Custer Care and Rehab Center
1065 Montgomery St, Custer, SD 57730 · Custer County · 43 certified beds · avg 0 residents/day · certified since Dec 1, 2025
—/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
0.00
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: —/5 · CMS overall rating: —/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (17)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 26, 2025 | F · Potential for harm, facility-wide | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Aug 26, 2025 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Aug 26, 2025 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Aug 26, 2025 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Aug 26, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 26, 2025 | E · Potential for harm, repeated | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Aug 26, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 26, 2025 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Aug 26, 2025 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 26, 2025 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Aug 26, 2025 | E · Potential for harm, repeated | The facility did not designate a physician to serve as medical director — the doctor responsible for overseeing resident care policies and coordinating medical care across the facility. |
| Aug 26, 2025 | E · Potential for harm, repeated | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Aug 26, 2025 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2025 | 17 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 0.00 | 4.32 | 3.95 | — |
| Registered Nurse hours | 0.00 | 0.91 | 0.69 | — |
| Weekend total nurse staffing | 0.00 | 3.71 | 3.50 | — |
| Weekend RN hours (not acuity-adjusted) | 0.00 | 0.51 | 0.48 | — |
| Total nursing staff turnover (%) | 0.0 | 48.2 | 45.8 | — |
| RN turnover (%) | 0.0 | 34.7 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 0.00, RN 0.00, weekend 0.00. Staffing rating: —/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: —/5 · long-stay residents: —/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Custer Cares | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/01/2023 |
| Barta, Madison | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2023 |
| Barta, Madison | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2023 |
| Boyer, Janet | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
| Custer Cares | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2023 |
| McGowan, Monica | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
| Tennyson, Mike | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
| Van Voorst, Samuel | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
| Van Voorst, Samuel | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2023 |
| Wheeler, Ricky | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
- "How does your quality improvement program work, and can you share a recent example of a problem you found and fixed?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Michael J Fitzmaurice South Dakota Veterans Home | 23.6 mi | Hot Springs, SD | ★★☆☆☆ | 2/5 | |
| Seven Sisters Living Center | 25.0 mi | Hot Springs, SD | ★★★★☆ | 4/5 | |
| Clarkson Health Care | 25.3 mi | Rapid City, SD | ★★★★★ | 4/5 | |
| Avantara Arrowhead | 25.6 mi | Rapid City, SD | ★☆☆☆☆ | 1/5 | abuse |
| Westhills Village Health Care Facility | 26.6 mi | Rapid City, SD | ★★★★★ | 4/5 | |
| Avantara Mountain View | 27.0 mi | Rapid City, SD | ★★☆☆☆ | 2/5 | |
| Good Samaritan Society - St Martin Village | 27.2 mi | Rapid City, SD | ★★☆☆☆ | 2/5 | |
| Avantara Saint Cloud | 27.4 mi | Rapid City, SD | ★☆☆☆☆ | 2/5 | abuse |
| Fountain Springs Healthcare | 28.5 mi | Rapid City, SD | ★★★☆☆ | 3/5 | |
| Avantara North | 28.9 mi | Rapid City, SD | ★★★☆☆ | 3/5 | |
| Weston County Health Services | 30.4 mi | Newcastle, WY | ★★☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 435136.