Five Counties Nursing Home: Side Rail Safety Failures - SD
During a March inspection, federal surveyors found that maintenance director F was only monitoring one resident's bed rails monthly for safety. He was unaware that quarter-length side rails on 13 other residents' beds required the same attention.
"He thought all other residents' beds with side rails in the up position were for the remote of the electronic bed," inspectors wrote. "He was not aware the other residents' beds with side rails attached were being assessed by the nursing staff for use as side rails."
The facility's own policy required ongoing assessment and maintenance of bed assist bars, including regular inspections for entrapment risks. Federal regulations mandate that nursing homes inspect all bed frames, mattresses, and bed rails for safety, ensuring rails attach securely to prevent resident harm.
On March 9, inspectors observed residents throughout the facility with quarter-length side rails in the up position. Resident 36 had two rails at the head of her bed at 2:31 p.m. One minute later, they found resident 24 with the same configuration. At 2:36 p.m., resident 9 had identical rails, and at 3:42 p.m., resident 5 showed the same setup.
Over two days of observations, surveyors documented that all 13 sampled residents had quarter-length side rails on one or both sides of their beds.
The maintenance director told inspectors he was aware of only one bed with side rails. That resident, who wasn't among those sampled, had purchased his own bed with a box spring and metal frame. On May 2, 2024, maintenance director F had installed side rails on that bed and monitored it monthly for safety.
"He had not performed safety and preventative maintenance of side rails for any other residents' beds with side rails to ensure they were appropriately secured and in safe working order to prevent injuries," the inspection report stated.
The facility's maintenance log showed only one entry. Dated May 2, 2024, it documented room 11-2 as monitored, with repairs noted as "5-2 installed" and comments stating "will check quarterly." The maintenance director had initialed the entry.
According to facility policy, physical therapists initiated the use of side rails for residents. But the policy also required multiple safety steps that weren't being followed for most residents.
The facility's bed assist bar policy outlined specific procedures to prevent deaths and injuries from entrapment. Staff were supposed to ensure bed dimensions matched each resident, confirm rails were appropriate for the resident's size and weight, and check with manufacturers to verify compatibility between bed assist bars, mattresses, and bed frames.
The policy also required installation using manufacturer instructions and regular inspections of mattresses and bed assist bars for entrapment areas. "Regardless of mattress width, length, and/or depth, the bed frame, bed assist bar, and mattress should leave no gap wide enough to entrap a resident's head or body," the policy stated.
Staff were supposed to check bed assist bars regularly to ensure correct installation, as "bars may shift or loosen of loosen over time." The policy required following manufacturer equipment alerts and recalls, plus conducting routine preventative maintenance to meet current safety standards.
None of these requirements were being met for the 13 residents with side rails that the maintenance director didn't know existed.
The inspection found that maintenance director F believed the raised rails on most residents' beds were simply controls for electronic bed functions, not actual safety devices requiring monitoring. This misunderstanding meant that potential entrapment hazards went unchecked across the facility.
Federal data shows that bed rail entrapment has caused numerous nursing home deaths and injuries nationwide. The gaps between rails and mattresses, or between rails and bed frames, can trap residents' heads, necks, or bodies, leading to asphyxiation or other serious harm.
The facility's policy acknowledged these risks, requiring checks to ensure "no gap wide enough to entrap a resident's head or body." But without regular maintenance inspections, such gaps could develop as equipment shifted or loosened over time.
Five Counties Nursing Home received a minimal harm citation for the violation, indicating that while no residents were actually injured, the potential for harm existed. The citation affected "some" residents, though inspectors documented problems with all 13 residents they sampled.
The maintenance log's single entry from May 2024 showed the facility had the documentation system in place to track bed rail safety. The form included spaces for dates, room numbers monitored, repair dates, comments, and staff initials. But it remained largely unused despite multiple residents having the equipment.
The disconnect between nursing staff who assessed residents for side rail use and maintenance staff responsible for safety checks created a gap in the facility's safety system. Physical therapists initiated side rail use, nursing staff assessed ongoing needs, but maintenance staff remained unaware of most installations.
This breakdown meant that 13 residents lived with bed rails that hadn't been inspected for proper installation, manufacturer compatibility, or entrapment risks. The equipment designed to help residents could have posed unrecognized dangers due to the facility's failure to follow its own safety procedures.
The facility's policy required quarterly checks, but even that minimal schedule wasn't being followed for most residents with bed rails. Only the one resident whose family had purchased a private bed received the required safety monitoring.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
Five Counties Nursing Home in LEMMON, SD was cited for violations during a health inspection on March 12, 2025.
During a March inspection, federal surveyors found that maintenance director F was only monitoring one resident's bed rails monthly for safety.
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.
Frequently Asked Questions
- What happened at Five Counties Nursing Home?
- During a March inspection, federal surveyors found that maintenance director F was only monitoring one resident's bed rails monthly for safety.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in LEMMON, SD, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Five Counties Nursing Home or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 435090.
- Has this facility had violations before?
- To check Five Counties Nursing Home's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.