Five Counties Nursing Home: Bed Rail Safety Gaps - SD
The inspection, completed March 12, 2025, found that the nursing home had failed to ensure its bed assist bars were being properly monitored and maintained, leaving open the possibility that gaps between a bar, mattress, and bed frame could become large enough to trap a resident's head or body. The deficiency was cited at a level of minimal harm or potential for actual harm, and affected some residents.
The bed assist bar is a common piece of equipment in nursing homes, a metal rail that attaches to the side of a bed to help residents reposition themselves, sit up, or avoid rolling out during the night. It looks simple. The hazard it presents is not. When a bar shifts, loosens, or is mismatched to a particular mattress and bed frame combination, the gap it creates can catch a resident's head or body, and a person who is frail, disoriented, or unable to call for help can become trapped.
Five Counties had a policy that acknowledged this directly. The facility's own Bed Assist Bar Policy and Procedure, though undated, spelled out in clear terms what staff were supposed to do. Bars were to be installed using manufacturer instructions. Mattresses, frames, and bars were to be confirmed compatible before installation. Staff were required to check bars regularly because, the policy noted, "bars may shift or loosen over time." Routine preventative maintenance was to ensure equipment met current safety standards and was not in need of repair. The gap between bar and mattress, the policy stated, should never be wide enough to entrap a resident's head or body, regardless of mattress dimensions.
The policy existed. The monitoring form existed. What inspectors examined was whether the system those documents described was actually operating.
The monitoring form itself had designated columns: the date, the room number monitored, the date repairs were done, comments, and initials. It was the kind of form that, filled in consistently, would show a facility actively tracking a known hazard room by room, month by month. The first entry on the form was dated May 2, 2024. Room 11-2 was listed as the room monitored. Under comments, someone had written "will check quarterly." The initials belonged to the maintenance director, identified in the report as Maintenance Director F.
One entry. May 2024. Check quarterly.
The inspection was in March 2025. That is, at minimum, three quarters that could have been documented after that first entry. The inspection report does not describe subsequent entries filling those columns. It does not describe a completed record showing Room 11-2 checked again in August, then November, then February. What it describes is a form with a starting point and a policy that said quarterly checks should follow.
The facility's own procedure required checking bars regularly and conducting routine preventative maintenance. The monitoring form was the mechanism for proving that happened. An underpopulated form is not proof it happened.
What makes bed assist bar entrapment a particular concern in a nursing home population is the nature of the residents at risk. People who need bed rails are, by definition, people who have trouble moving safely on their own. They may have dementia and not understand that they are caught. They may have had a stroke and lack the strength or coordination to pull free. They may be heavily medicated and not fully alert to their own distress. A gap that a healthy adult would notice and avoid in seconds can hold an elderly nursing home resident long enough to cause serious injury or death.
The federal government has tracked entrapment deaths in this equipment category for decades. The concern is not theoretical. It is the reason facilities like Five Counties are required to have policies like the one inspectors reviewed, and why those policies require not just installation checks but ongoing monitoring.
Five Counties' policy was specific about what ongoing monitoring meant. It meant checking that the bar was still installed correctly, not just on the day it was put in. It meant following manufacturer alerts and recalls. It meant confirming, on a continuing basis, that no gap had opened up that could catch a resident. The word "regularly" appeared in the policy more than once.
The maintenance director's single May 2024 entry and the notation "will check quarterly" suggests awareness of the requirement. It does not, based on what inspectors found and documented, demonstrate that the quarterly checks that were supposed to follow were completed and recorded.
The deficiency was not cited at the highest level of harm. No resident was documented as having been injured by a bed assist bar at Five Counties in connection with this inspection. The citation reflects potential, the space between a policy that exists on paper and a monitoring practice that inspectors could not confirm was happening in the rooms.
But potential is the category that precedes actual. The gap on a monitoring form and the gap between a mattress and a bed rail are, in this context, the same kind of problem: something that should have been closed, that wasn't, that nobody outside the facility would have known about until an inspector walked in and asked to see the paperwork.
Five Counties Nursing Home sits on 6th Avenue West in Lemmon, a small city in Perkins County in the northwest corner of South Dakota. For residents there, the facility is not one option among many. It is, in a region of that size, likely the option. The people sleeping in those beds, including Room 11-2, are not in a position to transfer to another facility if they learn their bed rail was last formally checked ten months ago.
The monitoring form had space for dates, room numbers, repair dates, comments, initials. It had all the right columns. What it needed, and what inspectors found missing, was evidence that someone had come back to fill them in.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
The deficiency was cited at a level of minimal harm or potential for actual harm, and affected some residents.
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.