Five Counties Nursing Home: Privacy and Care Failures - SD
The March 2025 federal inspection of the 405 6th Avenue West facility identified a string of failures that touched nearly every corner of the home's operations, from how it handled a single resident's worry about a staff member to whether it could demonstrate any functioning system for catching and fixing its own problems.
The resident identified in the report only as Resident 5 had a concern about a staff member identified as certified nursing assistant R. What that concern was, the report does not say. What the inspection found was that the facility had not adequately responded to it. That gap, between a resident raising something and a facility acting on it, is one of the more basic obligations a nursing home carries.
Two other residents, identified 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 a delicate intersection of safety and dignity. When the surrounding protocols are not followed, the dignity side of that equation tends to lose.
Three more residents, numbered 10, 33, and 41, were discharged from Medicare Part A skilled services without the facility having completed their Medicare notices accurately. Those notices exist so residents understand what coverage they are losing and when. Getting them wrong, or not completing them at all, can leave a person making decisions about their care and their money without the information they need.
The inspection also found the facility's performance improvement plan and quality assurance program were not working. That finding carries weight beyond any single deficiency. A quality assurance program is how a facility is supposed to catch its own problems before inspectors arrive. When that system is not functioning, every other failure on the list becomes harder to explain away as an isolated incident.
The inspection report references 16 separate regulatory tags, spanning medication management, care planning, resident assessments, pharmacy oversight, food safety, and the administrator's responsibilities. The sheer breadth of that list points to something more systemic than a few staff members having a bad week.
The facility's own job descriptions, reviewed by inspectors, describe an administrator responsible for coordinating all activities of the care center and ensuring residents receive the highest level of care needed. The director of nursing's job description, dated October 2015, assigns that person responsibility for ensuring quality nursing care on a 24-hour basis, monitoring staffing levels, and overseeing compliance with care plans and resident assessments.
Those documents describe a management structure built to catch exactly the kinds of failures the inspection found. The inspection found them anyway.
The deficiencies were classified at a level of minimal harm or potential for actual harm, meaning inspectors did not find evidence that residents had been seriously injured by the time surveyors walked through the door. That classification matters legally and for the facility's rating. It does not mean the residents involved experienced nothing.
Resident 5 raised a concern about someone who works in their home, someone who helps them with the most basic functions of daily life. Whether that concern was about something minor or something that frightened them, the record shows it was not adequately addressed. For a person who cannot leave, who depends on the staff around them for food and hygiene and safety, that is not a small thing.
The inspection was completed March 12, 2025. The facility's plan of correction was not included in the materials reviewed.
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 9, 2026 · Our methodology
Five Counties Nursing Home in LEMMON, SD was cited for violations during a health inspection on March 12, 2025.
The resident identified in the report only as Resident 5 had a concern about a staff member identified as certified nursing assistant R.
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.