Custer Care and Rehab Center
1065 MONTGOMERY ST, Custer, SD, 57730
No. Federal inspectors recorded no deficiencies against Custer Care and Rehab Center in Custer, South Dakota at its most recent standard inspection on 2025-08-26.
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
The last 17 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · F0628 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
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.
Nursing and Physician Services Deficiencies · F0727 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Administration Deficiencies · F0851 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Have a plan that describes the process for conducting QAPI and QAA activities.
Administration Deficiencies · F0865 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies · F0637 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · F0641 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · F0655 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · F0657 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · F0757 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Nursing and Physician Services Deficiencies · F0841 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Administration Deficiencies · F0868 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · F0644 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · F0656 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
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.
Quality of Life and Care Deficiencies · F0700 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies · F0732 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
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.
Environmental Deficiencies · F0909 · 2025-08-26 · standard survey · No actual harm, potential for more than minimal harm
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
Who owns Custer Care and Rehab Center
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| CUSTER CARES | Organization | 100% | since 12/01/2023 |
| BARTA, MADISON | Individual | NOT APPLICABLE | since 12/01/2023 |
| BOYER, JANET | Individual | NOT APPLICABLE | since 09/01/2023 |
| MCGOWAN, MONICA | Individual | NOT APPLICABLE | since 09/01/2023 |
| TENNYSON, MIKE | Individual | NOT APPLICABLE | since 09/01/2023 |
| VAN VOORST, SAMUEL | Individual | NOT APPLICABLE | since 09/01/2023 |
| WHEELER, RICKY | Individual | NOT APPLICABLE | since 09/01/2023 |
| CUSTER CARES | Organization | NOT APPLICABLE | since 12/01/2023 |
| BARTA, MADISON | Individual | NOT APPLICABLE | since 12/01/2023 |
| VAN VOORST, SAMUEL | Individual | NOT APPLICABLE | since 09/01/2023 |
Ask Custer Care and Rehab Center a question
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Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 435136.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction