Five Counties Nursing Home: Bed Rail Safety Gaps - SD
Federal inspectors documented the failures during a March 12, 2025 survey of the facility at 405 6th Avenue West. The deficiency affected more than one resident. Inspectors classified the level of harm as minimal harm or potential for actual harm, which is the lower end of the federal scale, but the finding points to a breakdown in a safety process that exists specifically to prevent serious injury.
Bed assist bars, sometimes called bed rails, are among the more deceptively dangerous pieces of equipment in a nursing home. They are designed to help residents reposition themselves, get in and out of bed, or feel more secure. They also create gaps between the rail and the mattress, or between the rail and the bed frame, where a resident's head, neck, or limb can become trapped. The risk is not theoretical. Entrapment has killed nursing home residents. It is why the evaluation process exists at all.
At Five Counties, that process was not followed.
The facility's own written procedure required that before any bed assist bar is installed, a charge nurse or designee complete an assistive device assessment. That assessment is supposed to work through a specific set of questions: Why does this resident need a bed assist bar? What alternatives were tried first, or considered and ruled out? What are this resident's particular risks, given their cognition, their mobility, their ability to communicate if something goes wrong?
None of that was documented as having happened before installation.
The same procedure required that once a bar is in place, staff complete a re-evaluation every quarter to determine whether the resident still needs it and whether continued use remains appropriate. Inspectors found that ongoing assessment was not being maintained either.
And the residents themselves, or their representatives, were not informed of the risks. That piece matters because a resident who understands the danger of entrapment, or whose family understands it, can make an informed decision about whether the bar is worth using. A resident who doesn't know the risk cannot.
Five Counties is a nursing home in the far northwest corner of South Dakota, in Perkins County, one of the most sparsely populated counties in the state. Lemmon sits near the North Dakota border, and for many residents of the surrounding area, Five Counties is the closest long-term care option available. That geographic reality shapes what options families have when a loved one needs placement.
The deficiency cited in March was tagged at the minimal harm level, which means inspectors did not find evidence that a resident had already been injured as a result of the missing assessments. That is a meaningful distinction. It also has limits as reassurance. The assessment process is designed to catch problems before they become injuries. When the process is skipped, the absence of documented harm doesn't mean the risk wasn't there.
The facility's plan of correction was not included in the inspection materials reviewed for this report. For information on how Five Counties intends to address the deficiency, the facility or the South Dakota Department of Health survey agency can be contacted directly.
What the inspection record shows is a gap between a written safety procedure and what was actually happening in residents' rooms. Somewhere between the policy that said evaluate first and the bed rail that went up anyway, the check didn't happen. The resident lying next to that rail, and the family who trusted the facility to manage that risk, were not part of the conversation.
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 9, 2026 · Our methodology
Five Counties Nursing Home in LEMMON, SD was cited for violations during a health inspection on March 12, 2025.
Federal inspectors documented the failures during a March 12, 2025 survey of the facility at 405 6th Avenue West.
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.