resident 20 should have been provided a SNF ABN form. *He believed he had completed the Notice of Medicare Non-coverage form for resident 20. 3. Interview on 2/13/25 at 9:13 a.m. with licensed social service consultant L revealed: *She met with social services designee D once…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the South Dakota Department of Health (SD DOH) online report, interview, and policy review, the provider failed to ensure an allegation of sexual abuse made by one of one sampled resident (20), was reported within the required time frame of two hours from the time that the provider was made aware of the allegation. Findings include: 1. Review of SD DOH online report revealed the following: *On 1/11/24 at 7:52 p.m. resident 20 reported an allegation to certified nursing assistant (CNA) E that CNA D had sexually abused her. -CNA E reported the allegation to registered nurse (RN) F. *On 1/12/24 at 2:15 p.m. RN B submitted the allegation to the SD DOH online reporting system. Interview on 1/23/24 at 1:38 p.m. with administrator A regarding the above allegation revealed the following, he: *First became aware of the above-referenced allegation on 1/12/24 at approximately 1:00 p.m. *He was not aware that an allegation that would have been considered a serious bodily injury was to have been reported to the SD DOH within two hours after becoming aware of the allegation.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-23 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the South Dakota Department of Health (SD DOH) online report, interview, and policy review, the provider failed to ensure an allegation of sexual abuse made by one of one sampled resident (20) against a certified nursing assistant (CNA) (D) was thoroughly investigated. Findings include: 1. Review of the SD DOH online report revealed the following: *On 1/11/24 at approximately 7:45 p.m. resident 20 reported an allegation to certified nursing assistant (CNA) E that CNA D had sexually abused her. -CNA E had reported the allegation to registered nurse (RN) F. *The provider submitted that allegation to the SD DOH online reporting system on 1/12/24 at 2:15 p.m. Interview on 1/23/24 at 1:27 p.m. with RN B regarding the above revealed she: *Had thought the sheriff's office was completing the investigation. *Was not sure if anyone had interviewed CNA D. *Confirmed the provider had not completed a thorough investigation. Interview on 1/23/24 at 1:38 p.m. with administrator A regarding the SD DOH online report revealed he: *Had first become aware of the above-referenced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-26 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to implement Pull-Tab alarm assessments, reassessments of those alarm devices, update resident care plans to reflect the current use of those alarms, and notify the resident's family when the Pull-Tab Alarms were implemented for three of three sampled residents (10, 15, and 20). Findings include: 1. Observation and interview on 10/24/23 at 10:41 a.m. with resident 10 revealed: *He was lying in bed watching television. *A Pull-Tab alarm was attached to the bed and a garment clip was attached to his shirt. *He had a wheelchair and a walker in the corner of his room. *His feet were elevated, and he had heel protectors on both feet. *He stated that he had gone to the hospital after a fall for a broken hip, he had done some therapy afterwards and he had sores on his heels that were healing. Observation on 10/24/23 at 11:46 a.m. of resident 10 in the dining room during the lunch meal revealed: *The resident was sitting in a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to AVERA HEALTH — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.7 | +0.3 vs chain |
| Health inspection | 4 of 5 | 3.5 | +0.5 vs chain |
| Staffing | 4 of 5 | 4.3 | -0.3 vs chain |
| Quality measures | 2 of 5 | 3.1 | -1.1 vs chain |
The other 12 homes this chain runs (chain average 3.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AVERA HEALTH | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 01/01/2000 |
| ABOUREZK, SANAA | Individual | CORPORATE DIRECTOR | — | since 07/01/2024 |
| BOSCHEE, RYAN | Individual | CORPORATE DIRECTOR | — | since 07/01/2024 |
| BUNKERS, JENNIFER | Individual | CORPORATE DIRECTOR | — | since 07/01/2023 |
| CHRYSTAL, CANDYCE | Individual | CORPORATE DIRECTOR | — | since 07/01/2023 |
| COSTELLO, JOSEPH | Individual | CORPORATE DIRECTOR | — | since 07/01/2023 |
| CURRAN, MARY | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| DOVER, JAMES | Individual | CORPORATE DIRECTOR | — | since 10/23/2023 |
| FISHBACK, VAN | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| HILL JENSEN, CRISTINA | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| KIRBY, JENNIFER | Individual | CORPORATE DIRECTOR | — | since 07/01/2020 |
| KNECHT, RANDY | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| NAZIR, JAWAD | Individual | CORPORATE DIRECTOR | — | since 07/01/2020 |
| REINDL, ALISA | Individual | CORPORATE DIRECTOR | — | since 07/01/2021 |
| SEIFERT, ROXANNE | Individual | CORPORATE DIRECTOR | — | since 07/01/2022 |
| SOLOMON, BENJAMIN | Individual | CORPORATE DIRECTOR | — | since 07/01/2022 |
| STURM, TAMERA | Individual | CORPORATE DIRECTOR | — | since 07/01/2025 |
| WELBIG, LUCILLE | Individual | CORPORATE DIRECTOR | — | since 07/01/2014 |
| YOCUM, HARRIET | Individual | CORPORATE DIRECTOR | — | since 07/01/2021 |
| LAUTT, JULIE | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 03/01/2020 |
| PLACE, RONALD | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/05/2023 |
| BARTLING, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2006 |
| TIMANUS, ANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/02/2011 |
CMS files one row per role, so the 28 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in SD
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Dakota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 435029. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.