Five Counties Nursing Home: Care Plan Violations - SD
A federal inspection completed in March 2025 cited the 405 6th Avenue West facility for failing to investigate incidents involving residents, failing to review the findings of those incidents, and failing to revise care plans in response to what those incidents revealed. The deficiency affected a small number of residents and was classified as causing minimal harm or the potential for actual harm.
That phrase, "minimal harm or potential for actual harm," is a regulatory category, not a guarantee that nothing serious occurred. It means inspectors determined the situation had not yet produced severe injury, or that the harm it produced was limited. It does not mean residents were unaffected.
The care plan is the document that tells every nurse, aide, and therapist working with a resident what that person needs, what risks they face, and how staff should respond. When a resident falls, loses weight unexpectedly, develops a wound, or shows signs of a new medical problem, the care plan is supposed to be updated to reflect what happened and what should change. An uninvestigated incident is an incident that never reaches the care plan. The next staff member walking into that room has no record of it.
Five Counties Nursing Home is a small facility in Lemmon, a town of roughly 1,200 people in Perkins County, near the North Dakota border. For many residents, it is the closest option available. Rural nursing homes operate with fewer staff, fewer specialists, and less administrative infrastructure than their urban counterparts, and inspectors and advocates have long noted that the consequences of documentation failures compound quickly in settings where there is no redundancy.
The inspection report does not name the residents involved or describe the specific incidents that went uninvestigated. It does not say how long the failures continued before inspectors arrived, or how many separate incidents were affected. What it says is that the facility was directed to conduct investigations, review findings, and revise care plans as necessary, and to report per the appropriate timeline.
That last phrase points to a separate obligation. Certain incidents in nursing homes, including abuse, neglect, and unexplained injuries, carry mandatory reporting requirements with specific deadlines. Inspectors noted that the facility needed to report per the appropriate timeline, which suggests at least some of the uninvestigated incidents may have fallen into categories that trigger those requirements. The report does not confirm whether reports were filed late, not filed, or filed incompletely.
The deficiency was cited under a federal standard requiring nursing homes to protect residents from abuse, neglect, and mistreatment, and to respond when those things occur or are suspected. The investigation and care plan revision requirements flow from that standard. They exist because the harm from a single incident is often smaller than the harm from a pattern, and patterns only become visible when incidents are documented, reviewed, and acted upon.
For the residents involved, the practical consequence of a skipped investigation is that whatever put them at risk once may put them at risk again. A fall that goes uninvestigated does not produce a falls prevention update. A wound that goes undocumented does not prompt a repositioning schedule. A behavioral episode that no one reviewed does not lead to a conversation with a physician about whether medications or environment need to change.
The inspection report does not say what happened to the residents whose incidents went uninvestigated. It does not say whether their conditions improved, stabilized, or worsened in the weeks before inspectors arrived. It records what the facility was supposed to do, and what it did not do, and leaves the rest unwritten.
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.
The deficiency affected a small number of residents and was classified as causing minimal harm or the potential for actual harm.
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.