Custer Care And Rehab Center

Location & what’s nearby

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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

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.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. Inspectors cited this home for failing to submit its staffing data to CMS (F0851) — see the citation below. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

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.

17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.

• Potential for harm · F2025-08-26 · tag F0628 — widespread
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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 interview, record review, and policy review, the provider failed to ensure:*The resident or the resident's representative was given a bed hold notice for five of five sampled residents (6, 7, 8, 26, and 30) who transferred to the hospital. *The ombudsman was notified of resident transfers to the hospital for three of five sampled residents (6, 26, and 30) who transferred to the hospital. Findings include:1. Review of resident 6's electronic medical record (EMR) revealed: *The resident had a resident representative who acted on her behalf. *She was hospitalized on [DATE], and her EMR did not contain any documentation that indicated her resident representative had received a bed hold notification. *No documentation in her EMR indicated that the ombudsman had been notified of her transfer to the hospital. 2. Review of resident 30's EMR revealed: *She was hospitalized on [DATE] and 3/22/25, and her EMR did not contain any documentation that indicated she or her resident representative had received a bed…

  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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-26 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (Q2) (January, February, and March 2025). Findings include: 1.Review of the provider's Q2 2025 PBJ submission report to CMS revealed there was no registered nurse (RN) coverage (worked for eight consecutive hours each day) on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. Interview with 08/21/2025 at 12:30 p.m. with director of nursing (DON B) revealed:*She confirmed there was not always a registered nurse for eight consecutive hours each day at the facility.*She confirmed there was no registered nurse (RN) coverage on the days indicated for Q2 2025. *She was not aware that RN coverage was needed seven days per week.*She confirmed the provider had no nurse waiver. Interview on 8/21/25 at 12:45 p.m. with business office manager (BOM) H regarding PBJ submission and RN coverage revealed:*She…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-26 · tag F0851 — widespread
  Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (Q2) (January, February, and March 2025). Findings include: 1. Review of the provider's Q2 2025 PBJ submission report to CMS revealed:*There was no recorded 24-hour licensed nurse coverage on 1/2/25, 2/19/25, 3/15/25, and 3/22/25.*There was no registered nurse (RN) coverage for consecutive eight hours daily on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. Interview with 08/21/2025 at 12:30 p.m. with director of nursing (DON B) regarding submission of PBJ data revealed:*She confirmed there was no registered nurse (RN) coverage on the days indicated for Q2 2025. *She was not aware that RN coverage was needed seven days per week.*She was able to provide documentation that there was 24-hour licensed nurse coverage for the days indicated for Q2 2025, but not for the consecutive eight hours of…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-26 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and policy review, the provider failed to maintain an effective, ongoing quality assurance and performance improvement (QAPI) program regarding quality of care and outcomes to ensure:*A performance improvement plan (PIP) was implemented, actions were taken, and improvements were evaluated for the high-risk and problem-prone areas identified. This included the 14-day as needed psychotropic medication stop dates, missing consent forms, and the assessment tools used to monitor adverse side effects in residents taking psychotropic medications.*Governing board member oversight of the facility's QAPI program. Findings include:1. Interview on 8/21/25 at 10:05 a.m. and again on 8/25/25 at 2:44 p.m. with director of nursing (DON) B revealed:*She stated that residents receiving as needed psychotropic medications ordered by physicians must have a visit by the physician and be reassessed for the as needed medication order renewals every 14 days. *The pharmacy would send a message to the physician on HUCU (a confidential communication platform)…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-08-26 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and policy review, the provider failed to ensure infection control practices and facility policies were followed regarding the assessment for the risk of Legionella (bacteria that can grow in water and cause serious illness), the implementation of measures to prevent the growth of Legionella, and the establishment of testing protocols for Legionella.Findings include:1. Interview on 8/26/25 at 10:01 a.m. with director of nursing (DON) B revealed:*There was a hallway in the facility that was not currently occupied by residents.*That hallway had eight rooms in it.*Two of those rooms were currently being used by contracted travel staff, and the remaining rooms were vacant.*She did not know if the water in the vacant rooms was being flushed to avoid stagnant water in the pipes.*She did not know if there was a water flow map for the facility to identify areas where Legionella could grow and spread.*Maintenance manager (MM) G would be responsible for the provider's water management program.*There had been no cases of Legionella infections identified at…

  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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-26 · tag F0637 — pattern
  Assess the resident when there is a significant change in condition
  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 that two of two sampled residents (6 and 7), who experienced two or more areas of decline from their baseline conditions, had a significant change in status assessments completed related to fractures that resulted from their falls. Findings include:1. Review of resident 6's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE] and readmitted on [DATE]. *Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbances (consistent, unhealthy pattern of behaviors that significantly interfere with daily functions), major depressive disorder (a mental health condition with persistent feelings of sadness, hopelessness, and loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). *Her…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-26 · tag F0641 — pattern
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 October 2024 review, the provider failed to ensure two of two sampled residents' (3 and 4) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments were accurately coded for the area of restraints. Findings include: 1. Observation on 8/19/25 at 11:10 a.m. of resident 4's room revealed her bed had a side rail attached to it, on the left side of the bed, and it was the up position. 2. Observation on 8/25/25 at 12:20 p.m. of resident 4 in her bed, revealed the left side rail was in the up position. 3. Review of resident 4's medical record revealed:*Her admission date was 10/10/24.*Her 7/14/25 Brief Interview of Mental Status assessment (BIMS) score was an 8, which indicated she had moderate cognitive impairment.*Her diagnoses included: adjustment disorder (mental health condition characterized by…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-26 · tag F0655 — pattern
  Create 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, and policy review, the provider failed to ensure the resident or the resident's representative was involved in the development of a baseline care plan and given a copy of that care plan within 48 hours of admission for four of four sampled residents (1, 7, 21, and 26) reviewed. Findings include: 1.Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *The resident had a resident representative who acted on her behalf. *There was no documentation to support her (date) baseline care plan was reviewed and acknowledged [ML1] [DW2] by resident 7 or her representative. *There was no documentation that resident 7 or her representative was involved with the development of the baseline care plan or given a copy of it. 2. Review of resident 21's EMR revealed: *A baseline care plan dated 8/5/25 had areas that were partially filled out. *The areas that were filled out on the form included: -Initial goals, dietary orders, social services, activities…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-26 · tag F0657 — failed to keep the care plan current — pattern
  Develop 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 record review, interview, and policy review, the provider failed to ensure the resident's care plan was reviewed and revised to reflect the current necessary care needs for six of six sampled residents (5, 6, 12, 21, and 26). Findings include: 1. Review of resident 6's electronic medical record (EMR)revealed: *She was admitted to the facility on [DATE] and readmitted on [DATE]. *Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbances (consistent, unhealthy pattern of behaviors that significantly interfere with daily functions), major depressive disorder (a mental health condition with persistent feelings of sadness, hopelessness, and loss of interest in activities), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). *Her 8/13/25 Brief Interview for Mental Status (BIMS) assessment score was 0, which indicated she 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-26 · tag F0757 — failed to avoid unnecessary drugs — pattern
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interview, and policy review, the provider failed to ensure:*Psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) ordered to be given as needed were not discontinued after 14 days, and did not have a rationale documented for continued use for four of nine sampled residents (7, 13, 21, and 30) reviewed with physician's orders for psychotropic medications.*Abnormal Involuntary Movement Scale (AIMS) (an assessment to identify the severity of involuntary movements in residents taking neuroleptic medications) assessments were routinely completed to evaluate for signs of adverse effects for eight of nine sampled residents (1, 6, 7, 13, 18, 21, 23, and 30) reviewed with physician's orders for psychotropic medications.*Consent forms for the use of psychotropic medications were obtained for nine of nine sampled residents (1, 6, 7, 13, 18, 21, 23, 26, and 30) reviewed with physician's orders for psychotropic medications. Findings included:1. Review of resident 21's electronic medical record (EMR) revealed: *Four…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 10 rows in the source record cover these 7 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