Five Counties Nursing Home: Care Plan Failures - SD
The man's admission diagnoses read like a checklist of vulnerabilities. Muscle weakness. Abnormalities of gait and mobility. Low vision in both eyes. Anemia. Chronic congestive heart failure. He needed help with nearly every activity of daily life, including transferring between surfaces, walking, getting dressed, bathing, eating, and using the toilet. His hearing was impaired. His balance was poor enough that staff had documented his fall history as a specific focus of his care.
When he arrived on August 30, 2024, the facility initiated an interim care plan that same afternoon. It covered his vision impairment, his hearing problems, his mobility risks, and his need for hands-on assistance throughout the day. Staff finalized and locked the document on September 3. Four days after admission, the plan was complete and sitting in his record.
Nobody gave it to him. Nobody gave it to his representative either.
There is no documentation in his record that anyone reviewed the interim or baseline care plan with him or with anyone acting on his behalf. The inspection report, completed March 12, 2025, found no evidence that this step had ever been taken.
By September 3, a formal cognitive assessment had placed his score at 8 on the Brief Interview for Mental Status, a result that indicated moderately impaired cognition. He was not a man who could be expected to independently advocate for himself, track what care he was supposed to receive, or notice when something was missing from his daily routine. He depended on staff to know his plan and follow it. He depended on someone, whether a family member, a legal representative, or a facility staff member, having reviewed what was written down and confirmed it matched his needs.
That conversation, if it happened at all, left no trace.
Care plans in nursing homes are not administrative paperwork. For a resident with severely impaired vision and a documented fall risk, the mobility assistance section of a care plan tells staff how to move him safely, what equipment to use, what precautions to take. The communication section tells staff how to reach someone who cannot hear well. The ADL section tells aides what he can do for himself and where he needs help. When a resident or their representative never receives that document, they have no way to know whether what staff is actually doing matches what was planned, and no basis to raise a concern if it does not.
The inspection covered multiple residents, and the deficiency was cited as affecting some residents, with a level of harm characterized as minimal harm or potential for actual harm.
Five Counties Nursing Home is a 50-bed facility at 405 6th Avenue West in Lemmon, a town of roughly 1,200 people in the far northwest corner of South Dakota. For residents and families in communities this size, it is often the only option within a reasonable distance. There is no competing facility down the road to transfer to, no easy way to comparison shop, no practical alternative if care falls short.
The man's record shows a facility that did the work of writing a care plan and then stopped short of the step that would have made it meaningful. The assessment was completed. The focus areas were identified. The document was locked. And then, as far as inspectors could determine, it sat.
Whether anyone has since reviewed that plan with him or his representative, the inspection record 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 8, 2026 · Our methodology
Five Counties Nursing Home in LEMMON, SD was cited for violations during a health inspection on March 12, 2025.
The man's admission diagnoses read like a checklist of vulnerabilities.
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.