Custer Care and Rehab Center
1065 Montgomery St · Custer, SD · 57730 · 6056732115
43 certified beds Non profit - Corporation
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
No red flags in the current CMS record. Genuinely good news — pair it with an in-person tour before deciding.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 3.52 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.40 | 0.55–0.75 |
| Weekend hours / resident-day | 3.29 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | none |
Inspection citations (20 in the current record)
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Potential for harm · F August 26, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected October 10, 2025 · Resident Rights
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Potential for harm · E August 26, 2025
Assess the resident when there is a significant change in condition
Corrected November 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · E August 26, 2025
Ensure each resident receives an accurate assessment.
Corrected October 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 26, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected November 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · E August 26, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected October 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 26, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected October 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · E August 26, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected October 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 26, 2025
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 November 15, 2025 · Quality of Life and Care
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Potential for harm · F August 26, 2025
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 November 15, 2025 · Nursing and Physician Services
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Potential for harm · D August 26, 2025
Post nurse staffing information every day.
Corrected October 10, 2025 · Nursing and Physician Services
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Potential for harm · E August 26, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected October 16, 2025 · Pharmacy Service
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Potential for harm · E August 26, 2025
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected October 10, 2025 · Nursing and Physician Services
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Potential for harm · F August 26, 2025
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected October 10, 2025 · Administration
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Potential for harm · F August 26, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected October 10, 2025 · Administration
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Potential for harm · E August 26, 2025
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected October 10, 2025 · Administration
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Potential for harm · F August 26, 2025
Provide and implement an infection prevention and control program.
Corrected October 10, 2025 · Infection Control
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Potential for harm · D August 26, 2025
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 October 10, 2025 · Environmental
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Potential for harm · D April 23, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected June 7, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 23, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 7, 2025 · Quality of Life and Care
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Potential for harm · D April 23, 2025 · found via complaint
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected June 7, 2025 · Quality of Life and Care
Better-scoring options nearby
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 43A140 · certified since March 29, 2024. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.