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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D9 | E7 | F5 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Aug 6, 2026 | Fire safety | Fire Safety Standard | 0 | No citations | — | Open → |
| Aug 6, 2026 | Health | Health Standard | 2 | Potential harm | — | Open → |
| Aug 26, 2025 | Fire safety | Fire Safety Standard | 2 | Potential harm | — | Open → |
| Aug 26, 2025 | Health | Health Standard | 17 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D9 | E7 | F5 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 6, 2026 | F-0578 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 23, 2026 | |
| Aug 6, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Aug 23, 2026 | |
| Aug 26, 2025 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: — (case-mix index —).
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Custer Cares | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Dec 1, 2023 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Custer Cares | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Dec 1, 2023 |
| Madison Barta | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Dec 1, 2023 |
| Janet Boyer | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 1, 2023 |
| Monica Mcgowan | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 1, 2023 |
| Mike Tennyson | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 1, 2023 |
Coordinates as published by CMS.
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 435136 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 435136 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies · Emergency preparedness |
| D · Potential harm Isolated |
| Corrected Oct 10, 2025 |
| Aug 26, 2025 | K-0919 | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 14, 2025 |
| Aug 26, 2025 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0637 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 15, 2025 |
| Aug 26, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 15, 2025 |
| Aug 26, 2025 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 15, 2025 |
| Aug 26, 2025 | F-0727 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Nov 15, 2025 |
| Aug 26, 2025 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Oct 16, 2025 |
| Aug 26, 2025 | F-0841 | Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0865 | Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Oct 10, 2025 |
| Aug 26, 2025 | F-0909 | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 10, 2025 |
| Samuel Van Voorst |
| Individual |
| Operational / managerial control |
| OPERATIONAL/MANAGERIAL CONTROL |
| not provided |
| Sep 1, 2023 |
| Ricky Wheeler | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Sep 1, 2023 |
| Custer Cares | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Dec 1, 2023 |
| Madison Barta | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Dec 1, 2023 |
| Samuel Van Voorst | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Sep 1, 2023 |