01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-26 | 17 | 2025-08-26 | 2 |
CMS CCN 4351362026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Custer Care And Rehab Center
1065 Montgomery St · Custer, SD 57730 · Custer County
Certified beds43CMS provider file
Recent citation rows19current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
19 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 0 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-08-26 · FIREE0006Severity D · isolated; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0628Severity F · widespread; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0637Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Correction field: Deficient, Provider has date of correction · 2025-11-152025-08-26 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-11-152025-08-26 · HEALTHF0655Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0657Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Correction field: Deficient, Provider has date of correction · 2025-11-152025-08-26 · HEALTHF0727Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-11-152025-08-26 · HEALTHF0732Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0757Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2025-10-162025-08-26 · HEALTHF0841Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0851Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0865Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0868Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · HEALTHF0909Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-102025-08-26 · FIREK0919Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Correction field: Deficient, Provider has date of correction · 2025-10-1403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CUSTER CARESOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 12/01/2023
- BARTA, MADISONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2023
- BOYER, JANETIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2023
- MCGOWAN, MONICAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2023
- TENNYSON, MIKEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2023
- VAN VOORST, SAMUELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2023
- WHEELER, RICKYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2023
- CUSTER CARESOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/01/2023
- BARTA, MADISONIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2023
- VAN VOORST, SAMUELIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/01/2023
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours—per resident day
RN hours—per resident day
Weekend nurse hours—per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the South Dakota ledger →Other published facilities nearby
No second facility in the same city met the directory rule.