Five Counties Nursing Home: Staffing Disclosure Failure - SD
The violation documented during a March 2025 inspection is classified as minimal harm, but the word "minimal" can obscure what the requirement actually means in practice. What nursing homes are required to post is not administrative paperwork. It is the answer to a question every resident and every family member has a right to ask on any given day: how many nurses are actually here right now, and how many hours are they working?
The specific information inspectors found was not being properly displayed includes the current date, the facility's current resident census, and the actual hours worked per shift by registered nurses, licensed practical nurses, and certified nurse aides, the people directly responsible for resident care. The posting is supposed to be in a clear and readable format, in a prominent place readily accessible to residents, staff, and visitors.
Five Counties Nursing Home, located at 405 6th Avenue West in Lemmon, serves residents across a stretch of western South Dakota where the next nursing home can be a long drive away. Families who place someone there often have few alternatives. The staffing disclosure requirement exists precisely because those families and those residents cannot easily verify from the outside whether the facility is adequately staffed on any particular day or shift.
Understaffing is one of the most consistent predictors of poor outcomes in long-term care. Residents who cannot get to the bathroom in time. Call lights that go unanswered. Wound checks that get skipped because one aide is covering a floor that needs three. The posting requirement does not fix any of that on its own, but it creates a record, visible to anyone who walks through the front door, of what the facility is actually operating with at a given moment. When that information is missing or not properly displayed, the accountability mechanism disappears.
The inspection report does not describe what was found in place of the required posting, or whether any posting existed at all. It identifies the violation as affecting many residents, the broadest category short of immediate jeopardy. That designation reflects not a single resident's injury but a systemic failure that touches everyone living in the building.
Inspectors cited the facility under the requirement that nursing homes present staffing information in a clear and readable format in a location that residents, staff, and visitors can actually find and read. The plan of correction, if one has been submitted, is not included in the publicly available inspection record. For information on what the facility intends to do, the inspection report directs readers to contact the nursing home or the state survey agency directly.
Five Counties operates in Perkins County, one of the most sparsely populated counties in South Dakota. For the elderly residents of Lemmon and the surrounding ranching communities, the nursing home is often the only option within a reasonable distance when independent living is no longer possible. The people who live there, and the people who love them, are not in a position to comparison shop or transfer to a competitor across town if they are unhappy with what they find.
That is the context in which a staffing transparency requirement matters most. In a market where residents have real choices and family members can visit frequently and easily, the absence of a posted sign is a nuisance. In a facility that serves a captive population in a rural county with no nearby alternatives, the information on that sign, or its absence, is something closer to the only independent check a family has on what is happening inside.
The inspection was completed March 12, 2025. Whether the posting has since been corrected is not reflected in the available record.
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 10, 2026 · Our methodology
Five Counties Nursing Home in LEMMON, SD was cited for violations during a health inspection on March 12, 2025.
What nursing homes are required to post is not administrative paperwork.
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.