Five Counties Nursing Home: Narcotic Count Failures - SD
The finding affected many residents.
Narcotic count sheets are the basic paper trail that keeps controlled substances accountable inside a long-term care facility. A nurse going off shift and a nurse coming on are supposed to physically count every narcotic on hand and sign off together. The number on the sheet has to match what's in the drawer. When a sheet runs out, a new one gets requested from the pharmacy. When it's full, it goes to medical records, where it stays for three years.
At Five Counties, that system had broken down.
Inspectors found that count sheets were not being maintained for all narcotics in the building. In some cases, a sheet had never arrived from the pharmacy. In others, sheets that did exist weren't being used correctly, meaning the counts recorded on them couldn't be trusted. Completed sheets weren't making it to medical records the way they should have.
The pharmacy can send a replacement sheet when one goes missing. That's not a complicated fix. Someone has to ask for it.
Nobody had.
The inspection report does not describe a specific incident in which a resident was harmed, a pill went missing, or a diversion was confirmed. The cited level of harm is minimal, meaning inspectors found no evidence of actual injury. But the finding covers many residents, and the significance of a broken narcotic tracking system isn't measured only in confirmed thefts. It's measured in what you can no longer prove didn't happen.
When count sheets are missing or wrong, a facility loses the ability to account for controlled substances at all. Opioids, sedatives, and other narcotics prescribed to nursing home residents are among the most tightly regulated medications in medicine for a reason. Residents in long-term care are often unable to advocate for themselves if their medication isn't administered correctly. They may not know what they're supposed to receive, or when. The count sheet is one of the few mechanisms that creates a record someone else can check.
Five Counties Nursing Home sits on 6th Avenue West in Lemmon, a small city of roughly 1,200 people in Perkins County, near the North Dakota border. For many residents, it is the closest skilled nursing facility available. The inspection was conducted on March 12, 2025.
The deficiency was cited under a standard requiring that controlled substances be stored and accounted for in a manner that prevents diversion and ensures accurate records. The plan of correction, if one has been filed, is available through the nursing home or the South Dakota Department of Health.
What the inspection report leaves open is how long the count sheets had been missing or inaccurate before inspectors arrived. A gap in documentation that spans days is a different problem than one that spans months. The report doesn't say. It notes the condition existed, that it touched many residents, and that the facility had not resolved it on its own before the inspection found it.
A nursing home that cannot produce accurate narcotic counts cannot demonstrate that every resident received every dose they were prescribed. It also cannot demonstrate that doses were not taken by someone else.
That uncertainty is the finding. Not a confirmed diversion, not a named resident who went without pain medication, not a staff member under investigation. Just a paper trail that wasn't there, for drugs that require one, in a facility where the people most affected are often the least able to ask what happened to their medication.
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.
The finding affected many 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.