Cycle 1
Health 2025-08-26 · Fire 2025-08-26
20 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Custer, SD
Custer Care And Rehab Center
1-star overall rating with 1-star inspections with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1065 Montgomery St, Custer, SD
(605) 673-2115
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
35
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2024-03-29
CMS approved date
Coverage
Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Weekend hours
0.00
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 67.4% |
95.4%
28 pts worse
|
93.4%
26 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
96.9%
1.2 pts worse
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
5.1%
3 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 10.7% |
4.6%
6.1 pts worse
|
11.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 14.4% |
5.5%
8.9 pts worse
|
5.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.6% |
17.8%
21.8 pts worse
|
19.6%
20 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 30.1% |
25.1%
5 pts worse
|
16.7%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.9% |
21.3%
8.4 pts better
|
16.3%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
21.6%
2.1 pts better
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
2.0%
0.8 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
3.3%
0.1 pts better
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
25.8%
7.1 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.6%
0.7 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.8% |
83.2%
19.4 pts worse
|
81.7%
17.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-28 · Fire 2024-02-28
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-26
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-26
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-10-14
C · Minimal harm
2024-02-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-26
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-08-26
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-11-15
F · Potential for more than minimal harm
2025-08-26
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-08-26
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-08-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-26
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-11-15
E · Potential for more than minimal harm
2025-08-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-10-16
E · Potential for more than minimal harm
2025-08-26
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-26
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-26
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-11-15
D · Potential for more than minimal harm
2025-08-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-26
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-11-15
D · Potential for more than minimal harm
2025-08-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-26
F909 · Environmental Deficiencies
Health
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.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-04-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-07
D · Potential for more than minimal harm
2025-04-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-07
D · Potential for more than minimal harm
2025-04-23
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-06-07
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Michael J Fitzmaurice South Dakota Veterans Home
Hot Springs, SD
2-star overall rating with 2-star inspections with abuse icon flag with $39,293 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Seven Sisters Living Center
Hot Springs, SD
3-star overall rating with 3-star inspections with 5 recent health deficiencies
#3
Clarkson Health Care
Rapid City, SD
5-star overall rating with 5-star inspections with 3 recent health deficiencies
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