Five Counties Nursing Home: Medicare Form Violations - SD
That is what a March 2025 inspection found at the 405 6th Avenue West facility in this small city in the far northwest corner of South Dakota.
The form at the center of the findings is called a Skilled Nursing Facility Advance Beneficiary Notice, or SNF ABN. It is the document nursing homes give residents to notify them that Medicare is about to stop paying for their care. The form is supposed to include the specific date coverage ends so residents can make informed decisions about whether to stay, appeal, or make other arrangements. Without that date, the form does not tell the resident what they most need to know.
Inspectors reviewed the records of three residents and found problems with all three.
Resident 10's form was missing the section that stated when Medicare coverage ended, and that section appeared to have been whited out. The date box on the form carried a typewritten date of December 22, 2024.
Resident 33's form had the same problem. The coverage-end section was gone, apparently whited out. Another typewritten date sat in the date box.
Resident 41's record showed her last covered day of Medicare Part A skilled services was December 23, 2024. Her form was also missing the coverage-end date section, which appeared to have been whited out, and the date box carried a typewritten date of December 20, 2024.
Three residents. Three forms. The same section missing from each one.
When inspectors sat down with the administrator on March 11, 2025, she confirmed what the records showed. She agreed that the section of each form that included the date Medicare coverage ended was missing and appeared to have been whited out on all three residents' forms.
There was a second problem she could not explain. Residents 10 and 33 were cognitively intact. They were capable of signing their own documents. But their SNF ABN forms had been signed by family members over the phone, not by the residents themselves. The administrator said she was unsure why that had happened.
She did offer one explanation for how the forms ended up in this condition. The previous Director of Nursing, identified in the inspection report as DON P, had been responsible for the SNF ABN forms at the time they were provided to residents 10, 33, and 41. The administrator did not elaborate on where DON P was at the time of the inspection, or whether the facility had taken any action in response to the altered forms before inspectors arrived.
The SNF ABN exists specifically to protect residents at one of the most financially consequential moments of a nursing home stay, the point where Medicare stops paying and the resident suddenly faces the full daily cost of their care. A form with the coverage-end date removed does not protect anyone. It leaves the resident without the one piece of information the form was designed to deliver.
Inspectors rated the violation at the level of minimal harm or potential for actual harm, and noted that some residents were affected.
Whether residents 10, 33, or 41 made decisions about their care or finances based on incomplete forms, and what those decisions cost them, the inspection report does not say.
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 7, 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 a March 2025 inspection found at the 405 6th Avenue West facility in this small city in the far northwest corner of South Dakota.
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.