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 July 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.
Failure to Provide Bed-Hold Notices and Ombudsman Notifications: The facility failed to provide bed-hold notices to residents or their representatives when residents transferred to the hospital, and failed to notify the ombudsman of some hospital transfers. EMRs for multiple residents showed hospitalizations, but no documentation of bed-hold notices or ombudsman notifications. The DON stated the bed-hold notice was included in the admission agreement and signed on admission, but was not aware a notice was required with each hospital transfer.
RN coverage and PBJ reporting were deficient when the facility submitted Q2 2025 PBJ data showing multiple days without 8 consecutive hours of RN coverage. The DON confirmed the gaps and stated she was unaware RN coverage was needed 7 days per week, while the BOM said she helped with the PBJ submission and scheduling but did not know the requirement applied to this facility. Review of later nurse schedules also showed additional days with no RN coverage, and the facility had no staffing policy or nurse waiver.
PBJ staffing data submitted to CMS was inaccurate because the facility reported days without required 24-hour licensed nurse coverage and days without consecutive 8-hour RN coverage. The DON confirmed the missing RN coverage and said she was not aware RN coverage was needed 7 days per week, while the BOM said she assisted with the PBJ submission and scheduling but was unaware that a non-skilled nursing facility also needed RN coverage every day.
QAPI oversight was ineffective for psychotropic medication management. The DON stated that 14-day PRN psychotropic renewals were not tracked consistently, some stop dates were entered as indefinite, some medications continued beyond 14 days, and psychotropic consent forms and routine AIMS or other side-effect monitoring were not completed as expected. The QAPI binders did not show a clear PIP, documented outcomes, or consistent committee reporting, and no board member was assigned to oversee the QAPI program.
Failure to follow the facility's Legionella surveillance and water management policy was identified when the DON and MM stated the water systems had not been assessed for areas where Legionella or other opportunistic pathogens could grow, no prevention measures had been implemented, and testing protocols had not been followed. The DON reported a hallway with eight rooms was not occupied by residents, with two rooms used by travel staff and the remaining rooms vacant, and she did not know whether water in the vacant rooms was being flushed or whether a water flow map existed. The MM stated he was not aware of the need to routinely flush water in vacant rooms, and the policy required annual water testing and specific hot and cold water temperature controls.
Failure to Provide Bed-Hold Notices and Ombudsman Notifications: The facility failed to give bed-hold notices to residents or their representatives each time five residents were transferred to the hospital, and failed to notify the ombudsman of hospital transfers for three residents. EMRs showed no documentation that the required notices or ombudsman notifications were provided, and the DON stated she was not aware a bed-hold notice was required with each hospital transfer.
RN Coverage and PBJ Submission Deficiency: The facility failed to ensure accurate PBJ reporting to CMS and did not maintain RN coverage for eight consecutive hours on multiple days. The DON confirmed RN coverage was not always present and was unaware it was needed seven days per week, while the BOM stated she handled scheduling and was not aware the requirement applied to the facility. Review of the nurse schedule also showed additional days with no RN coverage, and the facility had no staffing policy or nurse waiver.
PBJ staffing data submitted to CMS was inaccurate because the facility reported dates with no 24-hour licensed nurse coverage and no consecutive 8-hour RN coverage. The DON confirmed the missing RN coverage and said she was unaware RN coverage was needed 7 days per week, while the BOM said she assisted with the PBJ submission and scheduling but was also unaware of the RN coverage requirement for a non-skilled nursing facility. A later schedule review also showed additional days with no RN coverage, which was confirmed by both the BOM and DON.
The facility failed to maintain an effective QAPI program for psychotropic medication monitoring. The DON stated PRN psychotropic meds were not consistently tracked for 14-day renewals, some stop dates were entered as indefinite, some meds continued beyond 14 days, and no routine psychotropic risk assessment tool or AIMS process was used to monitor adverse effects. Psychotropic consent forms were also not completed or updated for multiple residents, and the QAPI binders did not contain a clear PIP, committee reports, or board oversight documentation.
Failure to follow Legionella surveillance and water management policy: the DON and MM reported that vacant rooms in an unused hallway were not being assessed for stagnant water, there was no water flow map identified, and the water systems had not been evaluated for areas where Legionella or other opportunistic pathogens could grow. The MM stated no prevention measures had been implemented and the facility had not followed its testing protocols, despite policy requiring annual water testing and temperature controls.
Failure to complete significant change MDS assessments after fracture-related declines: Two residents had major status changes after falls and hospitalizations for fractures, including increased pain, cognitive decline, and worsening ADL and mobility needs. One resident with dementia and psychiatric diagnoses had a left hip fracture with surgical repair and multiple new care needs, while another resident with dementia with behaviors sustained a greater trochanter fracture and became unable to walk, needing staff help with transfers and repositioning. The MDS nurse/ADON confirmed the significant change assessments were not completed and stated she had no training on MDS completion.
MDS assessments for two residents were incorrectly coded to show bed side rails as restraints. One resident had a left bed rail used as a transfer loop to support turning and repositioning, and the other resident had a requested right side rail, but neither record showed a restraint being used. The MDS Nurse/ADON stated the rails were used for mobility and positioning, confirmed they were not restraints, and said she coded them that way because of her understanding of the RAI manual.
A facility failed to involve residents or their representatives in developing baseline care plans and failed to provide copies within 48 hours of admission for multiple residents. Records showed missing documentation of resident participation, partially completed baseline care plan sections, and delayed evidence of involvement, while staff said the DON completed baseline care plans on admission and care plans were not being updated as needs changed.
Care plans were not reviewed and revised to match residents’ current needs. A resident with dementia and a recent hip fracture had major changes in pain, mobility, ADLs, mental status, anticoagulant use, and psychotropic meds that were not added to the care plan. Other residents had delayed or missing comprehensive care plans, and a resident with nicotine dependence and bed rails had care plan gaps related to smoking behavior, nicotine gum, and side rail use. The MDS nurse/ADON confirmed care plan revisions had not been completed when conditions changed.
Psychotropic medication management was not properly documented for multiple residents. PRN psychotropic orders were continued without 14-day stop dates or documented reassessment rationale, psychotropic consent forms were missing for several residents, and AIMS assessments were not routinely completed for residents receiving antipsychotics and other psychotropic medications. The DON and consultant pharmacist both described inconsistent tracking of PRN renewals and monitoring, and the medical director stated he did not provide guidance on the 14-day stop-date requirement.
MD C did not fulfill his medical director duties to assist with patient care policies and QAA/QAPI oversight. DON reported that the facility had no psychotropic med policy, some PRN psychotropic meds continued beyond the 14-day stop date, and AIMS monitoring was not tracked in QAPI. MD C had not reviewed facility policies, could not explain the 14-day renewal requirement, and was unsure about recent QAA/QAPI participation. Consultant pharmacist recommendations were often delayed for 30 days or more.
QAA/QAPI committee participation and documentation were incomplete. DON stated monthly meetings were held, but MD C was not regularly involved, no board member was assigned to oversee the QAA/QAPI program, and committee reports were missing from the binder in multiple months. Attendance records showed no documentation that MD C or the dietary manager attended any meetings during the review period, while several other members attended only once. DON also confirmed that neither MD C nor a board member reviewed or signed the facility policies and procedures during scheduled meetings.
Failure to complete significant change MDS assessments after fracture-related declines for two residents. One resident with dementia, depression, and anxiety sustained a hip fracture after a fall and then had increased pain, mental status changes, lower-extremity impairment, opioid use, and multiple ADL declines. Another resident with dementia and a history of falls sustained a greater trochanter fracture after falling from her wheelchair and then lost walking ability, needed more staff help with transfers and repositioning, and had worsening cognition. The MDS nurse/ADON confirmed the assessments were not completed and stated she had not completed MDS certification training.
MDS assessments incorrectly coded side rails as restraints. Two residents had bed rail assessments and care plans showing side rails were used as enablers for mobility, positioning, or independence in bed, yet their MDSs coded the rails as restraints. The MDS nurse/ADON confirmed the rails were not restraints and stated she had misunderstood the RAI manual and had not received formal MDS training.
A resident's baseline care plan was not developed with the resident or representative involved or documented as provided within the required timeframe, and this occurred for multiple residents. Records showed incomplete or undocumented baseline care plans, including one partially filled form and others with no evidence of resident participation or receipt. Staff interviews indicated the DON completed baseline care plans on admission, while facility policy required the plan to be developed with input from the resident and family within 48 hours.
Care plans were not prepared, reviewed, and revised to reflect current resident needs. A resident with dementia, a recent hip fracture, pain medication, anticoagulant therapy, psychotropic meds, and major ADL changes had an outdated care plan, while other residents had missing or unchanged comprehensive care plans. Another resident’s plan did not address nicotine gum use, smoke-free policy noncompliance, or bed rail use. The MDS nurse/ADON confirmed care plan revisions were not being completed when conditions or orders changed.
The facility failed to manage psychotropic meds as required for several residents. PRN lorazepam orders were continued without 14-day stop dates or documented rationale, multiple residents had psychotropic meds ordered without documented consent, and routine AIMS monitoring was not completed for residents receiving antipsychotics, antidepressants, and antianxiety meds. Records showed missing consent and missing AIMS documentation for residents receiving meds such as lorazepam, quetiapine, sertraline, buspirone, citalopram, escitalopram, memantine, and risperidone, with some PRN orders also renewed without the required reassessment documentation.
MD C did not fulfill his medical director responsibilities related to policy development, policy review, and QAA/QAPI participation. The DON stated the facility had no psychotropic medication policy available, that policies were reviewed without MD C’s involvement, and that there was no board member review documented. The DON also confirmed PRN psychotropic meds with 14-day stop-date requirements were continued beyond 14 days and that these issues were not tracked in QAA/QAPI. The consultant pharmacist reported recommendations were emailed monthly but could take 30 days or longer for MD C to address, and MD C stated he did not know the rules for 14-day PRN psychotropic renewals and was unsure whether he attended recent QAA/QAPI meetings.
The facility failed to maintain an effective QAA/QAPI committee with required participation and documentation. Review of attendance records showed no evidence that the MD attended any meetings over a six-month period, the dietary manager did not attend, and several other required members attended only once. The DON stated the MD was not highly involved, no board member was assigned to oversee or acknowledge the QAA/QAPI program, and committee reports were missing from the Administrator’s binder in multiple months. The facility’s policy required monthly committee meetings and quarterly QA meetings with the MD and ancillary staff.
Failure to complete Level II PASRR after significant change in treatment needs. A resident with no initial SMI or IDD later developed anxiety, MDD, and dementia with behavioral disturbances and was treated with multiple psychotropic meds, including an antipsychotic. Her BIMS was 0 with severe cognitive impairment, and no EMR documentation showed a Level II PASRR after the change. The DON said SSD handled PASRRs, and SSD confirmed she did not complete the Level II PASRR and was unaware it was needed after a significant change.
Delayed Completion of Comprehensive Care Plans: A facility failed to complete comprehensive care plans within the required timeframe for multiple residents. One resident's care plan was documented late, another had only a partially completed baseline care plan with several sections left blank and no later comprehensive plan documented, and two other residents' comprehensive care plans were completed well after admission. The MDS nurse/ADON and DON both acknowledged the delays, and the facility policy required care plan completion by day 14 with measurable outcomes and specific interventions.
The facility failed to document attempts at alternative interventions before using bed rails for three residents. Two residents stated they requested the rails to help them get in and out of bed, and one used the rail to help sit up in bed; records showed bed rail assessments and consents, but the alternatives sections were listed as resident request, N/A, or had no documented attempts. The DON stated that when a resident requested a side rail, one was attached and no alternatives were tried first, despite the facility policy requiring alternative approaches before bed rail use.
Daily nurse staffing information was not posted with the total number and actual hours worked by each nursing discipline, and the current resident census was not listed. The posted form outside the activities room grouped staff by shift and pod, but did not identify RN, LPN, or CNA counts, and the resident listing was outdated. The DON and BOM stated they were unaware of the posting requirements and that staffing updates were typically made later for internal record-keeping.
Failure to inspect and monitor bed rails for safety affected three residents with side rails in the up position. The maintenance manager stated he installed rails when nursing requested them but did not perform routine maintenance or safety checks, including entrapment review. The facility policy required correct installation, maintenance, and regular inspection of the bed, mattress, and rails for entrapment risk.
Failure to complete Level II PASRR after significant change in treatment needs. A resident with an initial PASRR showing no SMI or IDD later developed anxiety, depression, and dementia with behavioral disturbances and was treated with multiple psychotropic meds, including antipsychotics and antidepressants. Her BIMS was 0 with severe cognitive impairment, and no EMR documentation showed a Level II PASRR after the change. The SSD confirmed she was responsible for PASRRs, was unaware a resident review was needed after a significant change, and acknowledged the Level II PASRR was not completed.
Delayed Completion of Comprehensive Care Plans: A facility failed to complete comprehensive care plans within the required timeframe for multiple residents. One resident’s first care plan was documented late, another had only a partially completed baseline care plan with several sections left blank and no later comprehensive plan, and two others did not receive comprehensive care plans until well after admission. The MDS nurse/ADON and DON acknowledged the delays, and the facility policy required care plan completion by day 14 with measurable outcomes and specific interventions.
A deficiency was cited after three residents had bed rails in use without documented attempts at alternative interventions before installation or use. Two residents said they requested the rails to help them get in and out of bed, and one said she used the rail to help sit up; records showed incomplete or inconsistent bed rail assessments and consent forms listing alternatives as not applicable or resident requested. The DON stated that rails were attached when residents requested them and that no alternatives were attempted first.
Daily nurse staffing information was not posted correctly. The posted form outside the activities room listed staff by shift and pod, but it did not identify each staff member as an RN, LPN, or CNA, did not show the total number of each discipline, and combined hours by shift instead of showing actual hours worked. A separate resident list did not show the current census and had not been updated daily. The DON and BOM stated they were unaware of the required posting details, and the facility did not have a specific policy for staffing postings.
Failure to inspect and monitor bed rails for safety: three residents had side rails on their beds in the up position, but the facility did not ensure the rails were checked for safe installation or entrapment risk before use and did not routinely verify they remained safe. The maintenance manager stated he installed rails when notified by nursing but did not perform routine maintenance or safety checks, including entrapment review, despite the facility policy requiring assessment of the resident, bed, mattress, and rail and regular inspection for possible entrapment areas.
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 Provide Bed-Hold Notices and Ombudsman Notifications
Penalty
Summary
The provider failed to ensure that the resident or the resident’s representative was given a bed-hold notice for five sampled residents who transferred to the hospital. Review of the electronic medical records for residents 6, 7, 8, 26, and 30 showed hospital transfers, but there was no documentation that a bed-hold notification had been provided to the resident or the resident’s representative for those transfers. Several of the residents had resident representatives who acted on their behalf, including residents 6, 7, and 8, yet their records still lacked documentation of a bed-hold notice at the time of hospitalization. The provider also failed to ensure that the ombudsman was notified of resident transfers to the hospital for residents 6, 26, and 30. Their records contained no documentation showing that such notifications were made. During interview, the DON stated the admission agreement included a bed-hold notification notice and that bed-hold policies were signed on the resident’s initial admission day, but she was not aware that a bed-hold notice was required with each transfer to the hospital. The BOM and social service director each stated they were not responsible for reporting resident transfers or discharges to the ombudsman and were not sure who was responsible, and the ombudsman reported not receiving notifications from the provider regarding residents who had transferred or discharged to the hospital.
RN Coverage and PBJ Reporting Deficiency
Penalty
Summary
The facility failed to ensure accurate PBJ data was submitted to CMS for Federal Fiscal Quarter 2 of 2025 regarding RN coverage. Review of the Q2 2025 PBJ submission report showed there was no RN coverage for eight consecutive hours on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. The DON confirmed there was not always an RN on duty for eight consecutive hours each day, confirmed there was no RN coverage on those dates, and stated she was not aware that RN coverage was needed seven days per week. She also confirmed the provider had no nurse waiver. The BOM stated she began working at the facility in January 2025 and assisted with the Q2 2025 PBJ submission to CMS with help from Administrator A. She completed the nurse scheduling and said she knew a skilled nursing facility needed RN coverage seven days a week, but was not aware this was required for a nursing facility that was not skilled. Review of the licensed nurse schedule from 8/1/25 through 8/24/25 showed no RN coverage on 8/9/25, 8/17/25, and 8/24/25, and the DON confirmed those three days had no RN coverage. Review of the 6/2025 Facility Assessment showed no indication that an RN was required to work eight consecutive hours a day, seven days a week, and the facility had no staffing policy.
PBJ Staffing Data Submitted Without Required RN Coverage
Penalty
Summary
The facility failed to ensure that PBJ staffing data submitted to CMS for Q2 2025 was accurate based on payroll and other verifiable and auditable data. Review of the Q2 2025 PBJ submission report showed no recorded 24-hour licensed nurse coverage on 1/2/25, 2/19/25, 3/15/25, and 3/22/25, and no RN coverage for a consecutive eight hours on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. During interview, the DON confirmed there was no RN coverage on the identified Q2 2025 dates and stated she was not aware that RN coverage was needed seven days per week. She was able to provide documentation showing 24-hour licensed nurse coverage for the identified dates, but not consecutive eight hours of RN coverage. The BOM stated she started in January, assisted with the Q2 2025 PBJ submission with the Administrator, and did the scheduling; she said she knew a skilled nursing facility needed RN coverage 7 days a week but was not aware that a nursing facility that was not skilled also needed it. Review of the licensed nurse schedule for 8/1/25 through 8/24/25 showed three days with no RN coverage, which was confirmed by both the BOM and DON.
QAPI Program Failed to Track Psychotropic Medication Oversight
Penalty
Summary
The facility failed to maintain an effective, ongoing QAPI program for high-risk and problem-prone areas related to psychotropic medication management and oversight. During interviews, the DON stated that residents receiving as needed psychotropic medications were supposed to be reassessed by the physician every 14 days for renewal, but the pharmacy was not tracking those renewals consistently and there was no process in place before July 2025 to monitor medications requiring 14-day renewals. She also stated that some as needed psychotropic medication stop dates were entered as indefinite, some residents continued receiving these medications beyond 14 days, and the facility had no psychotropic medication policy available for review. The DON further stated that a psychotropic risk assessment tool was not used routinely to monitor adverse side effects, and that the TAR notation to monitor for side effects was not an assessment. She confirmed that AIMS assessments were only completed when recommended by the consultant pharmacist and that psychotropic medication consent forms were not completed or updated for multiple residents receiving psychotropic medications. The MDS nurse/ADON also stated that she did not complete AIMS assessments during MDS assessment time frames and agreed that such assessments should be completed for residents on psychotropic medications. The facility’s QAPI process did not show a clear performance improvement plan for these issues. Review of the QAPI binders showed no clear PIP plan, no documented process or expected improvement outcomes for the identified concerns, missing committee member reports in various months, and no clear process to measure improvement outcomes. The DON stated that the QAPI committee had not implemented a PIP into the QAPI process, that she was auditing nurse documentation as part of a PIP but did not record the necessary information to identify results, and that she did not report her information at the scheduled monthly QAPI meetings. She also stated that no board member was assigned to review and acknowledge facility policies and procedures or oversee the QAPI program. The physician agreement and QAA policy showed that the physician was expected to participate in the QA committee and that the committee was to meet monthly and review outstanding QAPI plans, but the survey findings showed no active physician guidance regarding the 14-day psychotropic stop-date requirement and no documented board oversight of the QAPI program.
Failure to Follow Legionella Surveillance and Water Management Policy
Penalty
Summary
The provider failed to ensure infection control practices and facility policies were followed regarding the assessment for the risk of Legionella, the implementation of measures to prevent the growth of Legionella, and the establishment of testing protocols for Legionella. During interview, the DON stated there was a hallway in the facility that was not currently occupied by residents, with eight rooms in that hallway. Two rooms were being used by contracted travel staff and the remaining rooms were vacant. She did not know whether water in the vacant rooms was being flushed to avoid stagnant water in the pipes, and she did not know whether there was a water flow map for the facility to identify areas where Legionella could grow and spread. She also stated the MM would be responsible for the water management program, and there had been no cases of Legionella infections identified at the facility. The MM stated the water systems had not been assessed to determine where Legionella or other opportunistic pathogens could grow, no measures had been implemented to prevent the growth of Legionella in the facility, and testing protocols to monitor for Legionella in the water system had not been followed as indicated in the facility policy. He also stated he was not aware of the need to routinely flush water in vacant rooms to avoid stagnant water and potential growth of waterborne pathogens in the pipes. Review of the facility's 2023 Legionella Surveillance policy showed the facility was to establish primary and secondary strategies for prevention and control of Legionella infections, implement primary prevention strategies when there had been no identified cases for at least one year, test the water supply annually, and maintain specified cold and hot water temperature controls.
Failure to Provide Bed-Hold Notices and Ombudsman Notifications
Penalty
Summary
The provider failed to ensure that residents or their representatives were given a bed-hold notice each time five sampled residents were transferred to the hospital. Review of the electronic medical records for residents 6, 7, 8, 26, and 30 showed hospital transfers, but there was no documentation that a bed-hold notice had been provided to the resident or the resident representative for those transfers. Several of the residents had resident representatives who acted on their behalf, including residents 6, 7, and 8, yet the records did not show that the required notice was issued at the time of hospitalization. The provider also failed to ensure that the ombudsman was notified of resident transfers to the hospital for residents 6, 26, and 30. The EMRs for those residents contained no documentation of ombudsman notification related to the hospital transfers. During interview, the DON stated the admission agreement included a bed-hold notification notice and that bed-hold policies were signed on the resident's initial admission day, but the resident or representative was not provided a bed-hold notice each time the resident was hospitalized. The DON also stated she was not aware that a bed-hold notice was required with each transfer to the hospital. The BOM and social service director stated they were not responsible for reporting transfers or discharges to the ombudsman and were not sure who was, and the ombudsman reported not receiving notifications from the provider.
RN Coverage and PBJ Submission Deficiency
Penalty
Summary
The facility failed to ensure accurate PBJ data submission to CMS for Federal Fiscal Quarter 2 of 2025, and the submitted report showed no RN coverage for eight consecutive hours on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. During interview, the DON confirmed there was not always an RN on duty for eight consecutive hours each day, confirmed there was no RN coverage on the dates identified, stated she was not aware RN coverage was needed seven days per week, and confirmed the provider had no nurse waiver. The BOM stated she began employment in January 2025 and completed the nurse scheduling, and that Administrator A assisted with submission of the Q2 2025 PBJ data to CMS. She stated she knew a skilled nursing facility needed RN coverage seven days a week, but was not aware this was required for a nursing facility that was not skilled. Review of the licensed nurse schedule for 8/1/25 through 8/24/25 showed no RN coverage on 8/9/25, 8/17/25, and 8/24/25, and both the BOM and DON confirmed those three days had no RN coverage. Review of the 6/2025 Facility Assessment showed no indication that an RN was required to work eight consecutive hours a day, seven days a week, and the facility had no staffing policy.
PBJ Staffing Data Submitted Without Required RN Coverage
Penalty
Summary
The facility failed to ensure that PBJ staffing data submitted to CMS for Federal Fiscal Quarter 2 of 2025 was accurate based on payroll and other verifiable and auditable data. Review of the Q2 2025 PBJ submission report showed no recorded 24-hour licensed nurse coverage on 1/2/25, 2/19/25, 3/15/25, and 3/22/25, and no RN coverage for a consecutive eight hours daily on 1/26/25, 2/2/25, 3/1/25, 3/8/25, 3/15/25, and 3/22/25. During interview, the DON confirmed there was no RN coverage on the identified Q2 2025 dates and stated she was not aware that RN coverage was needed seven days per week. She was able to provide documentation showing 24-hour licensed nurse coverage for the identified dates, but not consecutive eight hours of RN coverage. The BOM stated she started in January, assisted with the Q2 2025 PBJ submission with the Administrator, and did the scheduling; she said she knew a skilled nursing facility needed RN coverage 7 days a week, but was not aware that a nursing facility that was not skilled also needed it. Review of the licensed nurse schedule for 8/1/25 through 8/24/25 showed three days with no RN coverage, which was confirmed by both the BOM and DON.
QAPI Program Failed to Track Psychotropic Medication Monitoring and Documentation
Penalty
Summary
The facility failed to maintain an effective, ongoing QAPI program for identified high-risk and problem-prone areas involving psychotropic medications. During interviews, the DON stated that residents receiving PRN psychotropic medications were supposed to be reassessed by the physician every 14 days for renewal, but the pharmacy was not tracking the 14-day renewals consistently and there was no process in place before July 2025 to monitor medications requiring 14-day renewals. She also stated that some PRN psychotropic medication stop dates were entered as indefinite in the EMR, some residents continued to receive these medications beyond 14 days, and the facility had no psychotropic medication policy available for review. The DON further stated that a psychotropic risk assessment tool was not used routinely to monitor for adverse side effects in residents taking psychotropic medications, and that the TAR notation to monitor for side effects was not an assessment. She confirmed that AIMS assessments were only completed when recommended by the consultant pharmacist and that psychotropic medication consent forms were not completed or updated for multiple residents receiving psychotropic medications. The MDS nurse/ADON also confirmed that AIMS assessments were not completed during MDS assessment time frames, despite agreeing they should be used for residents on psychotropic medications. The facility’s QAPI records did not show a clear performance improvement plan for the identified concerns. Review of the QAPI binders showed no documented process, procedure, or expected improvement outcomes for the 14-day PRN psychotropic stop dates, consents, or assessment tools. Committee member reports were missing from the administrator’s binder in multiple months, no reports from the physician were maintained there, and the DON stated that the QAPI committee had not implemented a PIP into the QAPI process. She also stated that no board member was assigned to review and acknowledge facility policies and procedures or oversee the QAPI program, despite the physician agreement and QAA policy describing physician participation in QA/QAA committee functions.
Failure to Follow Legionella Surveillance and Water Management Policy
Penalty
Summary
The provider failed to ensure infection control practices and facility policies were followed regarding the assessment for the risk of Legionella, the implementation of measures to prevent the growth of Legionella, and the establishment of testing protocols for Legionella. During interview, the DON stated there was a hallway in the facility that was not currently occupied by residents, with eight rooms in that hallway. Two rooms were being used by contracted travel staff and the remaining rooms were vacant. The DON did not know whether water in the vacant rooms was being flushed to avoid stagnant water in the pipes, and did not know whether there was a water flow map to identify areas where Legionella could grow and spread. The DON identified the MM as responsible for the water management program, and stated there had been no cases of Legionella infections at the facility. During interview, the MM stated the water systems had not been assessed to determine where Legionella or other opportunistic pathogens could grow. He also stated no measures had been implemented to prevent the growth of Legionella in the facility, and testing protocols to monitor for Legionella in the water system had not been followed as indicated in the facility policy. He was not aware of the need to routinely flush water in vacant rooms to avoid stagnant water and potential growth of waterborne pathogens such as Legionella in the pipes. Review of the facility's 2023 Legionella Surveillance policy showed the facility's policy was to establish primary and secondary strategies for prevention and control of Legionella infections, including annual water testing and temperature controls for cold and hot water.
Failure to Complete Significant Change MDS Assessments After Fracture-Related Declines
Penalty
Summary
The provider failed to ensure that two residents who experienced significant declines after falls and fractures had significant change in status assessments completed. One resident with dementia, depression, and anxiety fell in her room, was hospitalized with a left hip fracture requiring surgical repair, and returned to the facility with increased pain, mental status changes, lower extremity impairment, and a decline in multiple ADLs, including oral hygiene, toileting hygiene, bathing, walking, positioning, transfers, and wheelchair mobility. Her MDS assessments were completed quarterly, but a significant change MDS was not completed to reflect these changes, and her MDS dated [DATE] was not coded for dementia. The second resident, who had dementia with behaviors, a history of falls, right hip pain, anxiety, and diabetes, fell after transferring herself from bed to wheelchair and sustained injuries including an eyebrow laceration, skin tears, bruising, and a fractured greater trochanter. After hospitalization, she returned with a scab to her eyebrow and bruising in multiple areas, including a large swollen bruise over her left hip. A significant change MDS was not completed after her return to reflect her decline in mobility, including inability to walk, need for staff assistance with transfers and repositioning, and decline in cognition. During interview, the MDS nurse/ADON confirmed responsibility for completing MDS assessments and stated she had not completed significant change assessments for residents who experienced changes in condition. She also stated she was still learning the MDS process, had not completed MDS certification training, and had no training on completion of a resident's MDS. CMS guidance in the report states that a significant change involves a major decline or improvement affecting more than one area of health status and requiring interdisciplinary review and/or care plan revision.
MDS Assessments Incorrectly Coded Bed Rails as Restraints
Penalty
Summary
The facility failed to ensure that two residents’ MDS assessments were accurately coded for restraints. Resident 4’s record showed a bed rail attached to the left side of the bed in the up position during observation, and her medical record identified the rail as a transfer loop used to promote independence with turning and repositioning in bed. Despite this, her 8/16/25 MDS coded the side rail as a restraint, and there was no other indication in the EMR that a restraint was being used. Resident 4 was admitted on 10/10/24 and had a BIMS score of 8, indicating moderate cognitive impairment. Her diagnoses included adjustment disorder, anxiety, depression, intellectual disability, hearing loss, insomnia, osteoarthritis, and heart failure. Her care plan stated she needed partial assistance from one staff member for transfers and that the transfer loop on her bed was used to maximize independence with turning and repositioning. Resident 3’s record showed she requested and used a side rail on the right side of her bed, but her 8/25/25 care plan did not include that she used a restraint or a side rail. Her 6/25/25 MDS also coded the side rail as a restraint, with no other indication in the EMR that a restraint was being used. The MDS Nurse/ADON stated she was responsible for completing MDS assessments, used quarterly side rail assessments to complete the MDS, confirmed the bed rails were not restraints, and said she coded them as restraints because that was how she understood the RAI manual; she also stated she had not reviewed the full restraint section and had not received formal MDS training.
Baseline Care Plans Not Developed With Resident Involvement
Penalty
Summary
The provider failed to ensure that the resident or the resident's representative was involved in developing a baseline care plan and given a copy of that plan within 48 hours of admission for four sampled residents. For one resident, the EMR showed admission to the facility and that she had a representative acting on her behalf, but there was no documentation that the baseline care plan was reviewed and acknowledged by the resident or representative, and no documentation that either was involved in its development or given a copy. For another resident, a baseline care plan dated 8/5/25 was only partially completed, with several sections left blank, and although it was signed by the DON, SSD, and MDS nurse/ADON, there was no documentation that the resident or representative was involved or received a copy. For two additional residents, the EMR also lacked documentation showing resident involvement in the baseline care plan process. One resident's baseline care plan was completed on 8/27/24 by the previous DON, but there was no documentation that the resident was involved or given a copy. Another resident's first baseline care plan was developed on 11/18/24 without documentation of resident involvement, and the record did not show resident involvement until 12/6/24. Staff interviews indicated that the DON completed baseline care plans upon admission, that CNAs were given pocket care plans and task lists, and that care plans were not being updated from the baseline care plan as residents' care needs changed. The facility policy stated that the baseline care plan was to be developed with information gathered from the resident and family within 48 hours of admission.
Care Plans Not Updated to Reflect Current Resident Needs
Penalty
Summary
The facility failed to develop, review, and revise comprehensive care plans to reflect residents’ current care needs for multiple sampled residents. For one resident with dementia, behavioral disturbances, major depressive disorder, and anxiety disorder, the care plan dated 2/7/24 was not revised after she fell on 7/16/25, sustained a left hip fracture, underwent surgical repair, and returned to the facility on 8/6/25. The care plan did not reflect her left hip fracture, impaired left lower extremity, weight-bearing status, need for PT, increased pain and tramadol use, change in mental status, dementia with behaviors, or changes in ADLs such as oral hygiene, toileting, bathing, walking, positioning, transfers, and wheelchair mobility. It also did not include her anticoagulant order for Eliquis or her psychotropic medications, monitoring for side effects, gradual dose reductions, and monthly pharmacy and physician reviews. Other residents’ records showed care plans that were not updated after admission or after changes in condition. One resident’s first care plan was documented 19 days after admission, and 21 of 25 areas had no documented intervention updates since 9/12/24. Another resident had no documentation of a comprehensive care plan after the baseline care plan was completed with missing interventions. A third resident’s first care plan was created on 11/11/24, and six of ten areas had no documented revision after 11/18/24. Another resident’s comprehensive care plan was created 93 days after admission, and there were no documented revisions since it was created on 7/17/25. For a resident with nicotine dependence, the care plan included an intervention to “Do not smoke,” but did not address that she was non-compliant with the smoke-free facility rules or that she used nicotine gum. The resident stated she had smoked outside a couple of times, had been caught, and sometimes gave her cigarette and lighter to staff when she went outside. The same resident had one-quarter side rails on her bed in the up position, stated she had asked for them to help her get in and out of bed, and her care plan did not include the side rail use. Interviews with the MDS nurse/ADON confirmed responsibility for revising care plans when care needs changed and that revisions had not been completed.
Psychotropic PRN Orders, Consent, and AIMS Monitoring Not Properly Managed
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had those medications managed in accordance with the documented requirements for PRN use, consent, and monitoring for adverse effects. Based on record review and interviews, PRN psychotropic medications were not discontinued after 14 days and did not have a documented rationale for continued use for four residents. The survey also found that AIMS assessments were not routinely completed for residents receiving psychotropic medications, and psychotropic consent forms were not obtained or maintained for multiple sampled residents. Resident 21 had multiple lorazepam PRN orders and a quetiapine order for unspecified dementia with anxiety. The EMR did not show a stop date or rationale for continuing the PRN lorazepam beyond 14 days, no psychotropic consent was documented for lorazepam or quetiapine, and no AIMS assessment was completed. Resident 26 had memantine ordered for dementia, but no consent was documented. Resident 1 had citalopram and buspirone ordered for anxiety; consent was present for buspirone but not for citalopram, and no AIMS assessments were completed for either medication. Additional sampled residents had similar issues. Resident 6 had buspirone, quetiapine, bupropion, and mirtazapine orders, but consent was only documented for mirtazapine and no AIMS assessment was found. Resident 7 had PRN lorazepam for panic attacks with no 14-day discontinuation date or reassessment rationale, no consent, and no AIMS. Resident 13 had sertraline, PRN lorazepam, and PRN morphine sulfate with no documented 14-day discontinuation dates or reassessment rationale for the PRN medications, no consent, and no AIMS. Resident 18 had sertraline, quetiapine, and buspirone ordered for behaviors, but no consent or AIMS documentation was found. Resident 23 had escitalopram, PRN lorazepam, and PRN morphine sulfate; the physician renewed the lorazepam and morphine use orders, but no consent or AIMS documentation was present. Resident 30 had fluoxetine, trazodone, bupropion, lamotrigine, risperidone, and PRN oxycodone; no 14-day discontinuation date or reassessment rationale was documented for the PRN oxycodone, no psychotropic consent was documented, and the last AIMS assessment had been completed months earlier.
Medical Director Did Not Carry Out Required Policy and QAPI Oversight
Penalty
Summary
The facility failed to ensure that MD C fulfilled his responsibilities as medical director under the physician agreement, including assisting with the development and implementation of patient care policies and participating in the QAA/QAPI process. The agreement required him to monitor medical care, assist with patient care policies, and consult with the Administrator and DON on staffing and quality of care matters. However, DON B stated that MD C had not reviewed the facility policies and procedures, and there was no designated board member reviewing them either. The policy binder showed the most recent review was completed by the Administrator and DON, with no documentation that MD C or a board member had acknowledged review of the policies. The survey also identified problems with the facility’s handling of as-needed psychotropic medications and related monitoring. DON B stated that residents receiving as-needed psychotropic medications were supposed to be seen by the physician and reassessed for renewal every 14 days, but some medications were continued beyond the 14-day stop date. She also stated that the facility had no psychotropic medication policy available for review and that the process needed improvement. She confirmed that the 14-day stop dates for as-needed psychotropic medications and monitoring for adverse effects using AIMS assessments were neither reported nor tracked in the facility’s QAA/QAPI program. Additional interviews showed that consultant pharmacist D sent monthly medication review recommendations to DON B, but MD C often took 30 days or longer to respond. MD C stated he conducted monthly medication reviews but could not provide guidance on the 14-day stop-date requirement for as-needed psychotropic medications and did not know whether he had attended the last six months of QAA/QAPI meetings. He also gave no meaningful information about his involvement in the facility’s policy and procedure process. The Administrator was unavailable for interview throughout the survey.
QAA/QAPI Committee Lacked Required Participation and Documentation
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA)/QAPI committee that included the required members and met as expected. During interview and record review, DON B stated that the facility held monthly QAA/QAPI meetings and that each department member was expected to attend and bring reports of the information they monitored. She also stated that attendance by committee members needed improvement, that MD C had not attended regularly and was not highly involved in the process, and that no board member had been assigned to review and acknowledge the facility policies and procedures or oversee the QAA/QAPI program. Review of the QAA/QAPI attendance records from February 2025 through July 2025 showed no documentation that MD C attended any meetings during the six-month period reviewed. There was also no documentation that dietary manager U attended any meetings during that period. RD T and MM G each attended one meeting in March 2025, BOM H attended one meeting in July 2025, and consultant pharmacist D attended one meeting in July 2025. The record review also showed that reports from MD C were not maintained in Administrator A's binder, and committee members' reports were missing from the binder in various months. MD C stated by telephone that he did not know whether he had attended the last six months of QAA/QAPI meetings and would have to check his calendar. DON B confirmed that neither MD C nor a board member discussed, reviewed, or signed the facility's policies and procedures to acknowledge approval during scheduled board or QAA/QAPI meetings. The provider's policy stated that the QAA committee would meet monthly, committee members would provide written review and reports, and quarterly QA meetings would include ancillary staff, the RD, and the Medical Director.
Failure to Complete Significant Change MDS Assessments After Fracture-Related Declines
Penalty
Summary
The provider failed to ensure that significant change MDS assessments were completed for two residents who experienced major declines in status after falls and fractures. For one resident, the record showed severe cognitive impairment, dementia with behavioral disturbances, depression, and anxiety, along with a fall that led to hospitalization for a left hip fracture requiring surgical repair. After returning to the facility, her MDS was not updated to reflect the fracture, increased pain, mental status changes, lower extremity impairment, opioid use for pain control, or multiple declines in ADLs, including bathing, toileting, walking, positioning, transfers, and wheelchair mobility. For the second resident, the record showed dementia with behaviors, a history of falls, right hip pain, anxiety, and diabetes. After she fell from her wheelchair, she sustained an open gash, skin tears, pain, and was hospitalized with a non-operative greater trochanter fracture. When she returned to the facility, documentation noted bruising at various healing stages and a large swollen bruise over her left hip. A significant change MDS assessment was not completed to reflect her post-fall decline, including loss of walking ability, increased need for staff assistance with transfers and repositioning, and worsening cognition. The MDS nurse/ADON stated she was responsible for completing MDS assessments, was still learning the process, had not completed MDS certification training, and confirmed that significant change assessments had not been completed for residents who experienced changes in condition. The CMS RAI Manual cited in the report defines significant change as a major decline or improvement affecting more than one area of health status and requiring interdisciplinary review and/or care plan revision.
MDS assessments incorrectly coded side rails as restraints
Penalty
Summary
The facility failed to ensure two sampled residents had accurate MDS assessments for restraints. Resident 4’s record showed an admission date of 10/10/24, a BIMS score of 8 indicating moderate cognitive impairment, and diagnoses including adjustment disorder, anxiety, depression, intellectual disability, hearing loss, insomnia, osteoarthritis, and heart failure. Her bed rail assessment stated the left side rail was used as an enabler to promote independence while in bed, and her care plan noted a transfer loop (side rail) on the bed to maximize independence with turning and repositioning. Despite this, her 8/16/25 MDS coded the side rail as a restraint, and the record contained no other indication that a restraint was being used. Resident 3’s record showed an admission date of 6/12/25, a BIMS score of 15 indicating intact cognition, and diagnoses including depression, left shoulder and arm pain, weakness, abnormal gait and mobility, chronic pain, amnesia, heart failure, and incontinence. Her 6/25/25 bed rail assessment indicated she had requested and used a side rail on the right side of her bed. However, her 8/25/25 care plan did not include that she used a restraint or a side rail, and her 6/25/25 MDS also coded the side rail as a restraint, with no other indication in the EMR that a restraint was being used. During interview, the MDS Nurse/ADON stated she was responsible for completing MDS assessments, completed quarterly side rail assessments, and used that information for MDS coding. She confirmed the bed/side rails were used for mobility and positioning in bed and were not restraints, but said she coded them as restraints because that was how she understood the RAI manual. She also stated she had not reviewed the entire restraint section of the RAI manual and had not received formal training in completing an MDS.
Baseline care plans were not developed with resident involvement or shared within 48 hours
Penalty
Summary
The provider failed to ensure that the resident or the resident's representative was involved in the development of a baseline care plan and given a copy of that care plan within 48 hours of admission for four sampled residents. For one resident, the EMR showed admission to the facility and that she had a resident representative acting on her behalf, but there was no documentation that the baseline care plan was reviewed and acknowledged by the resident or representative, and no documentation that either was involved in its development or given a copy. For another resident, a baseline care plan dated 8/5/25 was partially completed, with some sections filled in for initial goals, dietary orders, social services, ADLs, special treatments, bowel and bladder, skin concerns, and physician orders, while other sections such as therapy services, alarms and restraints, medications, discharge plans, and resident or caregiver education needs were left blank. For a third resident, the baseline care plan was completed on 8/27/24 by the previous DON, but there was no documentation that the resident was involved in developing the plan or given a copy. For a fourth resident, the first baseline care plan was developed on 11/18/24 without documentation of resident involvement, and the record did not show resident involvement until 12/6/24. Staff interviews indicated that the DON completed baseline care plans upon admission and that care plans were not being updated as residents' care needs changed. The facility policy stated that the baseline care plan was to be developed with information gathered from the resident and family within 48 hours of admission.
Care Plans Not Updated for Changed Resident Needs
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed within 7 days of assessment and were prepared, reviewed, and revised by a team of health professionals for multiple sampled residents. Review of records showed that resident 6’s care plan, last revised on 2/7/24, was not updated after her readmission following a fall and left hip fracture, despite changes in her condition including surgical repair of the fracture, impaired left lower extremity function, weight-bearing status, need for PT, increased pain with tramadol started on 7/25/25, altered mental status, dementia with behaviors, and multiple declines in ADLs. Her care plan also did not include her anticoagulant order for Eliquis or her psychotropic medications, monitoring needs, gradual dose reductions, or monthly pharmacy and physician reviews. Additional record review showed similar care plan deficiencies for other residents. Resident 1’s care plan had 25 areas of focus, and 21 had no documented intervention updates since 9/12/24. Resident 21 had no documentation of a comprehensive care plan after the baseline care plan was completed with missing interventions. Resident 26’s care plan had 10 areas of focus, and 6 had no documented revision after 11/18/24. Resident 12’s comprehensive care plan was created 93 days after admission and had no documented revisions since it was created on 7/17/25. Resident 5’s care plan also did not reflect current needs. She had nicotine dependence and a physician order for nicotine gum PRN, but her care plan only included an intervention to not smoke and did not address noncompliance with the facility’s smoke-free policy or nicotine gum use. She also had one-quarter side rails on her bed, which she said she requested to help her get in and out of bed, but her care plan did not include bed rail use. Interviews with the MDS nurse/ADON confirmed responsibility for completing and revising comprehensive care plans and that revisions had not been completed when new orders were added or conditions changed; the DON also stated that baseline and comprehensive care plans were available in the EMR.
Unnecessary Psychotropic Medication Use and Missing Monitoring
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had those medications managed in accordance with the documented requirements for PRN use, consent, and monitoring for adverse effects. Record review showed that PRN lorazepam orders for residents 7, 13, 21, and 30 did not have 14-day discontinuation dates or documented rationales for continued use beyond 14 days. In addition, several residents had psychotropic medications ordered for anxiety, depression, behaviors, dementia, or bipolar disorder without documented psychotropic consent forms in the medical record. The records for multiple sampled residents showed missing or incomplete monitoring for involuntary movement side effects. Residents 1, 6, 7, 13, 18, 21, 23, and 30 did not have routine AIMS assessments documented, and the survey findings specifically noted that resident 21, who had lorazepam and Seroquel orders for unspecified dementia with anxiety, had no documented psychotropic consent and no AIMS assessment. Resident 26 had Memantine ordered for dementia, but no consent was documented. Resident 1 had Buspar with consent documented, but no consent for Citalopram and no AIMS assessments. Resident 6 had buspirone, quetiapine, bupropion, and mirtazapine orders, with consent documented only for mirtazapine and no AIMS assessment documented. Additional records showed the same pattern for other residents. Resident 13 had sertraline, PRN lorazepam, and PRN morphine sulfate orders without documented 14-day discontinuation dates or reassessment rationale for the PRN medications, no psychotropic consent, and no AIMS assessment. Resident 18 had sertraline, quetiapine, and buspirone ordered for behaviors without documented psychotropic consent or AIMS assessment. Resident 23 had escitalopram, PRN lorazepam, and PRN morphine sulfate, with physician renewal of the PRN lorazepam and morphine use orders, but no psychotropic consent and no AIMS assessment. Resident 30 had fluoxetine, trazodone, bupropion, lamotrigine, risperidone, and PRN oxycodone, with no documented psychotropic consent, no current AIMS assessment since the last one was completed on 6/26/24, and no 14-day discontinuation date or reassessment rationale for the PRN medication order.
Medical Director Did Not Fulfill Policy and QAA/QAPI Responsibilities
Penalty
Summary
The facility failed to ensure that MD C fulfilled his role and responsibilities as medical director to assist with developing and implementing patient care policies and to participate in the QAA/QAPI process. During interviews, the DON stated that the facility had no psychotropic medication policy available for review, that she and the Administrator reviewed policies in January 2025 without MD C’s review, and that there was no designated board member reviewing facility policies and procedures. The policy binder showed the most recent review was initialed only by the Administrator and DON, with no documentation that MD C or a board member had reviewed or acknowledged the policies. The DON also described the facility’s process for residents receiving PRN psychotropic medications, stating that the physician was expected to reassess these orders every 14 days, but that medications could be ordered and filled before the physician’s visit and no progress note would be completed at that time. She confirmed that some residents’ medications with a 14-day stop-date requirement continued beyond 14 days. She further stated that the 14-day stop dates for PRN psychotropic medications and monitoring for adverse effects using AIMS assessments were neither reported nor tracked in the facility’s QAA/QAPI program. The consultant pharmacist reported that monthly chart reviews generated nursing and physician recommendations, which were emailed to the DON, but that it could take 30 days or longer for MD C to respond. MD C stated he conducted monthly medication reviews, but he was unable to provide guidance regarding the 14-day stop dates for PRN psychotropic medications, did not know whether he had attended the last six months of QAA/QAPI meetings, and provided no other information about active involvement in the facility’s QAA/QAPI process or policy review process. The Medical Director Physician Agreement required him to assist in developing and ensuring implementation of patient care policies and to consult with the Administrator and DON on monitoring care and quality of care.
QAA/QAPI Committee Lacked Required Participation and Documentation
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA)/QAPI committee that included the required members and met as expected. During interview and record review, the DON stated that monthly QAA/QAPI meetings were held and that each department member was expected to attend and bring a report of monitored information, but also stated that attendance by committee members needed improvement. She further stated that MD C had not attended regularly and was not highly involved in the process, and that no board member had been assigned to review and acknowledge the facility policies and procedures or oversee the QAA/QAPI program. Review of attendance records from February 2025 through July 2025 showed no documentation that MD C attended any meetings during that six-month period. The records also showed no documentation that dietary manager U attended any meetings during that period. RD T, MM G, BOM H, and consultant pharmacist D each attended only one meeting during the six-month period reviewed. The DON confirmed that neither MD C nor a board member discussed, reviewed, or signed the facility’s policies and procedures to acknowledge approval during scheduled board or QAA/QAPI meetings. Additional record review showed that no reports by MD C were maintained in the Administrator’s binder, and committee members’ reports were missing from the binder in various months. MD C stated during telephone interview that he did not know whether he had attended the last six months of QAA/QAPI meetings and would have to check his calendar. The provider’s QAA/QAPI policy stated that the committee would meet monthly, committee members would provide written review and reports to the chair, and quarterly QA meetings would include ancillary staff, the RD, and the Medical Director. The Medical Director agreement also stated that the physician would serve on the QA Committee, participate in QA Committee services and functions, and prepare reports and other records related to those activities.
Failure to Complete Level II PASRR After Significant Change in Treatment Needs
Penalty
Summary
The facility failed to ensure that one sampled resident had a Level II PASRR completed after a significant change in treatment needs. The resident’s initial PASRR dated 12/20/23 indicated she did not have an intellectual or developmental disability and did not have a serious mental illness, and that a Level II PASRR was not required unless she developed a serious mental illness, IDD, or a significant change in treatment needs. She was admitted to the facility and later developed anxiety disorder, major depressive disorder, and dementia with behavioral disturbances during her stay. Record review showed multiple psychotropic medication changes over time, including buspirone for anxiety, quetiapine for anxiety, bupropion for anxiety, mirtazapine, and later an additional quetiapine dose for anxiety. Her 8/13/25 BIMS score was 0, indicating severe cognitive impairment, and she had severely impaired daily decision-making skills, rarely or never understood others, and had short-term and long-term memory problems, inattention, and disorganized thinking. No documentation in her EMR showed that a Level II PASRR had been completed after the significant change in her treatment needs. During interview, the DON stated she did not complete PASRR screenings and that SSD F was responsible for them. SSD F confirmed she was responsible for PASRR screenings, stated she was unaware that a Level II PASRR should be completed when a resident had a significant change in mental or physical condition, and confirmed she had not completed a Level II PASRR for the resident. She also confirmed the resident should have had a Level II PASRR completed when she started on an antipsychotic medication. The facility policy stated that PASRR resident review is required upon a significant change in mental or physical condition and that PASRR documents should be available in the active chart.
Delayed Completion of Comprehensive Care Plans
Penalty
Summary
The provider failed to ensure that a comprehensive care plan was developed within 14 days of admission for four sampled residents. Resident 1 was admitted on an unspecified date, and the first care plan was not documented until 19 days later on 9/10/24. Resident 21 was admitted on an unspecified date and had a baseline care plan dated 8/5/25 that was only partially completed, with some sections filled in for initial goals, dietary orders, social services, ADLs, special treatments, bowel and bladder, skin concerns, and physician orders, while therapy services, alarms and restraints, medications, discharge plans, and resident or caregiver education needs were left blank. There was no documentation of a comprehensive care plan after that baseline care plan. Resident 12 was admitted on an unspecified date, and the comprehensive care plan was not created until 93 days later on 7/17/25, with no documented revisions since then. Resident 3 was admitted on 6/12/25, had a baseline care plan completed on 6/13/25, and her comprehensive care plan was not developed until 7/18/25, 36 days after admission. During interview, the MDS nurse/ADON stated she was responsible for completing the comprehensive care plans and agreed that the residents' comprehensive care plans were not created within 14 days of admission. The DON also confirmed that resident 3's comprehensive care plan was not completed within 14 days and stated she would have expected all residents' comprehensive care plans to be completed within 14 days of admission. The facility's policy stated that the MDS Coordinator or designee was responsible for notifying departments for completion of the care plan by day 14 of admission and that care plans should include measurable outcomes and specific interventions.
Failure to Document Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to ensure that three sampled residents who had bed rails or bars attached to their beds had documented attempts at alternative interventions before the rails were used. Resident 5 had quarter bed rails in the up position and stated she requested them so she could get in and out of bed; she did not remember signing a consent form or having other alternatives tried. Her signed Bed Rails Informed Consent listed the alternatives section as "Resident Requested." Resident 8 had a bed rail on the right side in the up position and stated she requested it to help her get in and out of bed; her record showed a bed rail assessment noting non-ambulatory status, a history of falls, poor bed mobility, difficulty with balance or trunk control, and a desire for side rails, but the consent form listed alternatives as "N/A" and "per resident request," and a later assessment was started but not completed. Resident 3 had a right-side bed rail in the up position and stated she used it to help sit up in bed. Her EMR showed a baseline care plan identifying use of a one-quarter right bed rail, and the bed rail assessment documented a history of falls, poor bed mobility, postural hypertension, and visual challenges, but there were no documented attempts at alternatives to bed rails. The DON stated that when residents requested a side rail, one was attached to the bed and that no alternatives were attempted before they were provided. The facility policy required appropriate alternative approaches to be attempted before installing or using bed rails and listed examples such as roll guards, foam bumpers, lowering the bed, and concave mattresses.
Daily Nurse Staffing Information Not Posted Correctly
Penalty
Summary
The provider failed to ensure that the required daily nurse staffing information was posted with the total number and actual hours worked by licensed and unlicensed nursing staff, and with the current resident census. On 8/25/25 at 3:15 p.m., the posted staffing information outside the activities room listed staff scheduled for the AM and NOC shifts and identified staff by pod, but it did not categorize staff as RN, LPN, or CNA and did not list the total number of each discipline. The hours worked were combined by shift in the Total Hours area, and the separate resident listing above the form did not show the total resident census. The resident listing was dated 8/12/25, indicating it had not been updated to reflect the current census. During interviews, the DON stated the BOM was responsible for posting the daily nurse staffing information and believed the BOM updated it when staffing changed. The DON was unaware that the posted information needed to include the total number and actual hours worked by each nursing discipline and the current resident census. The BOM stated she was not aware of those posting requirements and said staffing updates were usually made about a week later for internal record-keeping. She also stated she was not aware the posted staffing information needed to be updated daily for residents and visitors to review. A policy regarding posting nursing staffing information was requested, and the DON stated the provider did not have a specific policy related to posting nursing staffing information.
Failure to Inspect and Monitor Bed Rails for Safety
Penalty
Summary
The provider failed to ensure that bed and side rails for three sampled residents were inspected for safety, including entrapment risk, before being placed on the residents’ beds and were monitored after installation to ensure they remained safe for use. Observation on 8/20/25 found resident 5’s bed with one-fourth-size side rails attached to the sides of the bed and in the up position. Observation and interview on 8/21/25 found resident 8’s bed with a side rail on the right side in the up position. Observation on 8/25/25 found resident 3’s bed with a side rail attached to the right side and in the up position. During interview on 8/25/25, the maintenance manager stated that when nursing notified him that a resident wanted side rails attached, he would install them, but he had not performed routine maintenance or checked the safety of side rails on resident beds, including entrapment. Review of the facility’s 12/2023 Proper Use of Bed Rails policy stated that if bed rails are used, the facility ensures correct installation, use, and maintenance, including assessment of the resident, bed, mattress, and rail for entrapment risk and regular inspection of mattresses and bed rails for possible entrapment.
Failure to Complete Level II PASRR After Significant Change in Mental Status
Penalty
Summary
The facility failed to ensure that one resident had a Level II PASRR completed after significant changes in treatment needs. The resident’s initial PASRR dated 12/20/23 indicated she did not have an intellectual or developmental disability and did not have a serious mental illness, and that a Level II PASRR was not required unless she developed a serious mental illness, IDD, or a significant change in treatment needs. She was admitted to the facility and later developed multiple mental health diagnoses during her stay, including anxiety disorder on 8/15/24 and major depressive disorder on 4/21/25. During the resident’s stay, physician orders were received for psychotropic medications to treat her mental health conditions and behaviors, including buspirone, quetiapine, bupropion, mirtazapine, and an additional dose of quetiapine after she was later diagnosed with dementia with behavioral disturbances on 8/19/25. Her 8/13/25 BIMS score was 0, indicating severe cognitive impairment, and staff documented that she had severely impaired daily decision-making skills, rarely or never understood others, and had memory problems, inattention, and disorganized thinking. No documentation in her EMR showed that a Level II PASRR had been completed after the significant change in treatment needs. The DON stated she did not complete PASRR screenings and that the SSD was responsible for them. The SSD confirmed she was responsible for PASRR screenings, stated she was unaware that a Level II PASRR should be completed when a resident experienced a significant change in mental or physical condition, and confirmed she had not completed a Level II PASRR for the resident. She also confirmed the resident should have had a Level II PASRR completed when she started on an antipsychotic medication. The facility policy stated that PASRR resident review is required upon a significant change in mental or physical condition and that PASRR documents should be available in the active chart.
Delayed Completion of Comprehensive Care Plans
Penalty
Summary
The provider failed to ensure that comprehensive care plans were developed within 14 days of admission for four sampled residents. Resident 1 was admitted on an unspecified date, and the first care plan was documented 19 days later. Resident 21 was admitted on an unspecified date and had a baseline care plan dated 8/5/25 that was only partially completed, with sections left blank for therapy services, alarms and restraints, medications, discharge plans, and resident or caregiver education needs; there was no documentation of a subsequent comprehensive care plan. Resident 12 was admitted on an unspecified date and did not have a comprehensive care plan created until 93 days later, with no documented revisions after it was completed. Resident 3 was admitted on 6/12/25, had a baseline care plan completed on 6/13/25, and did not have a comprehensive care plan developed until 36 days after admission. During interview, the MDS nurse/ADON stated she was responsible for completing the comprehensive care plans and agreed that the residents' comprehensive care plans were not created within 14 days of admission. The DON also confirmed that resident 3's comprehensive care plan had not been completed within 14 days and stated she would have expected all residents' comprehensive care plans to be completed within that timeframe. The facility policy stated that the MDS Coordinator or designee was responsible for notifying departments so the care plan could be completed by day 14 of admission, and that care plans should include measurable outcomes, specific interventions, and be reviewed quarterly, annually, and with significant changes in condition.
Bed Rail Use Lacked Documented Alternative Attempts
Penalty
Summary
The provider failed to ensure that three sampled residents who had bed rails attached to their beds had documented attempts at alternative interventions before the rails were used. Resident 5 had quarter bed rails in the up position and stated she requested them to help her get in and out of bed; she did not remember signing consent or having alternatives tried. Her signed bed rail consent listed the alternative section as “Resident Requested.” Resident 8 had a bed rail on the right side in the up position and said she requested it for getting in and out of bed; her record showed a bed rail assessment noting non-ambulatory status, a history of falls, poor bed mobility, difficulty with balance or trunk control, and a desire for side rails, but the later assessment was not completed and the consent listed alternatives as “N/A” and “per resident request.” Resident 3 had a right-side bed rail in the up position and said she used it to help sit up in bed. Her baseline care plan and bed rail assessment documented a history of falls, poor bed mobility, postural hypertension, and visual challenges, but the assessment also recorded that she had not expressed a desire for side rails while the placement section stated she did express such a desire. The record contained no documented attempts at alternatives to bed rails, and her signed consent listed alternatives as “N/A - Resident Requested.” The DON stated that when residents requested a side rail on admission, one was attached to the bed and that no alternatives were attempted before providing it. The facility policy required appropriate alternative approaches to be attempted before installing or using bed rails and required documentation of those attempts.
Daily Nurse Staffing Information Not Posted Correctly
Penalty
Summary
The facility failed to ensure that the required daily nurse staffing information was posted with the total number and actual hours worked by licensed and unlicensed nursing staff, and with the resident census current and posted daily. During observation on 8/25/25 at 3:15 p.m., the posted staffing form outside the activities room listed staff scheduled for the AM and NOC shifts by pod, but it did not identify whether each staff member was an RN, LPN, or CNA, and it did not list the total number of each discipline. The form also combined staff hours by shift in the Total Hours area rather than showing actual hours worked by each nursing discipline. A separate paper posted above the staffing form listed room numbers and resident names, but it did not show the total resident census, and the date on that resident listing showed it had last been updated on 8/12/25. In interviews, the DON stated the BOM was responsible for posting the staffing information and was unaware that the total number and actual hours worked by each nursing discipline, along with the current resident census, were required on the posted form. The BOM stated she updated the form when staffing changed, but those updates were usually done about a week later for internal record-keeping, and she was not aware the information needed to be updated daily for residents and visitors to review. The DON also stated the facility did not have a specific policy related to posting nursing staffing information.
Failure to Inspect and Monitor Bed Rails for Safety
Penalty
Summary
The provider failed to ensure that bed and side rails for three sampled residents were inspected for safety, including entrapment risk, before being placed on their beds and were monitored after installation to ensure they remained safe for use. Resident 5 was observed on 8/20/25 with one-fourth-size side rails attached to both sides of the bed in the up position. Resident 8 was observed and interviewed on 8/21/25 with a side rail on the right side of the bed in the up position. Resident 3 was observed on 8/25/25 with a side rail attached to the right side of the bed in the up position. During interview on 8/25/25, the maintenance manager stated that when nursing notified him that a resident wanted side rails attached, he would install them, but he had not performed routine maintenance or checked the safety of side rails on resident beds, including entrapment. Review of the facility’s 12/2023 Proper Use of Bed Rails policy stated that if bed rails are used, the facility ensures correct installation, use, and maintenance, including assessment of the resident, bed, mattress, and rail for entrapment risk, checking compatibility of the bed rails, mattress, and bed frames, and regularly checking mattresses and bed rails for possible entrapment areas.
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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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 July 2026) and official state health department websites.