Federal inspection record · CMS data as of October 1, 2026
Custer Care And Rehab Center
1065 Montgomery St, Custer, SD · (605) 673-2115
- Certified beds
- 43
- Residents per day
- 11
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- December 1, 2025
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in South Dakota.
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Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change (already 1)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among South Dakota homes
Custer Care And Rehab Center carries 64.5 inspection points. That is fewer than 35% of South Dakota's 94 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in South Dakota: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–14 pts
- 4★ 14–31.5 pts
- 3★ 31.5–55 pts
- 2★ 55–95.25 pts
- 1★ over 95.25 pts
Bars show every rated home in South Dakota by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
19 health citations on record since 2025. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Resident Assessment and Care Planning6E
- E
Assess the resident when there is a significant change in condition
- E
Ensure each resident receives an accurate assessment.
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Nursing and Physician Services3F
- F
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.
- E
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
- D
Post nurse staffing information every day.
Administration3F
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- F
Have a plan that describes the process for conducting QAPI and QAA activities.
- E
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Resident Rights2F
- D
Honor 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.
- F
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Infection Control2F
- D
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
Pharmacy Service1E
- E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Quality of Life and Care1D
- D
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.
Environmental1D
- D
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.
Inspection history
2026-08-06
2 health deficiencies · 0 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
2025-08-26
17 health deficiencies · 2 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine39.2 pts worse | 55.7% | 94.9% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.8 pts better | 100.0% | 97.2% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.1 pts worse | 6.6% | 5.5% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms8.6 pts worse | 14.5% | 5.9% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.1 pts worse | 6.8% | 5.7% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication19.6 pts worse | 37.3% | 17.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication11 pts worse | 35.8% | 24.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened12.4 pts worse | 30.7% | 18.3% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3.1 pts worse | 24.6% | 21.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.1 pts worse | 3.0% | 1.9% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2 pts worse | 4.9% | 2.9% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence6.7 pts worse | 31.2% | 24.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.5 pts better | 4.0% | 4.5% | 4.5% |
·
Who owns and runs it
10 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Custer Cares | 5% Or Greater Direct Ownership Interest · Organization | 100% | 1 facilities |
| Barta, Madison | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Barta, Madison | Adp Of The SNF · Individual | 0% | 1 facilities |
| Boyer, Janet | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Custer Cares | Adp Of The SNF · Organization | 0% | 1 facilities |
| Mcgowan, Monica | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Tennyson, Mike | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Van Voorst, Samuel | Operational/Managerial Control · Individual | 0% | 3 facilities |
| Van Voorst, Samuel | Adp Of The SNF · Individual | 0% | 3 facilities |
| Wheeler, Ricky | Operational/Managerial Control · Individual | 0% | 1 facilities |
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Fire safety
2 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Emergency Preparedness1D
- D
Conduct risk assessment and an All-Hazards approach.
Gas, Vacuum, and Electrical Systems1D
- D
Meet requirements for the use of electrical equipment.
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Other homes nearby
-
Michael J Fitzmaurice South Dakota Veterans Home
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★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- —
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-
Seven Sisters Living Center
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★★★★★- Worst citation, 3 yrs
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- Nursing / resident / day
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-
Clarkson Health Care
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★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 13 min
- Fines
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