Five Counties Nursing Home: Blood Sugar Failures - SD
Federal inspectors documented the gap during a March 12 survey of the 405 6th Avenue West facility. A nurse interviewed that day described her routine for handling low blood sugar readings, defined at the facility as anything below 70. She would withhold the scheduled insulin dose, give the resident juice, and recheck the blood sugar after fifteen minutes. She confirmed she was documenting those rechecks, but not in the right place and not completely. She was logging them under the vital signs tab in the electronic medical record. She was not documenting the hypoglycemic event itself.
That distinction matters. A blood sugar crash is a clinical event, not a routine vital sign. The facility's own standing orders treated it that way.
Those orders, which were undated, laid out a specific sequence for hypoglycemia. If a resident was conscious and able to swallow, staff were to give six ounces of juice, milk, regular soda, or another high-carbohydrate drink. They were to recheck blood sugar after fifteen minutes. If it was still below 70, they were to repeat the treatment. If two rounds of treatment failed to bring the number up, they were to call the provider. Once the resident stabilized, they were to check again at the sixty-minute mark. And they were to communicate any hypoglycemic event to the provider the next business day.
That last step requires a record. You cannot communicate an event you have not documented.
The director of nursing, identified in the report only as DON B, told inspectors she expected staff to follow the provider's policy. She said the treatment for a low blood sugar would involve glucagon or another intervention per standing orders. She expected a recheck after treatment. She expected all of it documented in the electronic medical record.
What inspectors found in the records did not match what the director of nursing said she expected.
The facility's medication management policy added another layer. It stated that medications are administered in accordance with written orders of the attending physician. Holding insulin during a hypoglycemic episode is itself a medication decision, one that the standing orders authorized but that also required documentation to confirm it happened and that the follow-up steps were completed.
The inspection report classified the violation as causing minimal harm or potential for actual harm and noted that some residents were affected. Hypoglycemia, even when treated successfully in the moment, carries real risk. Blood sugar that drops once is more likely to drop again. A provider who is never told about a hypoglycemic event cannot adjust medications, change a meal plan, or flag a pattern. Without documentation, that conversation never happens.
The nurse interviewed by inspectors did not describe skipping the treatment steps. By her own account, she was doing the clinical work. The failure was in the recording, in the translation of what happened at the bedside into the chart that the provider, the next shift, and the next nurse would rely on.
Inspectors found no evidence that the follow-up rechecks at sixty minutes, or the next-business-day notifications to providers, were being completed as written. The standing orders existed. The director of nursing knew what they required. The nurse on the floor knew how to treat a low blood sugar. Somewhere between the bedside and the medical record, the trail went cold.
For the diabetic residents at Five Counties whose blood sugar had been dropping below 70, their providers were making care decisions without knowing it had happened at all.
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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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 gap during a March 12 survey of the 405 6th Avenue West facility.
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.