Five Counties Nursing Home: Antipsychotic Oversight Failures - SD
That is what inspectors found at Five Counties Nursing Home during a March 12, 2025 inspection.
The resident at the center of the finding, identified in inspection records as Resident 5, was being monitored through AIMS evaluations, a standardized assessment used to detect tardive dyskinesia and other movement disorders that can develop in people taking antipsychotic medications long-term. The evaluations are not routine paperwork. Tardive dyskinesia causes repetitive, involuntary movements that can become permanent. The facility's own antipsychotic medication policy spelled out that any changes found through those assessments must be reported to the physician.
Nobody reported them.
The assistant director of nursing, identified in the report as ADON G, confirmed it directly during an interview with inspectors at 11:27 a.m. on the day of the inspection. Neither the physician nor the mental health provider had been notified of the changes in Resident 5's AIMS evaluations.
The facility's director of nursing, interviewed separately, acknowledged something else had also gone undone. A gradual dose reduction, the process by which facilities are expected to periodically attempt lowering antipsychotic doses to determine whether a resident still needs them at current levels, had not been presented to Resident 5's primary care physician or mental health provider. He told inspectors there may have been a gap in services.
A gap in services is one way to describe it.
The facility's own written policy, which inspectors reviewed, is detailed and specific about what staff are supposed to do. Nursing is required to monitor antipsychotic use daily, watching for a list of serious adverse effects: excessive sleepiness, functional decline, cardiac arrhythmias, symptoms resembling Parkinson's disease, akathisia, tardive dyskinesia, involuntary muscle contractions, anticholinergic side effects, and dangerous drops in blood pressure when a resident stands. If any of those effects appear, the charge nurse is required to document them and notify the primary care physician.
The policy also requires that AIMS assessments be performed every three to six months, and that any changes be reported to the physician. Gradual dose reduction recommendations are to be given to the physician unless the physician has documented a specific clinical reason why reducing the dose would harm the resident.
The gap between what the policy required and what actually happened with Resident 5 was not a matter of interpretation. The AIMS evaluations had been conducted. Changes had been noted. The physicians whose job it was to respond to those findings had simply never been told.
Antipsychotic medications are among the most scrutinized drugs in nursing home care, in part because of a long history of their use as chemical restraints on elderly residents with dementia, and in part because their side effects can be severe and sometimes irreversible. Tardive dyskinesia, one of the conditions the AIMS test is specifically designed to catch early, does not always resolve when the medication is stopped. The window for intervention matters.
When a physician is not told that a resident's monitoring scores have changed, that window can close without anyone in a position to act ever knowing it was open.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. The finding was documented under the category governing unnecessary drug use and antipsychotic medication oversight.
Five Counties Nursing Home's own policy described the clinical rationale required before a dose reduction could be skipped: the physician must document why an additional reduction attempt would likely impair the resident's function or cause psychiatric instability. That documentation requires a physician who has been told what the evaluations found.
Resident 5's physicians were not told. What they would have done with the information remains unknown.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Five Counties Nursing Home from 2025-03-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 10, 2026 · Our methodology
Five Counties Nursing Home in LEMMON, SD was cited for violations during a health inspection on March 12, 2025.
That is what inspectors found at Five Counties Nursing Home during a March 12, 2025 inspection.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.