Five Counties Nursing Home: Privacy and Care Failures - SD
The inspection, completed March 12, 2025, produced citations across 21 separate regulatory tags. The problems were not confined to one unit or one type of failure. They ran from the administrative to the deeply personal.
Two residents, identified in the inspection record as Residents 9 and 21, had audio and video monitoring devices in their rooms. Inspectors found the facility had not maintained proper privacy protections or required signage for those devices. Monitoring equipment in a nursing home room sits at the intersection of safety and dignity, and the rules around it exist precisely because residents in those rooms are often unable to advocate for themselves. Neither resident, according to inspectors, had been fully protected.
A third issue involved a certified nursing assistant identified in the report only as R. Resident 5 had raised a concern about this staff member. What the concern was, the inspection summary does not say. What inspectors found was that the facility had not responded to it adequately. A resident reporting a problem with a staff member is one of the more vulnerable moments in nursing home life. The response, or lack of one, matters.
Three other residents, numbers 10, 33, and 41, were leaving Medicare Part A skilled services when inspectors found that the required Medicare notices for their discharges had not been completed accurately. Those notices are not bureaucratic formalities. They tell residents what coverage they are losing, when they are losing it, and what options they have to appeal. Getting them wrong, or incomplete, can leave a resident without the information needed to challenge a coverage decision or plan for what comes next.
The inspection also cited the facility for failures in its performance improvement plan and quality assurance program. That citation, F865, points to the system a facility uses to identify problems and fix them before they compound. A deficient quality assurance program is notable not just for what it failed to catch, but for what it signals about whether any of the other problems found during this inspection would have been identified and corrected on the facility's own initiative.
The full list of cited tags, 21 in total, covered medication management, pharmacy services, staffing, food safety, resident rights, and care planning, among other areas. The inspection summary does not detail each individual finding, but the breadth of the tag list suggests inspectors moved through the facility and found gaps at nearly every turn.
Five Counties Nursing Home sits at 405 6th Avenue West in Lemmon, a town of roughly 1,200 people in the far northwest corner of South Dakota, near the North Dakota border. For many residents, it is the only nearby option for skilled nursing care. The nearest larger city is hours away.
The level of harm noted for the Medicare notice failures was classified as minimal harm or potential for actual harm. The privacy and staff conduct findings were listed under a broader category affecting many residents. No finding in this inspection was classified at the immediate jeopardy level, the most serious designation available to federal inspectors.
That classification matters for regulatory purposes. It matters less to Resident 5, who raised a concern about a staff member and waited to see what would happen next.
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 inspection, completed March 12, 2025, produced citations across 21 separate regulatory tags.
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.