Custer Care and Rehab Center

In the surveyor’s words

From the most serious findings on record at Custer Care and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF628Aug 26, 2025

  Based on interview, record review, and policy review, the provider failed to ensure:*The resident or the resident's representative was given a bed hold notice for five of five sampled residents (6, 7, 8, 26, and 30) who transferred to the hospital. *The ombudsman was notified of resident transfers to the hospital for three of five sampled residents (6, 26, and 30) who transferred to the hospital. Findings include:1. Review of resident 6's electronic medical record (EMR) revealed: *The resident had a resident representative who acted on her behalf. *She was hospitalized on [DATE], and her EMR did not contain any documentation that indicated her resident representative had received a bed hold notification. […]

• No harm, potential for more than minimal, widespreadF727Aug 26, 2025

  Based on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (Q2) (January, February, and March 2025). Findings include: 1.Review of the provider's Q2 2025 PBJ submission report to CMS revealed there was no registered nurse (RN) coverage (worked for eight consecutive hours each day) on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. Interview with 08/21/2025 at 12:30 p.m. […]

• No harm, potential for more than minimal, widespreadF851Aug 26, 2025

  Based on Payroll Based Journal (PBJ) CASPER (Certification and Survey Provider Enhanced Reporting) reports, interview, and record review, the provider failed to ensure the PBJ data was submitted accurately to the Centers for Medicaid and Medicare Services (CMS) for Federal Fiscal Quarter 2 (Q2) (January, February, and March 2025). Findings include: 1. Review of the provider's Q2 2025 PBJ submission report to CMS revealed:*There was no recorded 24-hour licensed nurse coverage on 1/2/25, 2/19/25, 3/15/25, and 3/22/25.*There was no registered nurse (RN) coverage for consecutive eight hours daily on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. Interview with 08/21/2025 at 12:30 p.m. […]

• No harm, potential for more than minimal, widespreadF865Aug 26, 2025

  Based on observation, interview, record review, and policy review, the provider failed to maintain an effective, ongoing quality assurance and performance improvement (QAPI) program regarding quality of care and outcomes to ensure:*A performance improvement plan (PIP) was implemented, actions were taken, and improvements were evaluated for the high-risk and problem-prone areas identified. This included the 14-day as needed psychotropic medication stop dates, missing consent forms, and the assessment tools used to monitor adverse side effects in residents taking psychotropic medications.*Governing board member oversight of the facility's QAPI program. Findings include:1. Interview on 8/21/25 at 10:05 a.m. and again on 8/25/25 at 2:44 p.m. […]

• No harm, potential for more than minimal, widespreadF880Aug 26, 2025

  Based on interview, record review, and policy review, the provider failed to ensure infection control practices and facility policies were followed regarding the assessment for the risk of Legionella (bacteria that can grow in water and cause serious illness), the implementation of measures to prevent the growth of Legionella, and the establishment of testing protocols for Legionella.Findings include:1. Interview on 8/26/25 at 10:01 a.m. with director of nursing (DON) B revealed:*There was a hallway in the facility that was not currently occupied by residents.*That hallway had eight rooms in it.*Two of those rooms were currently being used by contracted travel staff, and the remaining rooms were vacant.*She did not know if the water in the vacant rooms was being flushed to avoid stagnant… […]