Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Custer Care And Rehab Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple chronic conditions experienced an unwitnessed fall resulting in a skin tear. The fall report was incomplete, missing key details such as the resident's incontinence status, staff assistance provided, timing of last observation, call light accessibility, oxygen use, cause and treatment of the injury, and consideration for a toileting schedule. The facility did not thoroughly investigate the incident as required by policy, leaving potential abuse or neglect unruled out.
Two residents were not properly assessed for fall and elopement risks due to inaccurate scoring and incomplete evaluations by facility staff. One resident's fall risk was underestimated because medication use was not correctly documented, and required follow-up assessments were not completed after a fall. Another resident was not identified as at risk for elopement even after an actual elopement event, as the evaluation failed to reflect the incident. The facility lacked a policy for fall risk assessment and did not follow its own policy for elopement risk management.
A resident with severe cognitive impairment and multiple medical conditions eloped from the facility, resulting in involvement with law enforcement and a traumatic experience. Despite the incident, the social services designee did not assess the resident for psychosocial harm, discuss the event with the resident, or document any interventions, contrary to facility policy.
Failure to Thoroughly Investigate Unwitnessed Fall in Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with multiple medical conditions, including chronic obstructive pulmonary disease, diabetes, depression, anxiety, and chronic kidney disease, experienced an unwitnessed fall during the night. The resident, who used supplemental oxygen at night and was moderately cognitively impaired, was found sitting on the floor next to her recliner with a skin tear on her right upper arm. Documentation indicated she was incontinent at the time of the fall and attempted to change her bedding herself, but the fall report did not reflect this incontinence. The report also lacked details regarding whether staff assisted the resident with changing her bedding or clothing, if she was assisted back to bed, the time she was last seen before the fall, whether her call light was within reach, if she was wearing oxygen or if the tubing contributed to the fall, the suspected cause of the skin tear, any treatment provided for the injury, and whether she was a candidate for a nighttime toileting schedule. The facility's policy required thorough investigation and documentation of all incidents, including injuries of unknown source, and mandated reporting and analysis to prevent recurrence. However, the fall report was incomplete and did not provide sufficient information to rule out potential abuse or neglect or to analyze what changes could have been made to prevent future incidents. The administrator acknowledged that the report lacked necessary details and that the fall was not thoroughly investigated, as expected by facility policy.
Failure to Accurately Assess and Document Fall and Elopement Risks
Penalty
Summary
The facility failed to accurately assess and document the safety risks of two residents, resulting in deficiencies related to fall and elopement prevention. For one resident with a history of falls, the Fall Risk Evaluation completed on 9/19/24 was incorrectly scored, omitting points for medications that increase fall risk, despite the resident receiving hypoglycemic, diuretic, and psychotropic medications daily. This led to an underestimation of the resident's fall risk. Additionally, no subsequent quarterly Fall Risk Evaluations were completed after 9/19/24, nor was an evaluation performed after the resident experienced a fall on 2/10/25 that required medical care outside the facility. The administrator confirmed these assessments were not completed as required and that there was no facility policy for Fall Risk Assessment. For another resident with a history of elopement, the initial Elopement Risk Evaluation and the post-elopement evaluation both failed to identify the resident as at risk, even after an actual elopement event. The evaluation incorrectly marked that the resident had no history of elopement, despite the incident. The administrator acknowledged the error in scoring and confirmed that the evaluations did not accurately reflect the resident's risk status. The facility's policy required a systematic approach to monitoring and managing residents at risk for elopement, including proper identification and assessment, which was not followed in this case.
Failure to Assess for Psychosocial Harm After Resident Elopement
Penalty
Summary
A deficiency occurred when the provider failed to assess a resident for potential psychosocial harm following an elopement incident. The resident, who had severe cognitive impairment as indicated by a BIMS score of 5 and multiple diagnoses including bipolar disorder, traumatic brain injury, and alcohol abuse, left the facility without staff knowledge. He exited the facility with a church group, attended a service, and was later mistaken for a homeless individual by an ambulance service, which led to law enforcement involvement. The resident was handcuffed, transported to another community due to an outstanding warrant, and later returned to the facility after coordination with local authorities. Upon return, he was found to have redness on his wrists and expressed confusion and fear about the incident. Despite the traumatic nature of the event, there was no documentation that the social services designee (SSD) assessed the resident for any negative psychosocial outcomes related to the elopement. The SSD acknowledged having spoken with the resident after the incident but did not discuss the elopement or provide opportunities for the resident to express his feelings about the event. There was also no evidence of referrals for mental health evaluation, observation for changes in mood or behavior, or review and analysis of mood and behavior documentation in relation to the incident. The provider's policy required the SSD to reassess the resident and make referrals for counseling or psychological/psychiatric consults after an elopement, as well as to document findings and interventions in the medical record. However, interviews with facility staff, including the administrator and LPN, confirmed that these steps were not taken. The lack of assessment and documentation following the resident's elopement constituted a failure to provide medically-related social services to help the resident achieve the highest possible quality of life.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Custer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Michael J Fitzmaurice South Dakota Veterans Home | 23.6 mi | — | 0 | 0 |
| Seven Sisters Living Center | 25 mi | — | 0 | 0 |
| Clarkson Health Care | 25.3 mi | — | 1 | 0 |
| Avantara Arrowhead | 25.5 mi | — | 20 | 0 |
| Westhills Village Health Care Facility | 26.6 mi | — | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.